The stroke had left Dakota, a 63-year-old housewife, in a persistent vegetative state, dependent on a ventilator and a feeding tube. At best, her neurologist reported, Dakota could open her eyes, but she would never recognize her family. The doctor, Maya Petashnick, explained the options to Dakota’s husband – comfort care, for example, as an alternative to life support – but it was clear that was not the conversation he wanted to have. He wanted to know how the doctors were going to improve his wife.
“We want her to be better,” said Petashnick, “but realistically, the imaging and a lot of the lab results tell us that maybe she doesn’t. So we want to be able to prepare better. .
The husband was not willing to give up the dream of healing. “From what I understand, a person who is in a vegetative state can sometimes heal and wake up,” he said. “I don’t understand why we aren’t doing what we can at this point to save her.”
After several minutes, Tamara Vesel, head of palliative care at Tufts Medical Center, called for a time out. Everyone took a deep breath. Dakota’s stroke was just a scenario, as part of a one-day workshop hosted by Vesel for fourth-year medical students to practice talking to patients and their families about decisions end of life. Petashnick was actually a fourth-year student at Tufts University School of Medicine, and the role of Dakota’s husband was played by Charles Linshaw, a professional actor.
“It was kind of a roller coaster,” said Petashnick. “I think I could have started differently.”
“It’s difficult,” Vesel agreed. “We’re putting you in an awkward position here. “
With actors representing patients or their families, and a team of palliative care experts serving as coaches, the students experienced what it would be like to say to a 34-year-old man with cancer. lung that he may only have a few weeks to live. . Or tell a couple that their nine-month-old daughter, found not breathing in her crib, couldn’t be resuscitated.
These are the most difficult conversations these students will face as doctors. And they will face them soon.
Jan Fouad, A11, M16, a third-year internal medicine resident at Tufts Medical Center, told graduating doctors that even new interns sometimes have to speak with families in the ICU. During his first year in the hospital, Fouad did not feel prepared for these conversations. “At no point did I sit down and say to myself, ‘This is how you give bad news, this is how you talk about the end of life, this is how you offer options when the patient is medically not doing well. “, did he declare.
Yet being able to talk about difficult things will be increasingly important as the population ages and technology enables people to live longer, if not always better. Communication skills that help match care to patient goals make it easier for the patient, the physician, and the healthcare system. Recognizing the need, the Tufts School of Medicine has already committed to making advanced communication skills and end-of-life care a key component of its new program, which will begin this fall.
Vesel, who is also an associate clinical professor of medicine and pediatrics at the Faculty of Medicine, received an intramural Innovations in Education grant from the school to pilot these workshops with around fifty students, or around a quarter of the students. class of 2019, and conduct a study on its effects; she is analyzing the results now. Recently, an anonymous donation allowed the school to expand the workshop, which it will offer to 100 fourth-year medical students annually for the next three years.
In the workshop, they learn conversational frameworks which they practice with the actors. Vesel tells them it’s a safe place, where they can catch their words, get frustrated, even laugh to break the tension.
The actors take on trying characters, like siblings arguing and disagreeing over how to care for their mother, and a patient with terminal liver disease who just wants to get out. the hospital and doesn’t want to talk about what might happen. They ask conflicting questions: “Was there some kind of error that occurred? “Should we take her to another hospital that knows more about it?” “Do you recommend it because my mother is not rich?” “
All of these reactions are normal and expected, Vesel said. “When people are in pain, they can go wild,” she said.
After each scenario, the actors give feedback on the conversation, including the students’ body language: did they make eye contact? Did they listen to all of the family members or did they just focus on one? Did they remember to breathe?
“When you crossed your legs and leaned forward, you looked a little frustrated and angry,” Linshaw told a student. “Relax your shoulders, don’t cross your arms. You will look less threatening.
Students also hear from someone who has been on the other side of these conversations. Megan De Lisi, who lost her son Luca to a brain tumor when he was three, spoke about the good and bad interactions she had with members of her healthcare team, including Vesel.
“The first time you came to get a do not resuscitate order you sat down with my sister and looked at pictures of Luca,” De Lisi told Vesel. “You talked about what was going to happen. Because of the way you walked into our house and opened your hearts to us, I was more at peace with what was about to happen.
Since then, De Lisi has helped Vesel train doctors, nurses and social workers in conversations about palliative care, offering a parent’s perspective on end of life and grief. De Lisi said mid-career professionals may find role-playing in front of their colleagues difficult. “They’ve got all that experience, and they’ve got a little bit of ego to go with it. It’s hard for them. But she found that medical students were different, more willing to experiment, to ask for help, and to give their opinion.
The group discussed the prognosis and how to be honest with patients without taking all hope away from them; it is okay to ask patients what they want to know. “People change their priorities when they know they have less time to live,” Vesel said. “Maybe some will be demotivated, but most will be able to do something with the information.”
She spoke of a patient with failed kidneys who did not want to spend the last months of his life on dialysis three days a week. “He had planned trips every month – fly fishing, visiting his granddaughter,” she said.
Vesel encouraged students to guide their patients, not just provide them with a long list of care options. “People want to be responsible for their decision, but that doesn’t mean they don’t want to hear the recommendations,” Vesel said. In Dakota’s case, machines can keep her alive, but she can never leave the hospital. Is this really what his family wants?
“It’s really important that we consider the value system of these families. For some people, really, all life, no matter how good it is, is worth living, ”said Vesel. “We have to figure out how to help these families make decisions they won’t regret.
Barbara Ratto, who has been a palliative care nurse for 27 years, said she had heard that even experienced doctors were wrong. She recalls that a family member of a patient asked a prominent doctor, “What is my mother’s future?” “
“Future?” replied the doctor. “She has no future.”
If you catch yourself saying the wrong thing, correct it.
“It’s good to say, ‘I’m sorry, that was a stupid thing to say,'” said Vesel. “You want to be perfect. But we are human.
It was encouraging for Daniela Febres-Cordero, M19, who is heading towards an OB / GYN residence. “It really helps to know that it’s okay to admit these mistakes, so you don’t get crippled by the conversation,” she said.
Such humility goes a long way in gaining the trust of a patient or their family. In fact, while conversation frames are helpful, coaches agreed that the best advice is to be authentic. Be yourself, act as you would your own family member, and your empathy will kick in.
At the end of the workshop, Fouad warned future doctors that their first year will be exhausting and that it will be difficult to stay in the moment for every conversation. Still, it’s worth it. “The words and the way you pronounce them,” he said, “can change someone’s life. “
Julie Flaherty can be reached at [email protected]