Physicians learn the practice of comfort Medicine reconsiders the needs of the dying

July 28, 1996|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

In a brick rowhouse, in the quiet of a cloudy Thursday morning, the medical students meet death.

To the emaciated patients left demented by AIDS or wracked with cancer, they introduce themselves. Sometimes awkward, sometimes gentle, they try to reassure a 30-year-old man whose abdomen is swollen by cancer that he looks good. In the next room, the occupant died just a few hours before. All that's left is the strong scent of Lysol.

"This is the part I fear," confides Greg Cohen, 23, just beginning his third year at the University of Maryland School of Medicine, in the hallway of Baltimore's Joseph Richey Hospice. "They teach us disease and how to fight it. They don't concentrate too much on the giving up part -- and that's how it's seen -- giving up."

But a cultural shift is under way in medicine, as the principles of hospice move into academic medical centers across the country. Aspiring doctors, residents and even veteran physicians are being taught how to care for the dying.

They are learning how to be compassionate, how to break the news of a terminal illness and how to manage a patient who is afraid that if he goes to sleep he will never wake up.

"The attitude is, it's a sad part of my practice, but it's not rewarding," said Dr. Douglas D. Ross, professor of medicine and oncology, at the the Marlene and Stewart Greenebaum Cancer Center, formerly the University of Maryland Cancer Center. "We want to shift the attitude. It's not a failure. It's an incredibly important thing to do."

Ross is overseeing Maryland's $300,000 grant from the National Cancer Institute, one of 11 awarded in recent years as part of a $2.1 million effort to improve physicians' skills in care of the dying. Some groups are even pushing for comfort -- or palliative -- care to become a specialty. The first national exam to certify doctors in palliative care will be held this fall.

For generations, many doctors have shunned care of the dying.

Dr. Timothy J. Keay, a geriatrician with a master's in theology at the University of Maryland School of Medicine, said for many colleagues, "the mind-set was either full speed ahead or full stop."

Training in hopeless cases was limited. At Maryland, for example, the only lesson on how to break bad news was a one-hour lecture for first-year medical students, Ross said.

In an almost unspoken practice, the tradition went that if a patient refused treatment, there was one proper response by the doctor: "There's nothing more I can do for you."

Now physicians learn that that constitutes abandonment.

Joyce Kaminkow of Annapolis said she and her mother, Irene Gross, were left cold by a cardiologist who had been treating Mrs. Gross for a faulty heart valve. When the 82-year-old woman said she did not want surgery, the doctor responded with little more than the suggestion that she go home as an invalid.

"He never, ever offered the choice of hospice, and not being a medical person, I realized my mother was seriously ill but not how close to death she was," said Kaminkow. "He said, 'I can't do anything with you.' "

Eventually, other physicians carefully explained options for taking care of Mrs. Gross, who died in May. "It was nice to have someone who was so understanding," said Kaminkow. "My mother was a very sweet, lovely person, and to be treated so abruptly, I took offense."

Pressure for change has grown on many fronts, from major studies showing that many patients die in pain, isolated and alone, to the assisted-suicide movement and the wrenching experiences of millions of people whose relatives died tied down, biting on a ventilator tube.

"We are at the crest of the wave," said Dr. Susan Tolle, an internist and director of the Center for Ethics in Health Care at Oregon Health Sciences University, where first-year residents in a role-playing exercise must explain patients' deaths to relatives. The ethics center has held four statewide conferences within the last year on symptom management and communication with dying patients. Every one was sold out.

At the Johns Hopkins School of Medicine, Dr. Catherine De Angelis, vice dean for academic affairs and faculty, said students have always received some training in this area, but it has been strengthen in an recent overhaul of the curriculum.

At Maryland, now in the second year of its three-year grant, Ross held a conference last month for about 50 physicians. In each year of medical school, would-be doctors are taught aspects of palliative care, such as the best drugs to control nausea and shortness of breath. He has arranged for residents and third-year medical students to rotate through hospices.

The concept initially shocked some students. "They said, 'We came here to save people, not to help them die,' " said Ross. But in a survey after going through the new course work, 75 percent of freshman said caring for the dying could be rewarding, and they wanted to learn more.

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