How can one's personal history, family background, religion, art and coursework inform nursing and medical students' ability to navigate the waters of end-of-life care?
In late February, 250 medical and nursing students gathered to focus on just that.
The new program, called the HeArt of Medicine, seeks to help students understand their own feelings on death and dying, as well as the physiology of dying and how to navigate the difficult conversations that arise with patients and their loved ones surrounding end-of-life care. To do this, 125 students attended one of two workshops. Each three-hour workshop began with a large group presentation led by Jim Avery, MD, executive director of Hospice of the Piedmont, who outlined the physiological side of death and dying. Students then broke out into small groups (pictured with nursing prof. Jeanne Erickson, at right) to explore and discuss examples of art and other topics related to death and dying, seeking to embrace and explore the emotional side of end-of-life issues experienced by everyone, including doctors and nurses. The larger group then reconvened to debrief and discuss the challenges of end-of-life conversations with patients and their families.
The HeArt of Medicine program traces its roots back a year, to spring 2013, when a micro pilot gathered four medical student and four nursing student participants. Susan Murphy, a nursing student, was one.
“One of the big things about dealing with end of life and providing good end-of-life care is that you need to feel comfortable with your own perspective and feelings on death and dying,” Murphy says.
Meanwhile, in spring 2013, Pranay Sinha, Chelsea Becker and Hunter Poarch were among third-year UVA medical students inducted into the Gold Humanism Honor Society, a ceremony during which the HeArt of Medicine was discussed. Intrigued, Sinha, Becker and Poarch wanted to find out more. It turned out the organizers were looking for incoming fourth-year students to shepherd the project forward.
Sinha, Becker and Poarch had all found themselves in end-of-life situations with patients and patients’ families in which they felt underprepared. Poarch says by that point in his education, there had been times when a patient or a patient’s family wanted answers from him as a care provider, regardless of the fact that he was a student. “We didn’t necessarily have all the tools in our tool belts that we would have liked for those conversations,” he says. “That’s one area where we could have used some improvement in our curriculum to address some of those things.”
After her first year of medical school at UVA, Becker had spent a summer working with a family practitioner in Massachusetts and often did hospice rounds and home visits with the nurses.
“I was completely amazed by how hospice is a wonderful service and resource,” she says. “I found it amazing how much hope they end up giving the patients and their families. When I came back to UVA, I felt like this part of our curriculum was lacking and we didn’t really have a course that taught us about end-of-life care.”
For Sinha, a few specific cases with patients during his third year galvanized his interest in gaining a better understanding of end-of-life issues and care. He was struck at the difference between the second-year and third-year medical school experience, when a medical student moves from “digesting knowledge” to “needing to apply that knowledge intelligently and compassionately."
Invigorated by the trust felt in the program, Sinha, Becker and Poarch set out to foster its expansion. One of the first realizations they made was that the interprofessional mix of students who had participated in the micro pilot — both medical and nursing students — was as important as the program’s content. They sought out a nursing student who could partner with them as they took HeArt of Medicine to the next level. Susan Murphy from the micro-pilot proved the perfect choice.
Together, the four expanded HeArt of Medicine's scope to three workshops in October and November 2013 in which 40 medical and nursing students participated. The first took place at UVA’s Fralin Art Center, where a docent led students through art inspired by death and students then shared their interpretations of the pieces. The second workshop, led by Dr. Avery of Hospice of the Piedmont, focused on the science of death and dying, including palliative care and the spectrum of end-of-life issues, from psychological to medical.
The third workshop, at the School of Medicine Clinical Skills Center, aimed to bolster the participants’ ability to have the difficult conversations with patients and families that doctors and nurses face when confronting end-of-life care. To do this, Sinha, Becker, and Murphy wrote vignettes that tried to capture these types of delicate, challenging interactions.
“We wanted to help people lose their fear of difficult conversations,” says Sinha. “The literature suggests that often, the reason the conversation doesn’t happen or gets horribly delayed is because doctors and nurses do not feel comfortable talking about death and dying.”
The team was thrilled with the program's reception. The students who participated were enthusiastic about the program, and preliminary data from their responses showed that the workshops decreased fear of difficult end-of-life discussions, and increased the perception of how rewarding end-of-life care can be. Moreover, students said they enjoyed the interprofessional aspect of the program, with medical and nursing students coming together and learning from hospice, palliative and chaplain caregivers.
The interprofessional collaboration made an impression on Sinha, Becker, Poarch and Murphy, too.
“The reality is that we cannot provide compassionate, skilled care at the end of life unless it is collaborative,” says Murphy. “I have such a different perspective now on what life is going to be like for my medical colleagues as they become residents. And they now understand what drives the nurse at the bedside to do what he or she is doing. We’ve really learned a lot from each other.”
“Each care provider has their strength," sayd Poarch. "The way that we can most efficiently care for a patient is to let each team member use their strength. There’s a lot of trust that comes in that.”
With the success of the fall iteration of the HeArt of Medicine, the team determined to take another big step, meeting with curriculum committees about adding HeArt of Medicine to the formal School of Medicine and School of Nursing curricula.
“All of us were very excited about this project, and we wanted to see it in the curriculum before we all graduated,” Becker says. The faculty they pitched were supportive, but cautious. To the team’s delight, the response was swift: HeArt of Medicine would be added to each school’s formal curriculum, and in short order.
“I think it says something about the culture at UVA that the faculty and administrators were so receptive to our idea and really supported us,” Becker says. “It was wonderful. We were lucky.”
“Some of the very best ideas come directly from our students,” says Dorrie K. Fontaine, Dean of the School of Nursing, “and that’s the case with this course, which aims to fortify nursing and medical students’ interprofessional skills as they work together at the end of a patient’s life.”
“UVA has truly been a national leader in its focus on interprofessional learning, and the core of every School of Nursing and School of Medicine course is informed by this pioneering approach,” she adds. “Our clinicians hit the ground running, ready for the kind of seamless, collaborative, team-based care that 21st century healthcare calls for.”
Nancy Dunlap, MD, Dean of the School of Medicine, sees this kind of program as vital.
"We spend so much time dedicated to advancing our medical knowledge and attempting to preserve life, and yet, despite our best efforts, we are still fragile creatures,” she notes. “Many healthcare providers will have to cope with the death of a patient at some point in their career. Teaching the healers of tomorrow how to offer comfort and quality end-of-life care is something the entire care team needs to know. I am grateful that our students thought so, too, and put so much time and effort into developing core values, goals and interprofessional educational experiences around this topic."
Thus, with the blessing of the School of Medicine and School of Nursing, in February of this year, those 250 nursing and medical students attending HeArt of Medicine workshops, now as part of the formal curriculum of the University of Virginia.
“Executing our program on such a large scale and hearing the wonderful comments from the students and group leaders was immensely satisfying,” Becker says. “We are encouraged and inspired to continue the HeArt of Medicine Program and are hoping to expand our project design to other institutions as well. One year later, it is hard to imagine how far we have come.”
Sinha, Becker, Poarch and Murphy have seen an incredible culmination of their efforts. And yet, they are quick to note that HeArt of Medicine’s work will continue. While most of them are moving on from UVA upon graduation this spring, they have recruited another group of medical and nursing students to take over as the program’s shepherds.
“One of the particularly unique things about this program is that it was borne of students and it will continue to be carried out by students,” Poarch notes.
Over the past year, as the team has guided HeArt of Medicine, it has, in turn, guided them. Each member of the team faced situations with their own families and friends where the tools there were developing through their end-of-life studies became essential.
“It is interesting how loss has visited us while we were running the program,” Sinha says. “I think that all of us feel the program gave us the maturity to handle these difficult situations in our own lives.”
“This project really gets to the heart of why we all wanted to do medicine in the first place,” Poarch says. “It’s because we care about people, and we care about patients. I think it’s a breath of fresh air when we actually get back to what we wanted to do medical school for in the first place — it’s when we put our patient and their family in the center of everything. That’s what this project does.”