Life & death, mince & tatties

I HAVE TO admit I was disappointed. I had spent many hours revamping the week-long palliative care attachment for our 4th-year medical students. I had developed, coordinated and indeed delivered several new sessions. The end-of-block feedback forms came in and the students, ungratefully I thought, ranked ‘having a meal with the day unit patients’ as the most enjoyable and most useful session – the only session I had had nothing to do with.

Thankfully, my fragile ego got a boost as I examined the feedback in more detail. The students also recommended the new ‘quality of life’ session. Here groups of three or four students meet patients in the inpatient palliative care unit on the first morning of the week. They are forbidden from taking a traditional medical history, instead they are asked to find out what factors are important to these patients in improving or diminishing their quality of life. These interviews last between 5 and 15 minutes. All the students then meet for a facilitated discussion.

They are invariably amazed that these patients, with their severe, advanced and advancing pathologies, rarely spontaneously mention health-related concerns, but rather discuss their families, the attitude of care given (whether they feel they are listened to and whether the caregiver has time), maintaining independence, financial problems or spiritual issues.

Both the sessions described above allow the students to see and interact with the person behind the illness. This is obviously a transformative experience for some of them: “lovely to be able to interact in a non-clinical way”; “getting to know a patient’s experiences and connecting with them”; “made me think of issues I wasn’t even aware of”.

Unfortunately it is well recognised that medical students tend to become less patientcentred and less empathic as they progress through medical school. They are generally very poor at identifying patients’ concerns. This is probably unsurprising as most student–patient interactions occur in the context of the structured medical history: history of presenting complaint, past medical history, drug history, family history, social history and the dreaded systematic enquiry. It is difficult to imagine a more effective way of inhibiting patient-centredness, whilst emphasising that only medical concerns are important, although the instruction “go and feel bed 12’s abdomen, he has a great liver” probably does just that.

Equally bad are the health-related quality of life scales that we see used as primary or secondary outcome measures in clinical trials. Patients are bombarded with questions about symptomatology and deficits in function. Unremarkably, health-related quality of life correlates well with markers of disease severity. Thankfully for me, as the whole raison d’être of palliative care is the maintenance/improvement of quality of life in the face of life-limiting disease, individual quality of life (where the patient nominates the domains important to them) is not correlated with disease severity or functional ability. Indeed, individual quality of life can improve even as prognosis shortens.

I am lucky, I know, because I have time to spend with patients talking about hopes and fears, life and death. I don’t have the pressure of being expected to make them better. Yet, as the students discover on their first morning with us, it only takes a few minutes to effectively establish what an individual patient’s priorities are. This process ensures that patients feel listened to and validated. It can promote autonomy and inform an understanding of ‘best interests’ both for the physician and indeed the patient as they reconsider their life goals. Importantly, most patients don’t want or expect you to deal with all the issues they raise.

Now nothing makes me happier than the gentle hubbub of voices and laughter, the tinkle of cutlery on plates and the smell of mince and tatties. I know I could never teach that lesson in a tutorial.

Dr Gordon Linklater is a consultant in palliative care at NHS Grampian