Death and dying: what do young doctors need to know?

“What should I have been taught when I was a medical student, stuff that I recognize now as important?”Of course, the list is long. But the topic preparation for end-of-life, and death itself, seems to head the list. I read some of the online literature to learn: what has changed over a half-century. I learned how, in some cultures, death is a taboo subject, not included in textbooks and medical courses (1). But some subspecialties (oncology, for example) do have a stronger appreciation of palliative care issues. Most of my career in cardiac-IM looked upon the inevitability of death as a non-starter: it certainly wasn’t well remunerated, and I think poorly understood. There is more of an appreciation that this is a key role for physicians to understand and become familiar with (2). When I was young (1950-60s), your grandparents would die in their own bed, at home. “Grandma’s passed on.” There would be some mention of her strong religious beliefs, an afterlife, and a better place. You might see the body, but likely not until the funeral. It wouldn’t be unheard of for your father to die in his 60s, a sudden passing. “He had a good life.”Then as I got older, death was less obvious. People died in hospital. Recent retirees lived another 15 to 20 years. I wasn’t taught about death and dying in medical school, not a whit. But I had to manage a dying man in my final years in medical school. I think he was the first person I was with at the time of death. Big MI, sinus tachycardia, VT, cardiac arrest, no resuscitation (after all, he was 67 years old). Pronounced dead (another thing I wasn’t taught). Nurses took over the prep for the mortuary. How you explained death to newly grieving family members was up to you.Thereafter, cardiac arrests came and went. All dead people at the outset, some of whom we brought back from the abyss. A furious team effort, ACLS protocols, intensive care.But how has the role of the physician changed? In the old days, a physician might sit with the dying, counsel and empathize with family, and give comfort (he couldn’t give much else by way of effective medicine). The Art of Medicine slowly transformed into a Science in the 19th century, with tests and quasi-effective treatments, but still people died young, and in some significant distress (e.g. TB, smallpox, typhoid, cancer).Doctors would visit the house, make a diagnosis, leave a script, and disappear. Family would hold vigil.Nowadays, the role of the doctor has become further removed from one-on-one compassionate care. There is a sense of failure when someone dies: after all, we have a system that prolongs life, even if the gain in quality is often marginal. Sudden death has been replaced by a slow demise from a chronic illness (COPD, dementia, heart failure, cancer), and by that time, the extended family have become remote attendees. They don’t live downstairs or across the street. They live across the country, or abroad, and visit infrequently. Loneliness is the new companion for the dying person.Another facet of this relationship is how we (all of us) view death. We are a secular society, a significant change from previously. As such, support mechanisms are not there. But more than all of this is how SOCIETY views “death.’” A lot of this has to do with the portrayal of death by the media. “Man falls off roof, broken neck, family devastated” might elicit some sympathy. “Nearly 300 die in plane crash off Newfoundland” generates some degree of national abhorrence. “9,500 dead in a far off war zone.” What does that number mean? Am I supposed to be 39,500 times more shaken by such a statistic? “Mass shootings now a weekly event in the U.S.A.” hardly makes one blink—just a group of unlucky people in the wrong place at the wrong time: nothing that would generate a change in gun laws. We are being inured to violence.The news media presents powerful images of war, death and destruction on our televisions every night. Someone must be to blame, and often they take on the role of judge and jury. The film industry portrays death as an adrenaline surge (e.g. Furosia), with the human life-experience having no value, and outrageous slaughter justifying the price of admission. Extermination of the human race and the succession of ant-like creatures is surely next. But not before there is a wealth of blood and gore spilt along the way.As a senior citizen, I am able to look at a lifetime of change. Sure, we sent soldiers to die on foreign lands, and learned nothing from the futility of war. We lost millions to the Great Influenza Epidemic (1918-20) and covered it up for some unknown reason. We survived to see a century of understanding and growth and well-being, only to let the most poignant act of being—be forgotten. The end of a good life: the good death.Today, many people in Canada don’t have a physician they call their own. The divide between patient and doctor widens. If they go to a walk-in-clinic, or an emergency room, they feel they are a burden. We need to make connections, show empathy, and love our friends and neighbours. Teaching HUMANITY to those in the medical profession is the least we can do. Third round chemotherapy for metastatic adenocarcinoma, or a pill for a depressed widow, or a follow-up visit in eight weeks for the suicidal youth doesn’t project the compassion and care that is the core of our profession. Patients know this.Families know this.Do clinicians and their protégés know this? To quote Atul Gawande, we live in “a society that faces the final phase of the human life cycle by trying not to think about it.” (4)Let’s start by engaging everyone in communication, understanding, and compassion. Let’s say “no” to violence, it shouldn’t be our defining trait. Let’s address conflict with non-aggression and reasoning. We are so fortunate to live on this wonderful blue planet. We can be honest and open in our approach to End-of-Life (3). Physicians need to recognize the central importance of caring, much better addressed by those referred to below (5-7). I have recently spoken to three heads of medicine across Canada, who assure me that clinicians in training are coached in palliative care conversations (and other difficult topics): this is welcome news. I hope experience will fill in any gaps.If our society fuels the fires of division, of discrimination, of hate, we won’t have to wait long for before a viral pandemic or nuclear holocaust precipitates the next extinction event. It is inevitable. Maybe in my lifetime. More likely in yours.Further reading:What medical students learn about death and dying. Miguel JMD. Sociol Int J. 2020;4(1):7-20. DOI: 10.15406/sij.2020.04.00216Death education for doctors: Introducing the perspective of death and life studies into primary care physician training. Daisuke Son, MD, et al. J Gen Fam Med. Sept2021; 22(5): 309–310.What Doctors Need to Learn About Death and Dying. End-of-Life University. Karen Wyatt, MD. (April 18, 2023)Being Mortal: Medicine and What Matters in the End. Gawande, A (2017) ISBN 9780385677028Authenticity and Creativity in a University Death and Dying Course. Jeremy Cohen,Talk Death (Sept. 3, 2024)Educating medical students about death and dying. Black, D et al. Arch Dis Child. May 1989; 64(5):750–753. doi: 10.1136/adc.64.5.750 How future doctors learn to have End-of-Life conversations. Tufts University. May30, 2023.

Death and dying: what do young doctors need to know?

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