Introduction

In many medical schools, the first professional exposure medical students have to death is in the Gross Anatomy course. Unfortunately, many medical schools fail to use this initial experience to prepare students for the transition from didactic years to clinical years, when they will face the natural history of human existence in the form of living human patients, from gametogenesis through conception, pediatrics, adulthood, geriatrics and ultimately, dying. Gross Anatomy only vaguely resembles the medical student's first view of clinical death and, by itself, in no way prepares the student for what the first experience will be like. It does provide an ideal introduction to the topic and can be a springboard to introduce the student to this very important aspect of their eventual clinical practice of medicine and the life cycles that they themselves will seen and experience.

In many cases, the student enters the clinical realm with no cognitive understanding of death. Indeed, many of their teachers have not yet contemplated death beyond sterile clinical concept of the cessation of function, using euphemisms such as Athis pathology is incompatible with life. Unfortunately, this attitude extends to the wards. With few exceptions, when I hear physicians and nurses talking about a recent death, the commentary runs along the lines of he expired. Or as one physician commented when I informed him that his patient had pancreatic cancer, he's a goner. Most medical students are not even taught to recognize clinical death in the didactic years. Instead, they are exhorted to continue the ACLS/BCLS until someone else arrives, never for a moment considering whether the arrested patient is indeed alive or that he is a no code patient.

The revision of the medical school curriculum must include not only the education of the students in this most human of all events, but the faculty as well. Most importantly, the faculty need to be taught about death and dying and they need to be comfortable talking about the fate that ultimately awaits us all, in human terms. The ethics courses can well address this, insofar as the student's attitudes are concerned, but there remains the key issue of how the students will personally face death when it happens to one of their patients and how they will deal with the patient's family. How their patients and their families remember the death experience will directly reflect on the physician and their respect for the profession of medicine, and thus should be a focal element in the didactic as well as the clinical years for medical students.

The bulk of the core didactic medical curriculum focuses on and emphasizes life and the living. In the first year, the normal structure, function and processes of living are the key components of most school curricula. In the second year, integration of the normal structure, function and processes with infection, invasion and pathologies and how things go wrong are introduced, with a key goal of enabling students to pass the United States Medical Licensure Examination. This material is essential to the mechanics of medicine, and there is an enormous amount of material covered in a short time, but it omits the humanity of medicine. It is geared to the preservation of life, the identification of pathologies, their etiologies and their correction. In general, with few exceptions, it does not recognize that the ultimate outcome of human life is human death.

Instead the emphasis is on how to recognize pathology and disease. The emphasis is on treating the pathology and disease through drugs, surgery, radiation or other miraculous technologies. We are taught that the elimination of pathologies is the ultimate goal of medical intervention. The Advanced Critical Life Support, the endotrachial tube, the CPR and the vent are tools we use to stave off death for another day...and another watch. We are goal driven to keep the patient alive at all costs. We regard the failure of medical treatment to cure as a personal failure and the failure of medicine. We fear death, we don't want to talk about it, for to discuss dying with a patient is to give up on life and to lay bare our own mortality. So we press on with the mechanics of medicine despite the gnawing sensation that perhaps, in this case, our purpose is to simply hold the hand of the dying and wait with the family for the natural conclusion of the life process. Or we avoid the subject of dying altogether by abandoning our patients when all the mechanics of medicine prove insufficient to thwart the inevitable progression of a disease process by transferring their care elsewhere.

Gross Anatomy is the first exposure to the dead that most medical students face as professionals. Unfortunately, gross anatomy and dissection little resemble the scenes of clinical death. The cadavers are carefully positioned, arranged and preserved. The bodies are wrapped in plastic and burlap and covered with large amounts of preservatives. Despite the fact that these cadavers are the mortal remains of once living, breathing, laughing, sweating human beings, most medical students become quickly focused on the art of dissection, the skills of naming and the identification of function needed to pass the examinations. The thoughts of death and mortality quickly become buried in a mountain of details. Then, when the last muscle is dissected, the last vessel is identified and the last tendon named on the examinations, they all leave, never again to re-visit the gross lab and the rite of passage they have just experienced. Someone else unseen arrives to re-wrap and commit the earthly remains of the people on the tables to their ultimate resting place, while the post gross parties commence.

When my classmates heard that I was doing a Hospice rotation, some were aghast. How can you do a service like that? Your patients are all going to die! were the comments I heard. My stock response was, well, so are yours, I think, they just have less of an idea of when. Despite having been through the gross anatomy rite of passage, they still missed a fundamental of medicine. Their patients ultimately will live only their lifetime and no more. Medicine may prolong it. Medicine may make it better, and it usually does, but medicine cannot indefinitely postpone the mortality of life. This tells me that the schools miss a key opportunity by not addressing this issue head on at the time of beginnings in the gross lab. It is with this in mind that the following humanness of medicine be incorporated as an adjunct to the mechanics of medicine component of the gross anatomy curriculum.

Objectives

The humanness of medicinecomponent of gross anatomy should identify the eventual outcome of human life is human death. It should gently, but firmly approach the subject from a multifaceted perspective. It should address the issues of death and dying as they relate to the student personally, the issues as they relate to the sociological and cultural axes, the psychology of death and dying, and how it affects survivors.

Goals of this Curriculum

• To introduce medical students to the concepts of death, dying and appropriate medical intervention as they are first exposed in Gross Anatomy
• To provide a forum for students to confront the concept of mortality within the professional context of being a physician
• To provide education for students to identify clinical death and the factors associated with determining that a patient has died
• To provide students with information concerning the appropriate care of patients who have a terminal life threatening condition and to enable them to understand the nature of the dying process as it relates to the patient, the patient's family and friends
• To provide the student with case studies to understand the role of the physician in providing care for the dying and support for the family through the initial phase of the grieving process

Gross Anatomy Life...And Death

Death has always been an integral part of life. Modern medicine has learned to use technology and drugs to improve the quality of life, and to avoid, postpone or delay death, but ultimately death prevails. Given the current climate in contemporary society, how we deal with death is at least and probably more important than how we deal with life. For physicians, entering the twenty first century, we have advantages that are unprecedented. We can cure many diseases that two generations ago were incurable. We have learned to use vaccines to eliminate scourges from the face of the earth. We have improved the quality of life and the length of life beyond the wildest dreams of our colleagues a century ago.

Yet, in the end, the ultimate outcome is the same. The mechanisms are different. The course of the pathology is different, and we have succeeded in postponing, for a time, the end of life, but the end still comes. And it still comes in much the same ways as it always did. The disease that fills the lungs and cuts off the air supply, the infection that enters the bloodstream and causes sepsis, the traumatic death of a violent injury are all different manifestations of the same process. The current top five causes of death will probably not be on the list five decades from now as we enter the latter half of the twenty-first century, and there is even less doubt that the ultimate completion of life will remain death, for as we eliminate the current killers, more will move in to take their places. Mortality is an inescapable fact.

Physician Roles in Care of the Dying

Physicians have always played a key role in the care of the dying. Standing beside the clergy, at the bedside, they have reached into their black bags of tricks until there are no more tricks. What has changed is how physicians relate to death. In modern times, we have looked to technology to embrace a cure for whatever ails us, including the degenerative processes of aging. Then, when all else fails, the doctor tells the patient there's nothing more to be done medically, mounts his horse and rides off into the sunset, never to be seen again by the patient and family, to the next technical medical challenge of the hour. I submit that part of the argument for physician aid in dying are merely a call for physicians to return to a time when they did not simply walk away from their patients at the time of medicine's inability to cure. Medical care does not simply end with medical inability to cure. The medical paradigm must change from curing to caring, and doctors are the key agents in this change.

The gross anatomy course is the students first exposure to the possibility that patients may die. The course itself is directed to physical details, and after the first cut, many students give the fact that their cadaver was once a life, succumbed to a process that led to death no further thought. In this session, we wish to re-examine this idea as an ancillary concept to structural/relational goals of the laboratory.

Task 1: Mechanics of Disease

In small groups with a faculty member or student leader, preferably an upperclassman with some clinical experience, complete a brief history of a particular cadaver, based on the cause of death. The groups may form into tables corresponding to their particular cadaver, and where known, be given the cause of death. With the leader/tutor, develop a probable chief complaint retrospectively and an associated history of the present illness. Describe the symptoms a patient might have described with this condition. Include social-medical factors which might have contributed and suggest a family history that might correlate with the chief complaint. Then, selecting a representative of each group, present the case to the entire session. Give 10 minutes to develop this scenario.

Example: Cadaver A: 86 y.o. man. Cause of Death: COPD

Proposed Chief Complaint: Shortness of Breath

Proposed HPI: This man describes a shortness of breath at rest and on exertion. He relates that it has been getting progressively worse over time. Now, he can no longer walk to his mailbox, about 100 feet from his house and is too weak to climb stairs without resting on each step. Three years ago, he was able to walk to the grocery store, about three blocks without difficulty, but could not run.

FMH: Probably non-contributory.

PMH/OMH: Non-contributory or unknown.

SurgHx: Non-contributory or unknown

Speculated Soc-Hist: Speculate that smoking is a cause of COPD, probably patient smoked for a prolonged period of time. Other factors may include environmental toxin exposures, physical agent exposures etc. [The important thing is to encourage students to think about what happened medically, and what interventional failures may have occurred and how it will likely involve their future patients.]

Suggested Physical Findings Before Death:

On examination, we see an 86 year old man who looks older than his stated age. He is bedridden and on 28% oxygen via a cannula. He is visibly short of breath and is unable to walk unassisted.

HEENT: Normo-cephalic, PERRLA, EOMI, neck supple, throat pink with moist mucosa, no lymphadenopathy.

Lungs: Significant inspiratory and expiratory wheezes, hyper-resonant to percussion, on CXR, significant decreased density.

Heart: regular rate and rhythm with tachycardia. Normal heart sounds.

Extremities: Clubbing of the fingers probably seen

Impression: COPD with significant oxygen deprivation

Most freshman medical students will not have the clinical background to create this type of a scenario, unassisted. But, working with a mentor in small groups will enable them to begin to see the process of technical medicine and to reflect on the fact that their cadaver was once much more than just a cadaver.

Task 2: Mechanics of Death

Have the senior student or faculty member give a brief overview of the final natural history developed from a case note developed in Task 1. For example, with CHF, describe the increasing failure of the left heart to circulate blood, and resulting right heart failure and the ensuing pulmonary and dependant edema. Describe the possible treatments associated with the disease, superfically, and why they ultimately fail. Then go on to describe what a possible terminal event or condition might look like if they were to visit such a patient in the days or hours before death while doing inpatient rounds. How the natural history might follow. Describing, in this case, the increasing rales, the clubbing and cyanosis associated with CHF, followed by breathing changes.

Task 3: The Death Note

Collectively, discuss the medical aspects of death. How do we know, as physicians, when a patient has died. Every layman knows that a patient has died when the doctor says so. How do physicians decide. A brief discussion of the factors. For example, in the above case, develop a brief description of what might be observed in the patient shortly after death. Develop a sample case note.

Example Progress Note:

Mr. Cad Aver is a 56 year old man with a history of refractory laryngeal cancer for two years, recently multi-drug resistant, referred to Hospice service three months ago. He was treated palliatively with radiation therapy to the head and neck and with dihydromorphan titrated for pain management for the past three months. On previous consultation, he reported that his pain was under good control but he was having increasing difficulty breathing and generally felt bad.

This morning, on rounds, Mr. Aver was found to have died early this morning.

Physical Examination:

There were no respirations, no heart beat, and no peripheral pulses. The eyes were immobile, pupils were fixed and unresponsive. There was evidence that the laryngeal cancer had infiltrated and eroded the carotid artery causing an arterial bleed.

Impression:

Mr. Aver died sometime in the last hour due to arterial bleed and hypoxia.

Discuss with the students the physical findings on death. What must be seen and described medically to declare a person dead.

Task 4: Emotions Surrounding Death and Dying

Death is a very emotional process, for both the dying and all those involved in their care. This includes not only the physician, but the nurses, the custodians, and most importantly the family. How people deal with death, including the students own emotions should be discussed. How they will feel when they are faced with being the person on the scene at their first patient's death, how they will feel when they are called to observe a family being told that a Hospice referral is the best medical option remaining for themselves or their loved one. To address this topic without discussing this most vital aspect would be most remiss, although it is the most difficult aspect. It is this aspect of death which is central to the health of the patient, the patient's family, the student doctors and their mentors. It is this aspect of medicine, in my opinion, more than any other which will effect the change from medical student to student doctor and ultimately to respected physician.

To deny death, to avoid the eventual outcome and remain cold and aloof is to deny our own mortality and fallibility and will make us less able to properly care for those who need our skills the most. This task should be incorporated at various levels in the curriculum, and expanded upon as students learn more. It should be introduced as part of the Freshman Gross Anatomy discussions, enhanced and expanded as part of the medical ethics courses and further developed in the Sophomore year as part of the pathology/ethics courses. By the time the Junior year begins, students should be as comfortable with this topic and discussing it with their patients as they are taking a sexual history.

Task 5: Cultural and Spiritual Issues Associated with the End of Life

This task should be developed to describe how different cultures deal with issues surrounding death. Many cultures have different approaches to the end of life. And these approaches evolve over time. What is reasonable for one culture or even one family may be absolutely unreasonable for another culture or family. For example, at the turn of the 20th Century in North America, many people died at home. The undertaker came to the house, embalmed the body and people expressed their condolences at the house. Today, death frequently happens at the hospital, the funeral home is called and family and friends next see their loved one in a casket surrounded by flowers. Likewise, spiritual affairs vary greatly between people and cultures and change over time. A brief exploration of these issues may assist the physician in understanding what will be required for their patients at the end of life. A greater understanding of culture and spirituality in this most spiritual of times (at least for many people), will enable the physician to better aid the survivors of the patient at a time when they most need aid.