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Breaking the Ice

Dr. Christina Puchalski is on a mission. The third-year resident at George Washington University Medical School is seeking to make future physicians comfortable with talking with patients about end-of-life issues. Dr. Puchalski teaches medical students that physicians need to start raising advance planning topics early with their patients. "I try to have those conversations long before it becomes an issue," she says.

Having those discussions early and regularly makes a difference. Dr. Puchalski recently admitted a 95-year-old patient into the emergency room at the hospital. He had multiple health problems and was in severe respiratory distress. When she called his doctor to find out whether he had a do not resuscitate (DNR) order, the doctor told her that he had never discussed it with his patient. Dr. Puchalski was left with the task of talking to a family she had never met, and had no relationship with, about whether they should or should not resuscitate.

"It is at the worst time that we have these discussions," she says. "Those things can be done so much better, and should be done, by the patient's primary physician."

A Personal Experience

Like many of her peers, Dr. Puchalski's experience has shaped the way she practices medicine. Several years ago, she watched her fiance, also a medical student, die of leukemia. Dr. Puchalski says the experience affected how she deals with her terminally ill patients. "It's very enlightening to be around people in that phase of life. They are vulnerable and frightened but they also are very wise. They see things that we haven't yet seen." Dr. Puchalski says she feels honored to share in that experience and help patients with their struggles to "help them achieve some sort of peace."

When her fiance Eric was in the hospital, Dr. Puchalski was struck how little his doctors discussed death and dying options with him. Eric was realistic about his situation. But "it wasn't until five days before he died that a doctor actually came in and talked to him about it," says Dr. Puchalski. His doctor sent an intern down to talk to Eric and get his DNR status. When Dr. Puchalski confronted Eric's physician about it, she says he admitted he had a hard time dealing with failure.

A Continuing Dialogue

That experience has carried over in the way she cares for her patients today. "I think society has a hard time dealing with death. It is something we want to put off, yet it is important to talk about these things early. After all, it is going to happen."

Dr. Puchalski regularly talks to all her patients about advance planning issues. In her view, this is something that goes on between physicians and patients during their relationship. She characterizes it as continuing dialogue with patients that changes according to the situation. She asks all of her patients questions about their spirituality and what gives them inner strength. Even healthy patients need to start talking about their values and preferences and spiritual needs when it comes to their medical care, she says.

Dr. Puchalski is working to get the medical school to incorporate these kinds of components into its four-year curriculum, so future physicians make this routine in their patient interactions.

When a patient gets a serious illness such as cancer, Dr. Puchalski brings up end-of-life issues more frequently. "It is not difficult because people who are dealing with dying and chronic illness are thinking about death a lot more than we are," she says.

Talking About Fears

She often asks terminal patients what scares them most about dying. Patients often say they are afraid of choking; Dr. Puchalski can then assure them that she will do her best to avert that from happening. Other patients admit they are afraid of becoming incontinent; being a burden on their family; or losing control of their bodily functions in front of a child.

Her message to medical students is simple: "If you give patients permission to talk about things, they will be happy to share." Part of being a doctor is being with the patient, she adds, and that means being with them when they die. "If all students can get from this course is to respect and listen to a patient's beliefs, hopes, and fears, then that is great."

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