Essential Exposure: The Case for Mandatory Palliative Care Clinical Rotations

By Alexandre Veilleux

On a dreary day last January, I found myself in a contemplative conundrum, hunched over my laptop at McMaster University’s health sciences library. With the deadline to choose my next clerkship elective fast approaching, I felt utterly stumped.

Unsure as to which specialty I wanted to pursue in residency training, and with one elective already under my belt, I wrestled with the options before me. I reasoned that choosing an elective with a host of transferable skills would allow me to compile a compelling narrative germane to several different specialties.

With this criterion in mind, I scrolled through dozens of potential selections before one caught my eye: palliative care. Something I knew little about and might not have the chance to see again after medical school: a fitting option. I moved it to the top of my rank list, and clicked “save.”

As fate would have it, my choice could not have been better.

I was placed with the Palliative Care Outreach Team (PCOT) in Hamilton providing palliative consultations and longitudinal care in the community.

There, I learned that patients’ perception of PCOT and palliative care in general vary. Whereas some patients and families welcomed us with open arms, others looked at us apprehensively as harbingers of bad news. I came to understand the murky swirl of misconceptions that surround death and dying. Chief among them was the pervasive belief that a loved one’s pain would steadily escalate prior to their passing, eventually reaching an intolerable crescendo shortly before death. Dispelling this notion provided more than one patient and family with tremendous relief and comfort.

The compassion and communicative savvy required to gently educate patients about the expected course of their illness was truly inspiring. I was impressed with the physicians’ humanistic approach to care, their treatment paradigm devoid of the biological reductionism I had encountered in other specialties. It was a profoundly impactful experience and a genuine privilege to be welcomed into the circle of care of so many patients and their families.

My preceptors’ passion and enthusiasm for palliative care was contagious, and convinced me of its importance. Since our patients received care from myriad medical specialists, sometimes the most impactful intervention we could offer was medical systems navigation and the reassuring sense that someone was truly in their corner.

Death and dying, being inherent to life itself, must be discussed openly rather than shrouded in morbid mystique

My PCOT rotation led to a growing conviction: Death and dying, being inherent to life itself, must be discussed openly rather than shrouded in morbid mystique. This responsibility should not fall exclusively to a particular group of specialist physicians. Rather, physicians of every specialty should possess the basic competency to offer palliative care, a change that would necessitate systemic upstream interventions.

What better place to implement such innovative changes than Canada’s 17 (and counting) medical schools?

A 2020 study published in the Canadian Medical Association Journal noted that of Canada’s 17 medical schools, undergraduate palliative care rotations were mandatory at two schools, optional at 13 and not available at two others. In 2015-16, a mere 29.7 per cent of undergraduate medical students completed a clinical rotation in palliative care.

Considering that in 2017, the Canadian Society of Palliative Care Physicians anticipated that Canada would need twice as many palliative care specialists than were currently practicing, such little undergraduate exposure to palliative medicine is unacceptable. I can only guess at how many potentially stellar palliative care physicians opted for alternative specialities for no reason other than a lack of exposure.

Canada’s aging population has been dubbed the “Grey Tsunami” by alarmists who fear the economic burden posed by such a marked shift in demographics. Though recent literature has demonstrated that the volume of multimorbidity stems from adults as young as 35, somewhat disproving such ageist scaremongering, there is no denying that the proportion of Canadians above age 65 is increasing. Coupled with the increase in average life expectancy and the increased complexity of hospital inpatients, there is an impending need for palliative care specialists.

The Canadian government’s 2023 Report on the State of Palliative Care in Canada explicitly identifies that “one goal of the framework was that all health-care providers (regulated or not) would have core skills to provide a palliative approach to care, supported by specialists as needed.”

Potential economic benefit and financial feasibility are historically persuasive metrics when it comes to policy change. In Canada, greater use of inpatient palliative care has been identified as a cost-saving measure in terminal hospitalizations. Additionally, hospital-based hospice palliative care programs save the health-care system approximately $7,000-$8,000 per patient, per year.

There is no better time to enact such change; medical assistance in dying (MAID) is in its relative infancy. Policies and legislation surrounding MAID are dynamic and evolving, with a planned extension of eligibility criteria to include mental illness slated for implementation in 2027. Though palliative medicine is a comprehensive approach to care that extends well beyond MAID, palliative care physicians are uniquely well positioned to offer their insights and advocate on behalf of their patients.

Canada is also becoming increasingly diverse: 26.53 per cent of Canadians now identify as a member of a visible minority group, according to the 2021 census. As is the case with all of medicine, palliative care must strive to operate from a lens of equity, diversity and inclusion. Medical students would benefit from gaining exposure to the multitude of cultural and religious beliefs associated with death and dying. Doing so will allow them to better serve the diverse communities in which they will work, whether they choose to practice palliative medicine or not.

At present, clinical exposure to palliative care is not afforded the attention it deserves in undergraduate medical curricula, forgoing what otherwise could be an enlightening and perhaps even transformative clinical experience for medical learners. I can recall, in near perfect detail, the patients and families to whom I rendered palliative care. Nowhere else have I seen such displays of vulnerability and raw humanity. To rob medical learners of such experiences is a travesty.

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Previously Published on healthydebate.ca with Creative Commons License

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