JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 2, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0515

Comfort Measures Only and the Value of an Informal Curriculum Duc T. Do, MD

Dear Editor: Caring for dying patients in the acute inpatient setting can often be a challenging and stressful process for health care providers given the frequent unexpected, rapid clinical decline that requires timely and appropriate medications to control sudden onset of exacerbated symptoms such as dyspnea, pain, and agitation. In an attempt to better assess and address end-of-life symptom management, hospitals across the United States have implemented palliative protocols such as the comfort measures only (CMO) order set as standardized care.1 Such implementation has since positively altered some aspects of the palliative landscape, but unfortunately, recent studies continue to highlight both the need to improve education about end-of-life care and management for all health care providers and the inadequacy of palliative training for medical students.2–4 In 2009 I established an informal death debriefing curriculum for third-year medical students at the Geisel School of Medicine at Dartmouth. This required one hour session is an open forum in which students meet with me at the end of their internal medicine clerkship rotation to discuss any matters of death and dying as experienced on the wards. The topic, CMO, predominated in the sessions and hence a survey was conducted to assess their views, experiences, and knowledge. Seventy-two third-year medical students participated in this project, but only 69% (50 of 72) completed the survey. Ninety-two percent of students first learned about CMO on the wards, but only 6% had an ‘‘excellent’’ understanding and 46% felt the information they had received was insufficient. Eighty-eight percent of respondents preferred that CMO discussion be a part of core curriculum in their medical school and 80% wished that they had received information on CMO before their clinical years. Sixty-four percent of respondents did not receive an offer for death debriefing from any member on their team, and 91% cited a busy workload as an impediment to time for acknowledgement and reflection. Responses regarding the students’ own reflection on death and dying following our CMO discussion included the following: 

‘‘It allowed me to realize that CMO/end-of-life care is just as important as treatments with intents to cure.’’  ‘‘Safe place for intentional discussion.’’



‘‘Useful to have uninterrupted time that can be spent in this way (discussing death and dying).’’  ‘‘Just knowing simple steps like giving appropriate pain meds, providing chapstick, and giving families a meal tray are important. Knowing that I can actively make a patient be more comfortable makes me feel less helpless.’’  ‘‘The checklist of what CMO entails. What these mean for the patients and their loved ones.. Something as simple as turning on a fan to create a soothing breeze can go a long way.’’ This project suggests the value of an informal curriculum, for it offers a structured and safe space to help students reflect, understand, cope, and process their thirdyear experiences while instilling basic end-of-life materials and skills necessary for clinical practice. It also highlights that reflection on action through an informal curriculum fosters professional growth and identity in medicine.5 Acknowledgments

The author expresses his heartfelt gratitude to the medical students at the Geisel School of Medicine at Dartmouth for their wonderful survey responses and insightful feedback, to Dr. Edward Merrens for his encouragement, to Trevor Law for his support, and to both Holly Harrison and Lisa Gilman for their administrative assistance. This material is based on support, resources, and the use of the facility at the Dartmouth-Hitchcock Medical Center. References

1. Moneymaker K: Comfort measures only. J Palliat Med 2005;8:688. 2. Walker KA, Peltier H, Mayo RL, Kearney CD: Impact of writing ‘‘comfort measures only’’ orders in a community teaching hospital. J Palliat Med 2010;13:241–245. 3. Gibbins J, McCoubrie R, Forbes K: Why are newly qualified doctors unprepared to care for patients at the end of life? Med Educ 2011;45:389–399.

Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

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4. Morrison LJ, Thompson BM, Gill AC: A required third-year medical student palliative care curriculum impacts knowledge and attitudes. J Palliat Med 2012;15:784–789. 5. Suchman AL, Williamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS: Toward an informal curriculum that teaches professionalism. J Gen Intern Med 2004;19: 501–504.

LETTERS TO THE EDITOR

Address correspondence to: Duc T. Do, MD Dartmouth Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03756 E-mail: [email protected]

Comfort measures only and the value of an informal curriculum.

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