What Draws Clinicians to Palliative Care?

Article excerpt

At a recent dinner party, a fellow guest asked about my field of medicine. "I'm a geriatrician but I practice palliative care," I replied. An uncomfortable hush descended. Another guest asked, in (tactless) amazement, "Why would anyone choose to do that?" I've grown to expect this question-one I usually welcome as an opportunity to talk about the work I find so rewarding. It's also a question I didn't get when I practiced geriatrics.

Geriatrics and palliative care are similar but distinct. Both rely on interdisciplinary teams to provide patient care in the context of family, work and society. Both seek to minimize barriers to function and improve quality of life. Clinicians in both fields find gratification in providing specialized care to vulnerable patients, but are quick to point out that not all older people are dying, and not all dying people are older. When trainees are faced with choosing between specialties, what draws them to palliative care?

Motivation Is Personal

As associate director for the Harvard Palliative Medicine Fellowship Program, I have interviewed dozens of candidates about why they seek training in palliative care, and though specifics vary, two themes emerge.

First, candidates have often had personal experiences with the death of a loved one. Sometimes it was trying-a family member died in pain or the family was left unprepared and traumatized. Sometimes the experience was more positive, highlighting the ability of trained clinicians to improve symptom management and ease patients' and families' distress.

One candidate told me, "My family was desperate when my sister got sick. The palliative care team helped us through a terrible time. How is it possible I've had so many years of training and didn't know this field existed?" Trainees who have had intense experiences with the death of a loved one can know in an immediate, even visceral way how palliative care can alleviate acute suffering; this often resonates with their original motives for entering medicine.

Second, palliative care trainees report distress over situations encountered as medical students or residents, when suffering seemed impossible to alleviate, or when implementing aggressive treatment plans compromised quality of life and conflicted with patients' wishes. Often there is one intervention witnessed, such as chest compressions on an elderly, cachectic patient (someone with reduced strength from chronic disease) with advanced dementia, which is particularly troubling.

Candidates say, "I know there has to be a better way. I want to learn how to prevent what happened to my patient from happening to others." They want to help patients and families without realizing some of their motivation is to protect themselves from the helplessness and distress they experienced as trainees. Some who lean toward activism or advocacy may view palliative care as a way to contribute to culture change in medicine.

They find palliative care to be intense, fast-paced and gratifying. In some ways palliative care patients are the sickest of the sick: incurable, suffering, often requiring hospitalization and, sometimes, intensive care. There is a sense of urgency when patients and their families are unprepared for the approaching significant loss. …