The final year medical students of 2020 will be the first at Stellenbosch University's Faculty of Medicine and Health Sciences (FMHS) to qualify who have completed a short course in palliative care (PC) as part of their curriculum.
PC involves the comprehensive care of patients and their families dealing with the challenges of life-threatening illnesses. It is a pro-active, multidisciplinary science that supports patients and their families from the time of diagnosis with such an illness to death and beyond.
"A doctor's responsibility to provide care to a patient does not come to an end when the patient can no longer be cured," says Dr Henriette Burger, Specialist Clinical Oncologist and senior lecturer in the Division of Radiation Oncology at the FMHS.
"Many doctors feel that their only purpose is to cure, and they find it difficult to acknowledge the fact that they cannot save all the patients in their care. But that is not a realistic view of illness and disease."
She feels very strongly about the fact that a doctor's responsibility to a patient does not come to an end when cure cannot be achieved. "No patient should ever have to hear the words: 'Sorry, there is nothing more we can do for you.' Patients rightly feel rejected and abandoned when a doctor says this.
"Patients who are not likely to be cured have needs that are different from patients that have curable diseases," she added. "Patient care does not only involve the relief of physically distressing symptoms, but also being aware of the patient's psychosocial and spiritual needs."
The development of Palliative Medicine as an independent discipline
The World Health Assembly Resolution on PC declared in 2014 that "palliative care is an ethical responsibility of all health systems".
With its roots in the modern Hospice movement, Palliative Medicine has, over the past 40 years, developed into an independent medical discipline, with standardised educational curricula and specialist training programmes in many countries. In South Africa, PC provision has largely been the domain of non-governmental organisations and community volunteer organisations, organised under the Hospice Palliative Care Association of South Africa. More recently, as a result of the work of a few dedicated PC champions, PC is slowly being integrated into both the public and private health sectors of South Africa.
Through organisations such as PALPRAC (the Association of Palliative Care Practitioners of South Africa), remuneration models and standardised treatment guidelines have been developed. In 2020 the Cape Metro Health Directorate collaborated with PALPRAC to publish guidelines for palliative support of patients and families affected by COVID-19.
In South Africa patients still die every day from infectious and non-communicable diseases, mother and child mortality and trauma and violence. It is therefore essential that any healthcare education program in a developing country facing such a quadruple burden of disease, integrates PC into the training of all its health care professionals. Patients with palliative care needs can be found in all sub-specialities of medicine. It is therefore essential that all medical graduates have a firm grasp of basic PC. Burger mentions that students on their hospital rounds are often confronted with the realities of suffering or dying patients and grieving family members, and that it is essential for them to learn the professional skills necessary in order to cope with these challenging situations.
"It is essential that medical students, doctors and specialists learn to respond with clinical empathy, and to be more attuned to the psychological needs of dying patients. This includes them developing greater self-awareness and realising the importance of self-care."
But getting PC training incorporated into health sciences curricula has not been easy. At the FMHS the week-long module was introduced into the third-year medical curriculum in 2017. In some specialities, like oncology, the need for PC is especially pronounced. "In recognition of this, a dedicated PC module was incorporated into the national Clinical Oncology training programme and we are proud to say that we welcomed our first two Gynaecologic Oncology fellows into the program this year at SU."
In collaboration with the Division of Family Medicine and Primary Care, Dr Burger also facilitates a post-graduate online course in PC, which runs over 12 weeks and aims to equip medical practitioners for the critical role of co-ordinating the care pathway of patients diagnosed with life-threatening diseases. Dr Burger hopes that in future a position may be created in the faculty for someone to focus on the teaching and training of Palliative Medicine on a full-time basis. “The establishment of a structured PC service in Tygerberg Hospital would also assist in providing a practical platform to enhance the training of health care students."
A student's experience of this course
As mentioned, the students graduating in 2020 at the FHMS will be the first to have done this training session in their third year.
"This module provided me with the knowledge base required to develop my skills as a patient-centred practitioner," said Jameelah Edwards, a final-year medical student at the FHMS. "I learnt the importance of understanding a patient holistically in order for the doctor to be guided to (within the multidisciplinary team) provide the best possible care to patients until the very end.
"It taught me that death is the natural end to every life, and healthcare practitioners can assist in making this journey as peaceful and painless for patients and their families.
"I came across this mantra during the course: 'Cure sometimes, relieve often, comfort always'. I have carried it with me ever since and will continue to do so as a future doctor".
Caption: Dr Henriette Burger. Photo by Damien Schumann