Death and dying

American Journal of Pharmaceutical Education, Summer 1998 by Baron, Melvin F

Melvin F. Baron1

PROLOGUE

Caring for the terminally ill patient is a necessity and a challenge for any pharmacist but can be exceptionally intimidating to the pharmacy student. Exposure to topics such as "Death and Dying" helps prepare the student to provide not only clinical expertise but also emotional support to these patients and their families. The following article covers points I stress to the student, including pain management, stages in death and dying, the pharmacist's role in hospice care, the place of spirituality in healthcare, and the pharmacist's role in counseling terminally ill patients. By introducing these topics in the classroom and at the externship sites, the student will be better prepared to comfortably help the dying patient and their families deal with death.

RATIONALE

Pharmacy students are generally able clinicians but often lack the expertise needed to effectively counsel the terminally ill patient. This is a necessary learning experience lacking in many curricula.

Several years ago, during a hospital externship weekly class meeting, my students shared experiences gleaned from making rounds and visiting patients in their hospital rooms. A few students reported that they "freaked out" when they saw patients with tubes sticking out of them, comatose and semiconscious. These comments again reminded me that our students and many of us in hospital pharmacy practice relate simply to chart orders or prescriptions from our computers. The patient is merely a name and a bed number.

At that time, I began to explore the possibility of introducing to my students the concept that our patients are real. I dedicate one session during the four weekly externship sessions to the concepts of death and dying. This session is divided into the following components: pain management and comfort measures, stages in death and dying, the pharmacist's role in hospice care, the place of spirituality in healthcare, and the pharmacist's role in counseling terminally ill patients and their families.

PAIN MANAGEMENT

Managing pain and providing comfort are two important aspects in caring for the terminally ill patient. Often the clinician must go beyond conventional protocols to accomplish this goal. The clinician must keep in mind that pain control is the ultimate goal. They must be ready to address concerns over dosage ranges, addiction potential and side effects.

The student is introduced to the overall concept of pain management. Discussions relating to the impact of pain on patients and their families are incorporated into our interactive death and dying project. Students are made aware of the impact of pain on quality of life issues relating to the patient's physical. social, spiritual and psychological wellbeing. Good pain control can contribute immensely to the achievement of all the above.

As an example, to familiarize the class with pain management, each student is presented with a prescription order for a terminally ill patient. The prescription is for morphine sulfate, 15mg/cc, SIG: lcc IM q4h prn pain. The patient is in severe pain, agitated and screaming for her injection of morphine. The patient's last dose was two hours ago. The questions to the student are: what do you do with this order? Do you want to fill the order? What alternatives can you recommend to the ordering physician?

Options that are presented by the students are discussed among the class. The students are instructed on techniques such as changing the frequency, enlarging the dose, adding a medication to act as a potentiating agent, and the option of a morphine drip or a PCA pump (the uses and programming of a PCA pump are introduced).

DEATH AND DYING

The extern must realize that death is not a static process. Elisabeth Kibler-Ross, a pioneer in caring for dying patients, identified five stages that the terminally ill patient goes through: denial, anger, bargaining, depression, and acceptance(1). Recognizing and understanding these five stages can help pharmacists and caregivers relate to their patients. Students must also realize that some patients do not go through the stages in sequential order. To expose the students to the stages of death and dying, they are given several case studies from dying patients and asked to identify what they feel the patients are experiencing.

An unexpected observation during my own pharmacy practice was that patients who had a colostomy, ileostomy, or mastectomy appear to go through these same five stages. They were mourning the "death of a body part." This was born out in my own personal experience. When I had chest pains and was diagnosed with a blocked coronary artery, I was faced with two options: open heart surgery or angioplasty. Luckily, I was able to have the angioplasty, but during the time of diagnosis and months after the angioplasty, I exhibited all the stages described by Kubler-Ross and remember having to work through each stage separately.

It is extremely important that new pharmacists be able to communicate with terminally ill patients and those who have lost body parts or who have changed their body image. We must listen to and acknowledge the patient's fears and concerns, while showing that we care and are concerned with their well being.