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Ken White and Tim Short column: Palliative care citizenship
Our Work Has Changed

Ken White and Tim Short column: Palliative care citizenship

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By Ken White and Tim Short

We all have two passports, Susan Sontag famously wrote: one that offers us citizenship in the kingdom of the healthy, and one that gains us entry into the land of the sick and dying. And it is a 100% certainty that, given humanity’s 100% mortality rate, we all will travel to both places at some point during our lives.

Since its eruption, COVID-19 has forced many into the realm of the ill, where we as palliative care providers stand as crossing guards, quite by choice. Roving through the hospital all day and on call each night, weekend and holiday of the year, we and our palliative care colleagues tend the stricken across the spectrum of affliction. Our passports bear the repeated stamps of those close to death’s door. It’s our job to provide comfort, to ask questions and to provide answers to patients, their loved ones and our colleagues that are straightforward, compassionate and easy-to-understand.

COVID-19 has changed our work, making it less of a specialty and more of a desperately required competency. We have seen our fellow clinicians unsteadied by the end-of-life care they feel underprepared or unprepared to give during this pandemic. But these days, we all are palliative care providers, ready or not.

Part of that is our fault. As educators of both practicing physicians and nurses as well as clinicians-to-be, how we’ve taught palliative and end-of-life care falls far, far short. In most cases, curricular requirements from our accrediting bodies require minimal, if any, exposure to these subjects, which often are relegated to electives, brief workshops, book chapters or lessons touched upon in haste. Though there are exceptions, palliative and end-of-life topics usually are taught in silos, rather than collaboratively, so that many new nurses and physicians practice their first end-of-life or palliative care encounters together in moments when death quite literally is at hand. That has to change.

If the pandemic has taught us anything, it’s that palliative care competencies are necessary for all health care providers on the front lines. Our regulatory agencies — those accrediting organizations that guide what we are required to teach, and the saturation of subjects that doctors and nurses must practice and learn to be competent — must make palliative and end-of-life care required, not ancillary learning. Though progress has been made over the past 15 years, cohesive standards of learning on these topics remains a long way off. And introducing palliative care to nursing and medical students is not enough. It must be required training, for nurses and physicians together, as continuing professional development.

There’s a more practical reason for requiring the amplifications of these lessons, too, felt in numbers. Our own team at the University of Virginia recently was decimated by two-thirds when one of our team members was exposed to a COVID-19-positive colleague. With a skeleton palliative care service, we taught palliative care and counseled colleagues from the sidelines.

Clinicians and students already are thirsty for this learning, and eager to practice and learn. But it’s important to know that they seek out this learning because they know they should and need to; not because they’re required to. COVID-19 proves that needs to change.

There’s a lot we easily can do now. Those of us in the specialty can mentor. Learners can practice with colleagues across specialties — medicine, nursing, pharmacy and social work — to mimic how scenarios actually transpire. And lessons for those on the COVID-19 front lines must be accessible, digestible and meaningful. Even brief teaching videos like ones we have developed — simulating how a dying patient looks and acts, and offering basic ways to communicate with patients and their loved ones — really work. Palliative and end-of-life lessons don’t have to be fancy; just digestible, honest and collaborative.

These kinds of lessons must become — like CPR — a required part of how we train clinicians, not just a nice add-on or an elective. Yes, nursing and medical school are crammed with topics to cover, but COVID-19 has made us painfully aware of how important palliative and end-of-life care is in moments when it’s lacking.

It also helps us be there for one another. We cannot all be everything, and there remains plenty of room for increasing numbers of palliative care specialists. But the pandemic has shown that every one of us needs to know how to help patients die just as they lived: with dignity, without suffering or pain, and in a space of understanding and grace.

Let our governing bodies and health care organizations that guide how and what practicing clinicians and students of the healing professions learn take note: COVID-19 has changed everything. Let it also change how deeply we teach, understand and practice palliative and end-of-life care.

Ken White is associate dean at the University of Virginia School of Nursing, a palliative care nurse practitioner at UVA Health and president-elect of the American Academy of Nursing. Contact him at: krw6cc@virginia.edu

Dr. Tim Short is a longtime palliative care physician at UVA Health. He recently became associate medical director of Hospice of the Piedmont. Contact him at: Tim.Short@hopva.org

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