A patient who is a Jehovah’s Witness tells a nurse that he does not want a blood transfusion because of his religion. The husband of a patient requests that a physician assistant (PA) not speak directly to his wife about her impending death, and also asks the PA for help fulfilling traditional Sunni Muslim time-of-death customs. A terminally-ill patient asks a doctor “why is God doing this to me?”
How does a medical professional respond in these and other difficult situations, where culture and religion play a significant role?
In 2009, an interprofessional team from Yale School of Medicine (YSM) and Yale New Haven Hospital (YNHH) recognized that medical professional students were graduating unprepared to provide basic end-of-life palliative care. Additionally, the students had a weak understanding of the significant role that spiritual and cultural issues often play in this sphere. Moreover, while interdisciplinary teamwork is critical in a palliative care setting, there were few opportunities for YSM students to work in interprofessional teams at that time, and similar siloes existed at other health professional schools. This resulted in a lack of understanding of the way team members - including doctors, nurses, physician assistants, clinical social workers, and chaplains - could contribute to a patient’s care. The response of this interprofessional team was to create a course: the Interprofessional Palliative Care Module (IPCM).
The IPCM creators unanimously agreed it was critical that the module emphasize interprofessional collaboration in both its structure and content. Another key design element: prior to taking the course, the participating students must have experienced clinical exposure to patients with serious illnesses. For example, medical students now participate once they have started their clinical clerkships and have had exposure to patients with serious illness, and divinity students must have completed or currently be participating in a clinical pastoral inpatient rotation. This enables the students to share examples with the other students and have more of a framework on which to absorb the material. Additionally, although Yale medical, physician associate, and nursing students now gain interdisciplinary experience in their first year through the Interprofessional Longitudinal Clinical Experience, which became part of the curriculum in 2015, the IPCM intensifies the interdisciplinary experience, because the more experienced students have developed to be more differentiated by role and now have the opportunity to interact with clinical social work and chaplain learners too.
The original creators of the IPCM were: Susan Asher (MDiv), director, religious ministries, YNHH; Leslie Blatt (APRN), team lead advance practice nurse palliative care, YNHH; Margaret Bia (MD), professor emeritus of medicine; Matthew Ellman (MD), associate professor of medicine, director, medical student palliative and end-of-life care education; and Diane Viveiros (LCSW), clinical social worker, gynecology-oncology, YNHH.
The IPCM has expanded in size and scope since its launch. In 2009, about 150 students participated in the program, while this year about 400 students will complete the program in four separate cohorts.
The course originally was voluntary for Yale nursing and PA school students, and mainly relied on a small number of chaplain interns from YNHH and the Hospital of Saint Raphael. Over time, the creators saw the need to include other members of the health care team, including clinical social workers and more chaplains, which led to increased outreach to Yale Divinity School (YDS) students. This year, about 40 YDS students are participating. Additionally, 50 to 60 social work degree students from Southern Connecticut State University (SCSU) now also participate annually, as well as nursing students from Gateway Community College (GCC), in addition to the Yale School of Nursing APRN students.
Since its launch, the course has used a blended curriculum, with an initial online interactive component, followed by an in-person workshop. Ellman explains that the online program ensures everyone is exposed to the same background content; it also removes logistical barriers since the participants are from programs that are not co-located and have divergent schedules. The students then come together for one large workshop. The in-person workshop begins with representatives from the different professions that comprise a palliative care team explaining their roles and the value of teamwork. The larger group is then divided into small break-out groups, with a diverse representation of schools and programs in each one. These groups use a case study to discuss complex issues regarding culture, religion, and palliative care. At the end of the workshop, the larger group reconvenes to discuss the case and share general reflections.
Ellman explains that palliative care is a particularly good vehicle for this interprofessional training because the team approach is so strong in this sphere in practice. Moreover, chaplains play an especially important role in palliative care that does not exist in other areas, enabling a broader interprofessional experience. Ellman adds that “a team approach improves the quality of care, and palliative care is a model for how this is the case.” Blatt sheds light on one reason for this improved care: “Different professions learn about different aspects of a patient’s family, creating a more complete picture, which is critical to care.”
Ten years after its founding, Blatt continues to be a strong advocate for the IPCM. Because “everyone is so busy in the hospital, unless you go out of your way, you do not know what all the other disciplines have to offer.” This makes exposing individuals to the other disciplines while they are still students a valuable learning experience. Additionally, she stresses that cultural and religious issues often play a significant role in a patient’s decision in palliative care, and unless medical professional students understand this and have a sense of how to prepare, they will struggle in practice. Culture and religion may play such a big role, in part, because as a patient approaches the end of life, medical options become more limited, potentially making other factors more important.
On November 12, 2018, about 100 students from YSM, Yale’s Nursing and Divinity Schools, SCSU, and GCC gathered for two hours on the YSM campus for the in-person workshop. They were joined by faculty from most of the participating schools, as well as professionals from YNHH. The session began with the traditional panel discussion describing the roles of different members of the palliative care team, and the benefits of the team approach. Blatt shared, “I am one person on a team and rely extensively on others in areas I am not an expert.” Viveiros, another actively-involved founder, advised students about the role of clinical social workers. Afterwards, she expanded on her remarks, explaining that “clinical social workers address psychosocial and emotional issues in the healthcare setting. We facilitate communication within families, as well as between patients and medical providers. We also work together with the team to address barriers that exist that might have a negative impact on patient care. We are practical problem solvers and link people to important resources in the community that can help them successfully navigate through the challenges of illness and life.” At the workshop, Kendall Palladino, D. Min., YNHH manager of spiritual care, explained that because, according to the bio-psychosocial spiritual model, humans are integrated, with spiritual, social, and physical elements, the team helping them must be able to see all of these elements, and that is why a team is so valuable, adding “I love the team.”
Another key point the faculty introduced to the students about providing palliative care: the importance of self-care for healthcare professionals who confront human suffering on an almost daily basis.
There were few silences during a November 12 small group session. In response to the question “how do you have conversations about goals with a patient who is expected to die?” a student suggested refocusing from the unattainable goal of getting better, to more attainable goals such as surviving until a particular special event. Another offered language that others could try using in this situation: “I wish that it were possible to cure your disease, but given that it is not, what else are you hoping for?” Other advice shared between peers: to remind oneself that if a patient expresses anger, not to take it personally, because it likely reflects a range of emotions the patient is experiencing, such as fear and frustration. Similarly, the students discussed how to respond when a patient says “why is God doing this to me?” One participant pointed out that most people are not actually looking for an answer, so this question is an opportunity to open a conversation about how the patient is feeling. Another suggestion was to affirm that the person’s situation is unfair, as that may bolster the patient’s dignity.
Another major theme in the conversation: the importance of being nonjudgmental with religious and cultural issues, for example, when someone does not want a recommended treatment for a religious or cultural reason. One participant reminded her peers that body language can portray judgment, just as words can.
Several medical professional students noted that when the topic of religion is raised in a hospital, the automatic response in their experience usually has been to call in the chaplain. Second-year master of divinity student Will Dickinson responded that much of religion is really just meaning-making, so a lot of people can step in to these conversations, not just the hospital chaplain.
Dickinson, who served as a full-time chaplain to the Medical ICU and General Medicine units at the University of Virginia Medical Center in Charlottesville, Virginia this past summer through a Clinical Pastoral Internship, shared reflections on the IPCM several days after the workshop: “sometimes folks assume chaplaincy is walking into a room, saying a prayer, and leaving, or worse, trying to convert patients. This group was eager to learn about and integrate spiritual care into their work, for which I'm immensely grateful. I found myself a bit surprised to hear how seriously I was taken - I felt like I had expertise thrust upon me simply because I had a vocabulary to describe meaning-making. Religion and spirituality is by its nature metaphysical and theoretical, maybe the quintessential opposite of medicine, and yet here we were all united around the same goal: the wellness of the patient.”
Demonstrating why an interdisciplinary approach is critical in end-of-life situations, Dickinson added that he “might have been there to remind the clinical students that wellness need not always look like more time or more therapies, but instead the wellness of the patient. Have they lived well? Are they satisfied with the memories they have and will leave behind with others? Have they found joy and meaning in their life? I wonder what an interdisciplinary approach to medicine would look like if it were based on these questions. I was happy to learn we're closer to that future than I thought.”
Every participant in the IPCM brings a unique cultural and religious background to the course’s workshop, including people who do not identify with any religion. Blatt said this diversity, layered with the interprofessional diversity, enriches the workshop, expanding the number of lenses through which people view issues. One small example she noted: a nursing student in her small group on November 12 shared that she had asked a patient if it was alright to pray for them. This interested Blatt; she had never considered doing this, based on her personal level of religiosity.
The course creators seek student feedback on the IPCM after each workshop session, to ensure it continues to be effective and think about how to make it even more so. They, along with a few others, have published a scholarly analysis of the course’s impact on students. The study found that while there were some differences across disciplines, all students left the course recognizing important issues beyond their own disciplines, the roles of the other members of the team, and the value of the team approach. Ellman began the November 12 panel discussion by noting that “we don’t have enough of these opportunities” to learn collaboratively. He hopes the IPCM will spark an interest in more collaborative learning.