Why medical students need to talk about dying

When first-year medical student Ramisha Arora (18) saw “death cafe” on her class schedule, she thought it was a metaphor for something else. But, she says, it turned out to be “exactly what it sounded like”.

Yes, she and two dozen other fellow first-year students at the Royal College of Surgeons Ireland (RCSI) spent a morning discussing death over coffee, tea and baked goods. They reflected on how they would like to die and be commemorated. In what is believed to be the first time a death cafe has come to a medical school, it proved to be a highlight of a new, week-long course on death, dying and bereavement. This is an optional module which the college on St Stephen’s Green in Dublin has introduced in the redevelopment of its medical curriculum to focus on case-based learning.

The death cafe movement was founded in the UK in 2011 by Jon Underwood and his mother Sue Barsky Reid, a psychotherapist. Inspired by Swiss sociologist Bernard Crettaz, who organised the Café Mortel to host public discussions about death after his wife died in 1999, they wanted to increase awareness of dying to help people make the most of their lives. Underwood then died suddenly in 2017 at the age of 44, with death cafes now his legacy.

Death is inevitable but few people want to talk about it. And if they do, many like to reach for euphemisms, such as “passed away”, “kicked the bucket” and “sorry for your troubles”.

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Young adults who go into medicine with ideals of fixing, curing and caring, are unlikely to be any more comfortable talking about death than the rest of society. But their choice of career will mean being confronted with death and bereavement more often than most, so the sooner they start speaking about it the better — for their own sakes as well as the patients and families they will be working with. While only a small percentage of students may go on to specialise in palliative care, they will all meet people who are dying and who are bereaved.

RCSI lecturer Eric Clarke who developed the death, dying and bereavement module, with the assistance of a fourth-year student, sees it as a “gentle introduction” to a topic that will be revisited as these students progress through their medical education. He is keen that they will be better prepared to encounter death and bereaved families while on clinical training placements.

Students are well versed on what they can and cannot do on placements but they will be talking to patients and families “providing a level of care and comfort”, he says. “We recognise these conversations are difficult for everybody but we think the week gives a safe and positive environment for students. We are preparing them for something they will inevitably do.” The trainee doctors may find themselves, for a short period of time, being a key person for a dying patient and their family, he points out. In these circumstances, being able to speak with clarity and confidence is vital. The death cafe encouraged the students to start the conversation for themselves by answering the basic question: ‘what do you want to happen when you die?’”

Another part of the module was visiting the morgue at Beaumont Hospital in Dublin and meeting the end-of-life co-ordinator there, Gillian Rufli. She explained how more than 40 per cent of all deaths in Ireland occur in hospitals, and all deceased patients are brought to the mortuary before leaving the hospital.

“The students walked in the front door of the mortuary as a bereaved member of a family might, so it is that experience of putting yourself in somebody else’s shoes,” says Clarke, who lectures in health informatics but has also completed a masters in loss and bereavement, a programme which the RCSI runs in conjunction with the Irish Hospice Foundation (IHF).

The first-year medical students also met undertaker Gus Nicholls, another professional who becomes so important for a few days in the life of a bereaved family. He, says Clarke, told the students that the service provided by an undertaker must be right and it takes hard work to ensure it is. If it is not right, that is what people will remember.

RSCI lecturer Dr Lisa Mellon, a health psychologist, addressed the subject of prolonged or complicated grief and how it might be avoided. It affects about 8 or 9 per cent of the population after a bereavement and they are the ones who may require professional help, says Clarke. “Most of us get there with family, friends, or community groups; we would not necessarily need that level of support.”

While there tends to be a focus on a doctor’s role in “breaking bad news”, he says, their work with the dying and the bereaved is much wider than that. “Sitting with or talking to somebody about their wishes is not breaking bad news. Or indeed sitting chatting in a GP surgery with somebody whose husband died six weeks ago is not breaking bad news.”

Valerie Smith of the IHF went into the RCSI to help guide the death cafe. Participants were provided with a bit more structure than usual due to the young age profile, she explains, in case they got stuck in talking about experiences of bereavement and their own death preferences.

“But their conversations were fascinating and they went in all sorts of directions. Some were very light and funny, others engaged in the cultural differences.” For some students it would be the first time they had really thought deeply about their own mortality, she suggests. “It can be a powerful spark.”

Smith admits she was a bit cautious about how to approach the event with this age profile but “they were really brave and really open to having these conversations”. Next time, she will have more faith in their abilities to take on this topic themselves.

“One of the things that really stood out for me was conversations around culture,” she says. The diversity of students who attend RCSI enabled comparisons about how death is handled in different cultures. This was another valuable aspect for students who could end up working anywhere in the world and with patients of different cultural backgrounds to their own. Smith says it was eye-opening for her, for instance, to hear about the variations in rituals and attitudes within different countries where Islam is the main religion.

She welcomes the fact that the students are being given this opportunity in their first year. “We are all confronted with death in our lives — much younger than 18 and 19 even — so to have these conversations fostered as early as possible helps to reduce that stress, fear and anxiety around all of this.”

Medical student Meghan Gipson (22) from Canada, who has one more year to go in her training at RCSI, helped Clarke devise this new module. “Going into healthcare you think a lot more about how I am going to treat people, how I am going to improve their lives and help them live longer. You don’t think so much necessarily about the death, loss and grief that comes with a job like that.”

Research shows that junior doctors say they are not prepared for their first losses and for when they must break bad news. “I think this [module] is really going to start the conversation on how this is part of the job and comes with the territory.”

Gipson wishes she had more exposure to this topic earlier on in her studies. Currently, the level of preparedness among medical students for death and bereavement depends more on personal exposure, she believes, than what is covered in their training. Her grandfather died in the past year and through that process, she talked with her grandmother about palliative care, a specialisation she has had a strong interest in ever since high school in Toronto. It was then she got the opportunity to shadow Dr Helen Senderovich in Baycrest Health sciences centre, a Jewish hospital for geriatric patients.

“She was this amazing doctor; I got to follow her for the day.” Later she was invited back to attend a family meeting and the multidisciplinary nature of the work particularly appealed to her.

Attending the RCSI death cafe, Gipson was very interested to hear how the conversations differed from table to table, often depending on the cultural background of the students. For the next academic year she will be chairwoman of the RCSI’s Palliative Care Society and hopes to be involved in repeated deliveries of the new module for both first and second-year students. It is also being rolled out in RCSI Bahrain.

What the students say

Three first-year medical students at RCSI talk about participating in the new week-long module on death, dying and bereavement:

Ramisha Arora (18) from Dubai

“I want to study oncology and I know that no matter how much I deny it or how said it is, death will be part of the cancer field.” She has lost grandparents through cancer so is familiar from that perspective but “I wanted to know more about what goes through the healthcare professionals’ minds when they see death.

“What I liked about this week was that each day we were faced with something new and unexpected.” Perhaps surprisingly, the visit to the morgue at Beaumont Hospital was something of a highlight for her. “It didn’t look like what I thought and was better than I expected.”

The death cafe was another highlight. As someone who was brought up “half Hindu and half Christian living in a Muslim country”, she was interested to hear how an Irish wake is often more about celebrating a life than grieving the death. “We just grieve, we don’t really celebrate,” she says of her own cultural traditions.

For Ramisha and many of her Middle Eastern peers, hospice care is something they were not familiar with. “I think if you know death is coming then providing them with the comfort of the hospice would be so great.” A story of how one hospice facilitated a horse being brought in to visit its dying owner demonstrates how care there can be limitless, she suggests. The module has made her think much more about palliative care.

“An entire week just talking about death helped me realise how everybody has similar thoughts but no one really brings it up. It is not a topic we talk about.” Now an optional module, she thinks it should be compulsory for all her fellow students.

“It really helped us understand how we need to control our emotions, so it doesn’t cloud our work or our decision-making. But it also made us feel we can’t just be all mechanical and we need to understand what the family are going through and to be supportive.”

Nowf Alshammari (22) from Saudi Arabia

Before taking this course, “the reality of having to eventually experience death myself or through losing others, be they loved ones or future patients, really scared me”. While she went into it seeking answers, “I came out with way more than that. It was a very cathartic experience and left a lasting positive impact on my peers and myself.” For Alshammari, the death cafe was the standout part of a valuable week of learning. “We were given a safe space that allowed us to speak so freely about a universally shared but I think an under-communicated topic.

“I found myself connecting with my peers in a very different but positive way. We were allowed to be vulnerable and we were exposed to each other’s cultural perspectives of death and how funerals are held and performed around the world.” She notes with interest how here in Ireland the body is usually present, in an open or closed coffin, where the deceased’s life is being remembered and celebrated. “That’s not typical where I’m from.”

Death no longer feels as “foreign” to her as it did at the start of the course. “I can confidently say I ended that week feeling much lighter, possibly more flexible with the topic, particularly regarding my role as a future healthcare provider. My initial feelings about death have changed; it feels much more natural now and I feel I can communicate it much more easily.”

Beatrice Yeoh (20) from Malaysia

“I am quite taboo about death; I am fearful of it. In Malaysian culture, we don’t really talk about it.” Although she was allocated to the module rather than actively choosing it, “I was open to learn about it.”

She had expected the death cafe to be “a bit dull and scary”. But instead, she found it “eye-opening” in that she was not the only one struggling with uncertainty and anxiety around death.

The module also introduced many of them, she says, to the idea that patients might not actually want further surgeries or treatment when they come towards the end of their life. “They want to be in peace and that’s where palliative care steps in.”

Overall, she adds: “I don’t feel as fearful of death anymore and I am open to speak to my family about how they would like the end of their lives to be: if they would like to spend their time at home or in a hospital. It is good to know what they want.”