In search of a quiet death
ANN ARBOR—Palliative medicine in Brazil still crawls. Many don’t understand its concept of providing care for patients with a life-threatening illness to give them a better quality of life. There are no abusive interventions, but an integrated and customized treatment.
“We look at the patient in a complete, global way and work with his physical, psychosocial and spiritual needs,” explains Marcos Montagnini, director of the University of Michigan Palliative Medicine Education Program.
The palliative professionals work harder for the humanization of medicine in a deeper way, where the doctor-patient relationship goes through a variety of disciplines, exercises and case studies. The services include therapeutic measures for the control of physical symptoms, psychotherapeutic interventions and spiritual support to the patient, from diagnosis to death.
The service also helps the patient’s loved ones, with actions like social and spiritual support and psychotherapeutic interventions from diagnosis to the period of mourning.
“The population is aging and the problem is that there is no room for palliative care in Brazil,” Montagnini says. “It is imperative to align the physical treatment with the emotional side of a patient. It is really an emerging field.”
Only three of the 180 medical schools in Brazil, or 1.7 percent, offer education in palliative medicine.
In order to fill this gap, the Department of Internal Medicine at the University of Sao Paulo (USP) and the UMMS Division of Geriatric Palliative Medicine launched collaborations and a new program. Since 2016, eight Brazilian residents have spent a month in Michigan to learn and experience the basics of palliative medicine.
The program includes an in-depth clinical observational experience at the Ann Arbor VA, Michigan Medicine and Arbor Hospice.
A resident in Geriatrics at USP, Murilo Dias was one of the first exchange students of the partnership between the universities. He emphasizes that there are a few Brazilian professionals with great knowledge and expertise in the field, but that most physicians are unaware of the most basic concepts.
“The structure focused on palliative care in hospitals, clinics and hospices is very incipient and the general population is still marginalized from this discussion,” he says. “The future is promising, but there is a long way to go.”
At U-M, Murilo was able to follow U-M resident physicians, to attend the integrated work of the multidisciplinary team and participate in clinical discussions with experienced teachers.
“In addition, I was able to witness patients in the most complex end-of-life situations and compare the reality here with the experience I had in Brazil,” he said.
During their time in Michigan, the visiting residents learn about end-of-life pain management, gain communication skills regarding the delicate situations faced by patients with chronic illnesses, and see how an interdisciplinary team works within a hospice, as well as learn other skills such as the importance of spending more time with patients. The experience enriches their training as doctors when they return home.
In contrast to the United States, palliative medicine training is not a requirement in Brazilian medical schools, and the related activities still need to be regularized law. Palliative medicine education at the graduate level is also insufficient, a fact that Montagnini hopes this new partnership will help change. In the U.S., this discipline has been mandatory for over a decade.
Montagnini explains that the long-term goal is to collaborate with USP in creating a development program to train its own students in palliative care, in addition to developing joint research projects and exploring medical education programs and clinical research in this area.
“We are already seeing an impact for our USP residents who are returning to Brazil and are now actively engaging with their patients and families in palliative care discussions,” Montagnini says. “Considering the effort is so new, I am very pleased with the impact the partnership is already having.”
This may be a major step towards the future of palliative care in Brazil and an important tool for combating the lack of information about the area.
Murilo, the resident in geriatrics from USP, wants much more after his time in Michigan.
“My plan is to study palliative care in depth and apply the experience I had both at U-M and at Hospital das Clínicas in my elderly patients, improving care for them and for their families,” he says.