The Problem
At my medical school, there was a strong emphasis on whole person care from the first day. With noses upturned from Krebs cycle diagrams wearing our short unstained white coats, we were pleaded to see our patients beyond their diagnoses. Before seeing our first patient, we were introduced to the bio-psycho-social-spiritual model of healthcare.¹ These ideas, however, were being fed to us at a time when it did not seem most appropriate to palate. To the preclinical student, all that matters is the next exam. A certain tunnel vision develops when trudging through textbooks, practice questions, and flashcards. It is easy to forget the heart of medicine and original passion for patients, especially when not practicing medicine and not seeing patients.

The concepts of whole person care have always been present in a good physician prior to being expressly named, it was not until the mid-to-late 2010’s that the LCME began formally recommending instruction of less tangible, socioeconomic factors of health.² This growing paradigm shift, I believe, encompasses a warranted response to the modern medical machinery and its sequelae of patient angst. Returning to the mind of the pre-clinical medical student, the poisonous friction to empathetic care spilled by American medical insurance is hard to contextualize before walking in the shoes encumbered by it. I believe this is an unrecognized difficulty in training preclinical medical students in whole person care: sympathy vs empathy.

In my last year of medical school, marginally wiser and exponentially indentured, I had experienced the near breadth of medical exposure: from communicating cancer diagnoses to delivering newborns. I had seen life birthed, and life taken, and the physician standing bedside through it all, striving to provide care. But one thing is often present: the pull of the next room, the next task, the invisible timer in the mind’s eye keeping schedule. I believe each doctor wishes they could give every patient exactly what they need, whether that be the right medication, the appropriate procedure, or time to process and grieve. The barrier to this provision, as a “provider”, is not so easily identified, and the solution even less so attempted. Insurance, the faceless dragon it is, seems easy to blame (not that I am the devil’s advocate). But if every patient were allowed to have everything they need, would there be enough people to hand it to them? Is there enough time in a day for every doctor to give their time likewise? A resulting cognitive dissonance develops, a frustration from being unable to help those frustrated, a pursuit with a perpetually distancing destination.

The Solution
Also during my last year of medical school, I elected for a palliative care rotation. To start, palliative care is not a panacea. It cannot provide incurable diagnoses with a magic pill. However, it does provide some answers to some problems confronting the pursuit of whole person care. Palliative care, as defined by a 2025 American Heart Association review, is “specialized medical care that aims to improve quality of life; to minimize physical, emotional, and spiritual suffering; to facilitate complex discussions about prognosis and goals of care; and to provide emotional and psychosocial support to patients, family members, surrogates, and caregivers throughout the illness trajectory.”³ By this definition, quality of life is paramount. These practitioners focus on the patient’s experience of their illness rather than the illness at the often expense of the patient.

This ideology is most obvious in the concept of palliative care’s attached board certification of hospice medicine: two distinct, but interrelated terms. Palliative care is the practice model of “active holistic care of individuals across all ages with serious health-related suffering.”⁴ To be referred to palliative care, patients can have cancer diagnoses, heart failure, pulmonary disease, kidney disease, neurodegenerative diseases, or even frailty. Practically, palliative care can involve complex symptom and pain management using opioids, coordinating care across multiple specialties and locations, and extended conversations on goals of care while addressing emotional, existential, and spiritual concerns. Hospice is a specific Medicare-guided program with strict requirements of an average prognosis fewer than 6 months and relinquishment of curative treatments, but not comfort measures (a nuanced definition). For example, a patient with disseminated lung cancer metastasized to bone may not undergo directed radiation therapy if its goal is to prolong life, but a patient with the same bone metastasis may potentially undergo directed radiation therapy if the goal is to relieve significant discomfort or pain. Palliative care, on the other hand, does not require such strict guidelines and can occur concurrently with extended, disease-remediating therapy.

The specific practice of both of these became a unified specialty with ACGME-approved certification beginning in 2008.⁵ The specialty was founded with many of its proposed benefits rooted in apparent common sense, yet it was not until 2010 that the landmark “Temel study” would prove palliative care’s place in medicine. The study enrolled and randomized 151 patients with newly diagnosed metastatic non-small-cell lung cancer to one of two treatment arms: standard oncologic care with integrated early palliative care versus standard oncologic care alone. Quality of life and depression scores were measured along with median survival. The results of the study showed that early palliative care resulted in better quality of life (98.0 vs 91.5, P=0.03), lower depressive symptoms (16% vs. 38%, P=0.01), and most notably, longer median survival rates (11.6 months vs. 8.9 months, P=0.02) despite the early palliative care group opting for less aggressive end-of-life care (33% vs. 54%, P=0.05).⁶ These findings corroborate the central tenet to the common sense of whole person care: happy patients live longer.

The Challenge
Despite these hopeful results, there is a hesitance to the early implementation of palliative care. The ambivalence I have seen is twofold, for patients but also providers: a lack of education. The morbid reality is that some patients and their family may see consulting palliative care as inviting a condemnation to death. They can feel that they are “giving up.”⁷ And many, if not most, do not know the difference between palliative care and hospice. Approaching this topic with patients is best approached by initially evaluating for potentially dangerous, misperceived connotations associated with these buzzwords, or associations with “what happened to grandma.” Falsely presuming a mutual understanding may inadvertently lead to a premature closed encounter and jeopardize the patient relationship.

One recommendation to better align with the patient’s best interests is the “Ask-Tell-Ask” model of communication.⁸ When opening conversations about palliative care (or any hard topic for that matter), ask first for the patient’s understanding. Next comes tell. A helpful script is available from the Palliative Care Network of Wisconsin’s Fast Facts: “[Palliative care is] a specialized, interprofessional team available to support [you] and [your] family throughout this illness… This team focuses on symptom relief and promotion of comfort and quality of life during treatment while supporting patient/family values. They will partner with your current team of specialists to provide an added layer of support and help make sure we are considering all of [you] and your family’s needs while providing individualized care that aligns with your goals.”⁹ This education is then followed by asking the patient their thoughts and questions.

Additionally, when making a recommendation for palliative care or hospice, it is best to link the patient’s goals of care with the suggested plan. This is especially effective after intentional rapport and trust building. For example, “You’ve told me you want to be as independent and comfortable as possible. Hospice care is the best way I know to help you achieve those goals.”¹⁰ Regardless of patient understanding, however, practitioner referral is a major barrier to early care as well. Even non-palliative physicians may only request a consult for little more than outsourcing the signing of a DNR. But for palliative care to work best, it must have time to grow. It must be intentional. And it must be a true partnership between the members of the medical team and the patient.

When facing such difficult situations, a truth to understand is that facing mortality affects more than just the patient. One aspect which I feel is emblematic of palliative care’s embrace of the “whole person” is that its care and consideration extend beyond the patient and to their family and friends. It considers that the factors which create our identity reach further than just our person, but to those who love us and those we love. End of life is a complex burden which attacks identity: a mother losing her daughter, a son losing his father. “How do I still be a wife without a husband?” For many patients, this challenge does not present suddenly. In patients or the families who are experiencing palliative care or hospice, the grieving process may prolong for months after… or may begin months prior. It is in this “anticipatory grief” that a palliative care physician can find the greatest impact.¹¹

The experience of medicine has multiple different faces: to be a provider, to be a patient, to be a student. As a student, how do I be the best provider I can be? How can I alleviate the most suffering in my patients? I believe that the “bio-psycho-social-spiritual” model of medicine can be an answer. It helps center my purpose on the person in front of me. And while prophylactic pre-clinical education on humanity in medicine is helpful, I believe true character development can only occur after experiencing what it means to be a human in medicine. And few fields show this more than palliative care.

References:

1. Saad M, de Medeiros R, Mosini AC. Are we ready for a true biopsychosocial-spiritual model? The many meanings of “spiritual.” Medicines (Basel). 2017;4(4):79. doi:10.3390/medicines4040079
2. Mangold KA, Bartell TR, Doobay-Persaud AA, Adler MD, Sheehan KM. Expert consensus on inclusion of the social determinants of health in undergraduate medical education curricula. Acad Med. 2019;94(9):1355-1360. doi:10.1097/ACM.0000000000002593
3. Bohula EA, Landzberg MJ, Menon V, et al; American Heart Association Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing. Palliative and end-of-life care during critical cardiovascular illness: a scientific statement from the American Heart Association. Circulation. Published online May 15, 2025. doi:10.1161/CIR.0000000000001334
4. Radbruch L, De Lima L, Knaul F, et al. Redefining palliative care—a new consensus-based definition. J Pain Symptom Manage. 2020;60(4):754-764. doi:10.1016/j.jpainsymman.2020.04.027
5. Dunn GP, Miller N. Patient-centering approaches for the surgical oncologist: palliative care, patient navigation, and distress screening. J Surg Oncol. 2014;110(5):621-628. doi:10.1002/jso.23713
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678
7. Ambuel B. Establishing end-of-life goals: the living well interview. Fast Fact #65. 4th ed. Palliative Care Network of Wisconsin; 2024. Accessed August 7, 2026. https://www.mypcnow.org/fast-fact/establishing-end-of-life-goals-the-living-well-interview/
8. American College of Surgeons Trauma Quality Improvement Program. ACS TQIP Palliative Care Best Practices Guidelines. American College of Surgeons; 2017. Accessed August 7, 2026. https://www.facs.org/media/g3rfegcn/palliative_guidelines.pdf
9. Spruit JL, Bell CJ. Describing pediatric palliative care concepts to patients and families. Fast Fact #442. Palliative Care Network of Wisconsin; 2022. Accessed August 7, 2026. https://www.mypcnow.org/fast-fact/describing-pediatric-palliative-care-concepts-to-patients-and-families/
10. von Gunten CF. Discussing hospice. Fast Fact #38. 4th ed. Palliative Care Network of Wisconsin; 2024. Accessed August 7, 2026. https://www.mypcnow.org/fast-fact/discussing-hospice/
11. Singer J, Roberts KE, McLean E, et al. An examination and proposed definitions of family members’ grief prior to the death of individuals with a life-limiting illness: a systematic review. Palliat Med. 2022;36(4):581-608. doi:10.1177/02692163221074540