Hospice Home Immersion Project: Advancing Medical Education

The University of New England College of Osteopathic Medicine (UNECOM) Hospice Immersion project was piloted in 2014 in southern Maine. It was designed and implemented as an experiential medical education learning model whereby medical students were “admitted” into the local Hospice Home to live there for 48 hours. Until this project, palliative and end of life care education at US Medical Schools and specifically UNECOM were accomplished through traditional medical education methods. The Hospice Immersion project utilizes qualitative ethnographic and autobiographic research designs, whereby a unique environment or “culture” (Hospice Home) is observed and life experiences of the medical student before, during, and immediately after the immersion are reported by him/her. The purpose of the Hospice Immersion project is to provide second year medical students with firsthand experiences of living in the Hospice Home for 48 hours to answer the question: “What it is like FOR ME to live in the Hospice Home?” The results focus on the students’ common themes that include 1) Unknown Territory; 2) Support; 3) Role of Staff; 4) Role of Immersion Learning in Palliative and End of Life Care; 5) Facing Death and Dying; and 6) Clinical Pearls. This project humanizes dying and death, solidified student realization that dying is a part of life and what an honor it is to be a part of the care process that alleviates pain, increases comfort, values communication, and human connections. Students report new found skills in patient care such as the 1) importance of physical touch; 2) significance of communication at the end of life for the patient, family, and staff; 3) the value of authenticity and sincerity that comes from being comfortable with oneself, which allows silence to communicate caring; 4) connection with and awareness of the person (rather than their terminal illness) and their family; and 5) the importance of speaking with patients and their families about end of life plans in advance. Although this is a time intensive experience for the faculty member and the Hospice Home staff, the depth of learning experienced by the students and opportunities to advance medical education in death and dying are well worth the efforts. Corresponding author. M. R. Gugliucci et al.


Introduction
Unlike a four hour preceptorship that offers a brief snapshot of a patient's case and physician's day, a weekend at the hospice house will allow me to more fully immerse myself in the field of palliative care and gain a stronger understanding of patients', families', and physicians' lives in this setting… (Andrea, UNECOM 2 nd yr Medical Student, 2014).
The University of New England College of Osteopathic Medicine (UNECOM) Hospice Immersion project was piloted in 2014.It is designed and implemented as an experiential medical education learning model by the Director of Geriatrics Education and Research within the Medical School's Department of Geriatric Medicine.It is fashioned after the UNECOM Learning by Living Project that "admits" medical students into nursing homes for 2 weeks to live the life of an older adult nursing home resident; complete with a diagnosis and standard procedures of care [1].For the Hospice Immersion project, medical students are "admitted" into the local Hospice Home to live there for 48 hours.Thus far, four second year medical students have piloted the project.This article presents the project design and outcomes from the first two pioneer medical students who participate in the project.

Current Status of End of Life Care in the United States
In the recently published Institute of Medicine (IOM) Report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life [2], education on end of life care has improved within the United States.One marker is that hospice and palliative care has become a recognized medical specialty and palliative care is more widely addressed within professional organizations, clinical education, and research.However, as noted in the report, deficiencies persist: "First, recent knowledge gains have not necessarily translated to improved patient care.Second, the supply of palliative care and hospice specialists is small, meaning that many patients must rely on other clinicians who provide care for individuals with serious advanced illness but who may lack training and experience necessary to meet their patients' palliative care needs."[2].With this disconnect in the field of end of life care, it is essential that training and education are provided throughout the health professions and especially for physicians who will all too often be faced with end of life care issues for their patients.
The IOM Committee on Approaching Death: Addressing Key End-of-Life Issues who conducted and wrote this report recommends that key institutions, professional societies, accrediting bodies, and health related organizations work to increase the number of palliative care specialists and advance education to increase the knowledge base on end of life care [2].This will determine our ability to address the deficiencies that we currently face on end of life care in the United States.

Medical Education in Palliative and Hospice Care
"…So we had asked the Hospice Home manager her perspective about hospice care and why she got into it.I loved her response that 'Hospice chooses you, you don't choose it'." (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
We have yet to accomplish a society that expects a "good death" or one that embraces informed and, more importantly, universal palliative and end of life care practices.The truth is, in our society, dying and death continues to be perceived as negative.As Atul Gawande's book Being Mortal (2014) took the country by storm, we may finally be paying attention to his message that those in medicine fail to realize the damage caused "when we fail to acknowledge that such power is finite and always will be" [3].He states that we have been wrong about what our job is in medicine; it is much more than to ensure health and survival.The role of the physician is to enable well-being and the patient gets to decide what that is for him/herself; what is the reason s/he wants to be alive?[3].A leading palliative care physician, Ira Byock, stands by his earlier premise from his book Dying Well (1998), that America is in a state of crisis regarding the manner in which we care for those who are dying.The general consensus is that medical care for those who are dying is poorly planned and the wishes of the dying person and their family are frequently ignored.This is where medical education in the field of palliative and end of life care can assist with shifting the prevailing paradigm.As medical educators enhance palliative and end of life knowledge, attitude, and skills within the curriculum and through experiential learning, quite possibly this will assist in turning the tide [4].
Until this project, palliative and end of life care education at the University of New England College of Osteopathic Medicine was accomplished through traditional medical education methods, such as case studies, occasional mention in lectures, and episodic encounters through volunteer preceptorship experiences, and more formerly in the geriatrics practicum.As alluded to, training in palliative and end of life care are peripheral to the medical education curriculum stifling students' ability to learn about and absorb this important aspect of patient and family care, Medical student trainings and experiences with palliative and end of life care are often viewed as inadequate in the medical field, which mirrors the views expressed by Dr. Gawande and Dr. Byock, as well as many other practitioners.Traditional medical education methods rarely include visits to hospice homes; much less provide bedside approaches to end of life care.Medical student training and experiences in hospice, palliative, and end of life care are often viewed as incomplete, time is short and experiences are superficial as each experience may last for only a few hours and occur rarely.In 2003, Sullivan et al. concluded that: "Students and residents in the United States feel unprepared to provide, and faculty and residents unprepared to teach, many key components of good care for the dying.Current educational practices and institutional culture in US medical schools do not support adequate end-of-life care and attention to both curricular and cultural change are needed to improve end-of-life care education" [5].Disturbingly, this remains true a decade later.
As stated by Dr. Byock, "Dying is more than a set of problems to be solved.The nature of dying is not medical, it is experiential.Dying is fundamentally a personal experience, not a set of medical problems to be solved."[4].This Hospice Immersion project builds on this premise; end of life care education may best be learned experientially.Ellman and Fortin's end of life care work in medical education resulted in the following perspective: "While preparation by reading, listening to a lecture, and observing a role model's demonstration are clearly useful, a student cannot move toward skills competency with these passive modes of learning alone.Students need to experience asking the questions, saying the words, responding to emotion, and experiencing their own response to the interactions" [6].Thus the Hospice Immersion project was designed and implemented with these issues in mind: to provide exposure to palliative and end of life care early in medical students' education through a multi-day experiential training with the support of skilled leaders and practitioners in the field.

Experiential Learning/Hospice Immersion
Discussing the immersion project with others, my mother reminded me to "bring my bedside manner" and my best friend expressed a lot of encouragement for participating in such a great opportunity.Several classmates seemed surprised that I would go for the whole weekend and predicted that it will be intense (Andrea, UNECOM 2 nd yr Medical Student, 2014).
For the purposes of this article, references to Experiential Learning apply to living within the Hospice Home for an extended period of time (48 hours) and the resulting journaling the students wrote to convey feelings, emotions, thoughts, observations, and experiences during the Hospice Immersion project (described in the Methodology).Experiential learning connotes gaining practical knowledge or wisdom through what one has encountered or undergone [1].Additionally, the experiential learning opportunities offered by participating in the Hospice Immersion project provided avenues for praxis, the application of theory through the integration of reflection (reflexivity) and action (practice) [7].Augmenting medical education in palliative and end of life care of adults with extended experiential learning provided by the Hospice Immersion project integrates theory with practice, broadens perspectives about death and dying, and makes "real" for students what end of life entails.
Reflection within the Hospice Immersion Project is essential; it is the important link in this experiential learning process to create change in attitudes, skills and knowledge.Reflection-in-action (Hospice Immersion fieldwork) and reflection-on-action (the experience after fieldwork) capture the learning process proposed by Schon [8].Medical students' experiences with adults may only last 48 hours but understanding the experiences and integrating the learning takes time.Hospice Immersion can be "messy" and journals capture the students' expe-riences through objective and subjective mind banter.Then add the comments of Dr. Gugliucci (described in Methodology), that necessitates further internal and external reflection by the students to process this profound and dynamic experience.Additionally, the students' conversations with staff, dying people, and their families yields new discoveries, meanings, and insights into their lives now and how they want to practice medicine in the future [1].

Hospice Immersion Project Defined
The Hospice Immersion Project utilizes qualitative ethnographic and autobiographic research designs, whereby a unique environment or "culture" (Hospice Home) is observed and life experiences of the medical student before, during, and immediately after the immersion are reported by him/her.The purpose of the Hospice Immersion project is to provide second year medical students with firsthand experiences of living in the Gosnell Memorial Hospice Home (aka: Hospice Home) for 48 hours to answer the question: "What it is like FOR ME to live in the Hospice Home?"And from this experience, be thoughtful about how the answers to this question can aid the student in becoming a better physician.
There are three stages of the Hospice Immersion ethnographic research: 1) pre-fieldwork-Getting ready for the experience; 2) fieldwork-Living in the environment building relationships with dying individuals, families and staff; and 3) post-fieldwork-Reflection on what occurred during fieldwork [1] [9] [10].

Living in the Hospice Home
The Hospice Immersion project was designed with these aforementioned views in mind and is based on three significant premises to augment medical education extended experiential learning: 1) death is a part of life and all those in the dying process deserve compassionate and effective care that includes respect and dignity as part of the care process; 2) medical students can attain advanced and varied care skills from living in the Hospice Home for an extended period of time; and 3) family members are part of the care team and as such their perceptions are relevant to the care process.The Experiential Learning Model of the Hospice Immersion project is based on progressivism [11], whereby living in a Hospice Home enables medical students to build knowledge about individuals at the end of life and the role of their families by constructively adapting to the environment and engaging in reflection on their own experiences.

Research Design
The Hospice Immersion experiential learning project applies qualitative ethnographic research methods based in phenomenology and hermeneutics [10] [12]- [15].This methodological approach is used to collect students' perspectives and experiences about life lived in a Hospice Home.Phenomenology, the study of the human phenomena of the lived experience, is the foundation for capturing the students' experiences of being immersed in a Hospice Home.Hermeneutics, the interpretation of those experiences, provides the student an approach to discover meaning and understanding from his/her experiences and observations; eventually applying these to the practice of medicine.It is important to note that each student must focus on his/her own experiences.Interpretations are always in relation to "self" rather than on the Hospice Home practices, staff, patients, or family members.To date, the Hospice Immersion research only focuses on students' outcomes; data are not formally collected from the Hospice Home staff, administrators or patients and their families.

Student Preparation and Process
The Hospice Immersion project is a volunteer experiential learning immersion research project that is available to second year medical students.The students featured in this article were chosen to pilot this experiential learning project because of their expressed desire to expand their understanding of palliative and end of life care.Selection processes may be adapted in the future but having a strong interest in palliative and end of life will be a strong pre-requisite.
Students selected to participate were asked to complete a form that included demographic data, an essay on their interest in participating as a researcher in this project, and a list of their assumptions about death, dying, and hospice care (being conscious of one's assumptions is an essential component to qualitative research).Once the admission and discharge dates are determined, the student is oriented to the project.This initial orientation includes an overview of the Hospice Immersion project, information about the research design and data collection methods, the role the student will assume, the support systems for the student, and open dialogue to address any questions.One week prior to admission the secondary orientation takes place, which includes providing the student with a preparation document-what clothes to pack, items the student may want to bring along to aid in creating a safe feeling within the environment, and information about data collection.The admission process is then discussed and plans are made for student arrival at the Hospice Home (Dr.Gugliucci drives the students to the home).Additionally at this meeting, a review of how to conduct qualitative note taking or journaling begins as the pre-fieldwork stage (mentioned above) is about to begin, usually 2 to 3 days prior to admission.Each student records reactions by friends and family members about entering a Hospice Home, also the student's thoughts and feelings about remaining in the Home for 48 hours, packing, deciding what to do with pets and/or possessions, and preconceived notions about what the experience will be like.The journal is reviewed and commented on prior to admission as this is the first chance to respond to the student's journaling technique and content prior to fieldwork.
Fieldwork begins on the day of admission.Upon arriving at the Home, the pair of students is provided with a 90 minute orientation to the Hospice Home, a badge with their name and magnetic strip to provide them access to select staff areas, and shown to the room they will share.Upon entering the Home, the students are expected to be ambassadors for the University of New England College of Osteopathic Medicine and learn as much as they possibly can in 48 hours.At the close of the orientation, the students and Dr. Gugliucci meet to discuss next steps and do a final review of any questions about the project or their role during the immersion.Then they are paired with nursing and certified nursing assistants (CNA) staff to conduct rounds in the Home.Fieldwork continues for the next 48 hours.Journals are sent each evening and reviewed each morning by Dr. Gugliucci.She maintains contact with the students during their immersion via phone, email, and texting.The fieldwork phase ends with a debriefing session by the students and Dr. Gugliucci with the Hospice Home administrator and staff on Sunday afternoon.This session is scheduled for one hour and includes information sharing about the students' experiences and their reactions to being immersed in the Home.The debriefing is monitored closely by Dr. Gugliucci.Open dialogue with the students and staff is encouraged throughout the debriefing.
Post fieldwork begins once the student is discharged from the home.The student returns to his/her home and for the next 3 days is asked to continue with journaling about leaving the Home, re-entering their usual environment again, reuniting with family/friends, and post impressions of the experience.The journal is emailed to Dr. Gugliucci for final review in which she may request additional information or further explanations on what is written in the journal.Although this officially ends the experiential learning portion of the Hospice Immersion project, students in some cases continue to write in their journals.
As this is a pilot project, the plan is to approach each student once a year, on the anniversary of their immersion to collect longitudinal data on the project.Students are also provided with opportunities to publish, conduct state and/or national presentations on their experiences as ethnographic researchers.

Data …after completing the immersion project, reflecting on my experiences, and writing about it, I can't imagine that I would have ever gained as much from this opportunity had I not written about it. By journaling, I was better able to collect and process my thoughts and identify areas of curiosity that I wish to further explore (Andrea, UNECOM 2 nd yr Medical Student, 2014).
Data for this project is collected in the form of subjective and objective journaling (field notes).Qualitative note taking involves presenting a descriptive and detailed account of the student's experiences, thoughts, and actions.Each entry requires day, date, and time accountability, as each student tends to write at varying times of the day or when presented with a significant event.Notes include subjective accounts-"my feelings" as a person immersed in a Hospice Home-and objective accounts-"my thoughts" as a medical student.While the student is immersed in the Home, his/her notes are reviewed daily and feedback is provided to ensure data collection is effective and meets qualitative research standards.This process also monitors each student's well being as s/he experiences this new culture.The journal notes taken throughout the pre-fieldwork, fieldwork, and post-fieldwork stages of the research are the key data source for Hospice Immersion project.Journals are shared as a confidential document with the Hospice Home administrator at the close of the project.

Hospice Home Participation and Staff Role
Today has undoubtedly been the best day of my semester, and I have been captivated since the moment I arrived [at the Hospice Home].The feel of the Home is incredibly warm and welcoming and maintains both impeccable cleanliness and a homey sense of coziness.Through our…conversations with staff, I was surprised to learn that the average length of stay for patients at Gosnell is 2 -5 days (Andrea, UNECOM 2 nd yr Medical Student, 2014).This article focuses on the participation of the Gosnell Memorial Hospice Home in Scarborough, Maine (aka Hospice Home).It is located 30 minutes north of the University of New England osteopathic medical school.The Hospice Home is associated with the Hospice of Southern Maine and is the only non profit Medicare certified agency with an inpatient hospice facility.The 18-bed Gosnell Memorial Hospice House was designed to meet the unique needs of patients with a life-limiting illness.It is not a hospital, nursing home or rehabilitation center; it is a comforting, homelike atmosphere where patients and family members can share time together while the patient's symptoms are being managed.
The services include professional nursing and medical care to manage pain and distressing symptoms that cannot be managed at home.If the clinical condition improves, the patient may be able to return home.Frequent and ongoing patient assessments and interventions are conducted providing the students in the immersion project the opportunity to have multiple interactions with staff, patients, and family members.Each patient has a private suite that includes a kitchenette, dining table, extra large bathroom, and a sofa bed.The Home also offers a Spa and other amenities for patients (such as wireless internet), a living room with a fireplace, a dining room for families to gather in, the Grief and Loss Library, landscaped gardens and trails, and a sanctuary and several quiet places for reflection.
The leadership at the Hospice of Southern Maine approved this pilot immersion project.The dates of the students' immersion were determined by the Hospice Home Manager and Dr. Gugliucci.The key was to ensure that each student immersed at the home had a staff member who aided in their orientation to end of life care.The Hospice Home manager communicated the overview of the project with the staff.The communication key points included discussion on the parameters and procedures regarding what it means to have two medical students living in the environment for a 48 hour time period, staff preparation and possible communication with residents and families, followed by a discussion on the staffs' availability to have the students observe and shadow the staff.There are two points stressed during this meeting: 1) the patients of the Hospice Home come first; and 2) it is respected that staff are busy and working hard-staff members are expected to tell the student when they are too busy to aid student learning.Communication between the staff, Dr. Gugliucci, and the students is imperative during the stay.
The Hospice Immersion project is based on advancing students' learning, recognizing that Hospice Home staff are contributing to the preparation of future physicians.

…as I reflected on my weekend, I was in a state of awe by how much had happened and [I was] moved by
all the people who had shared their stories with me (Andrea, UNECOM 2 nd yr Medical Student, 2014).
It is not the intent of this article to discuss the details of qualitative research analysis.Inherent in the results of qualitative research design is the identification of themes.There have been reoccurring themes for these students with tendencies toward additional themes specific to each individual journal.This article includes themes common to the two students who were immersed in the Gosnell Hospice House and some mention of the disparate themes.These disparate themes will need further review as more students engage in this immersion project.
The common themes included 1) Unknown Territory; 2) Support; 3) Role of Staff; 4) Role of Immersion Learning in Palliative and End of Life Care; 5) Facing Death and Dying; and 6) Clinical Pearls.Only a few student quotes are supplied per theme as these are representative of the both students' thoughts, feelings or expressions of being immersed at the Hospice Home.

Unknown Territory: Theme 1
For each student, the pre-field notes tend to mention a mixture of excitement and anxiety.The excitement must win out as the students show up to be immersed in the Hospice Home.It is common to read the following: It is clear that there is a desire to learn about palliative and end of life care.As both students write their prefield notes in their journals preparing for this immersion experience, they continually reframe and juxtapose their nervousness with desire.Both agree that there is little time allocated to learning about death and dying in the first two years of medical school.Andrea's following quote is representative of statements that Himanshu had included in his journal.
…in recognizing my shortcomings and fears, I am even more appreciative of this opportunity to expand my understanding, to learn about palliative care, and to share my experiences with others, especially since there is little discussion of end of life care in the medical school curriculum.In fact, it seems like there is little discussion of death and dying in general conversation, despite its inevitability for every person (Andrea, UNECOM 2 nd yr Medical Student, 2014).
It is clear from the pre-field notes in both students' journals that they are eager to learn regardless of how nervous or anxious they may feel.They exhibit thoughtfulness about entering the Hospice Home and their future careers as physicians.
Over the past couple of days the most important thing that I am reminded of is that I will be staying at a venue where there will be real patients and those who are dying.I want to pursue a field that will be focused on quality of life and I am fortunate to experience this [living in the Hospice Home… (Himanshu, UNECOM 2 nd yr Medical Student, 2014).

Support: Theme 2
The term "Support" recurred throughout both journals-it was a native concept 1 .It was noted that support occurs on a number of levels 1) between the students; 2) between and among staff members; 3) between staff, the patients and their family; 4) between the loved one and the family; and of course 5) between family members and their friends.As this was a new pilot project, the support between the students was paramount.Himanshu summed it up for both students by writing: We had talked about us being there for each other.Throughout our time here Andrea inquired about how I was doing and vice versa.We bounce off our thoughts about meeting different patients and their families so we could process our feelings about everything (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
Andrea's journal expressed her appreciation of having the support of Himanshu and took this one step further to speculate that peer support in her medical career would be important.

I was so thankful to have the support of a classmate throughout my preparation for and immersion at the
Gosnell House.Shu [Himanshu's nickname] expressed concern, curiosity, and optimism, and asked thoughtprovoking questions since the initiation of the project.Moreover, we were able to check in with one another regarding our reactions and process events and feelings as they came up.Certainly it will be important to have a trustworthy peer with whom to reflect on events, share ideas, and raise questions throughout our medical careers (Andrea, UNECOM 2 nd yr Medical Student, 2014).
It was especially poignant to read this quote about the role of Hospice Home staff in supporting the students during this immersion.…Everyone at Gosnell is incredibly hospitable, continually checking in on the well-being of me and Shu.They include us in everything, placing an emphasis on expanding our education and enhancing our experience in palliative care (Andrea, UNECOM 2 nd yr Medical Student, 2014).
Support is essential for all who are part of the Hospice environment and at first the students didn't appear to discern how that support is similar and different for each family.But this was a lesson quickly learned as they listened to stories from numerous family members and from some of the dying patients.They appreciated the distinctiveness of each story they heard, realizing that although the dying process is specific to each dying person and his/her family the need for support appears to be shared.The following quote provides an excellent summation.
As we heard more and more stories from patients and families, each story remained unique, yet the need and appreciation for support remained the same (Andrea, UNECOM 2 nd yr Medical Student, 2014).

Role of Staff: Theme 3
It was determined that in this Hospice Home it would work best to immerse two medical students at a time, as there are always two nurses on duty.As such, each student had the opportunity to partner with a nurse as she conducted her care practices.Students also teamed up with nurses when the situation warranted this approach.These one on one and paired encounters for the students with the nurses on duty during the 48 hour immersion project appeared to provide ample learning and connection.

I just love [these Hospice] nurses! These two are amazing and I think palliative and hospice medicine brings the best out of people. The care and concern they put in to their patients is phenomenal. …While discussing every patient, they ask about the family [and]… their family dynamic, anything they should be notified about. They also paint a character sketch of what the patient is like and how they interact with family. I love it! They are not just caring about the patient but the patient's family too!… I noticed that [the nurse]
uses human touch as a conduit to console others, she touches them and leans in to support them and reassure that she is there for them (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
The students teamed up to shadow the Hospice physician on his visits with patients.Observing a physician was an invaluable experience to both students as evidenced by their quotes.
Following the Hospice Physician allowed me to assess how he engages patients.I also noticed that he touches people, just like the other nurses did.He took the time to listen to the gentleman and address his concerns.He was emotionally invested in his patient and he always asked whether he was in pain (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
Andrea's observations and experiences with the Hospice Physician included notes about how he worked with family members and training skills he shared with the students.
He included family and friends in the conversation, and expressed appreciation to the nurses.He was an excellent teacher, describing breath sounds, arrhythmias, and skin changes.He described how difficult it is to predict when a patient will die, either anticipating a sooner or later death by hours to days (Andrea, UNECOM 2 nd yr Medical Student, 2014).
Both students wondered why elements of palliative care weren't incorporated into all forms of medical care; beyond hospice or end of life care.The humanism involved in palliative care practices was moving to these students, especially as they observed consistencies across 48 hours of patient care and patient/family reactions to this type of care.As they went on patient rounds with the Hospice Physician, he shared his insights about palliative care that Andrea paraphrased in her journal.
…the Hospice Physician believes that palliative care is a philosophy and that any good doctor is a pallia-tive care doctor; the field applies to all specialties in its mission to increase comfort and communication and to decrease and understand suffering (Andrea, UNECOM 2 nd yr Medical Student, 2014).
When reviewing a patient's chart with a nurse, Himanshu had the opportunity to hear the nurse share a philosophy of the Hospice Home when they spoke of a patient's chart.…She responded that this patient's chart doesn't [merely] represent the patient but [rather] it is a testament to the number of lives that have been touched by this patient (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
As the students experienced the Hospice Home staff and volunteers during the 48 hours of the immersion project, it is evident that they were touched by the health practitioners, the nurses, personal care attendants, the cook (and her sticky buns), as well as housekeeping and administration.This, in and of itself, was a unique experience for the students to encounter; as it offered a much broader scope of what is involved in palliative and end of life care.

Role of Immersion Learning in Palliative and End of Life Care: Theme 4
There was an assumption that students would learn more about palliative and end of life care by living for an extended period of time in the Hospice Home or at least feel the impact more deeply.This assumption proved to be true as evidenced by these representative quotes.
…This has been amazing…I have learned so much just by observing and interacting with the patients.We get stuck with the daily webs of life that we tend to forget the simple basic emotion of love.I am so fortunate to have experienced this through interacting with patients and their families (Himanshu, UNECOM 2 nd yr Medical Student, 2014).…undeniably, my experience at Gosnell allowed me to reach my ultimate goal of learning more about palliative care and growing more prepared to discuss death and end of life care with patients.The immersion project offered an unforgettable, firsthand experience in a hospice house, where I gained the perspective of healthcare providers, staff, patients, and families-not just their job descriptions or titles or roles, but their thoughts, feelings, experiences, hardships, and joys (Andrea, UNECOM 2 nd yr Medical Student, 2014).
Certainly this experience is a challenge.The immersion for an extended period of time has its pressures and these students experienced three deaths from the time they entered the Home on Friday to when they left on Sunday.This tension was captured by Himanshu…There was a lot going [on], learning from the patients, their stories, and their family dynamics.Spending time with the patients, whether it was looking at them [if]

Facing Death and Dying: Theme 5
As these students immersed themselves in the Hospice home, their encounters with dying and death generated increased depth to their thoughts and feelings as revealed in each of their journals.The significance of Himanshu's encounter with a dying patient was measured by the number of times he mentioned and reflected upon this encounter as his journal progressed.I met "J," an 80 year old patient suffering from bladder cancer and metastasis to the spinal cord.This was a wonderful conversation…I found it very liberating to have a conversation about dying with an actual dying person.I had asked him about his perspective about dying and whether it has changed through this process.He responded by saying that he knew everyone will die at some point but you don't actually realize everything you have until you…are dying.When asked about his experience here, he said "you know Shu, if you can take someone's pain away, I bet that means a lot" (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
Andrea's encounters at the Hospice Home led to posing some philosophical questions in her journal as she faced dying and death in this environment.
This experience raised the question, what is life really about?At death, people face this question, they face their battles, they come together with family, with friends, they mend wounds.Why wait until death?…This weekend has undoubtedly pointed out the importance of cherishing each moment.We shouldn't wait until we get diagnosed with a terminal illness to make the most of our life (Andrea, UNECOM 2 nd yr Medical Student, 2014).
Quite possibly Himanshu's short statement epitomizes the power of witnessing the dying process of the patients who were present at the Hospice Home during his stay.
Dying isn't "nothing" it really is "something" and you need to be there to experience it and feel it (Himanshu, UNECOM 2 nd yr Medical Student, 2014).

Clinical Pearls: Theme 6
Data coded by the students from their field notes and post-field notes revealed significant learning experiences, various pearls of wisdom that were meaningful to them that they either heard from others during the immersion or came up with themselves upon reflection.These clinical pearls will not be easily forgotten as they pursue their careers as physicians.This first quote from Himanshu illustrates the trajectory of where he was at the start of this project and the comfort he was able to experience while living at the Home.
I was definitely super duper nervous before going into a room with the nurse.It's because we are jumping right into a situation where someone is imminently going to die or in the active process of dying.I guess I just wasn't ready to accept that since, I had no prior background and I wasn't sure how the family was doing.However, through our conversations with staff, patients and family it definitely made me a lot more comfortable.Going from learning how to treat leukemia, in school to jumping into a facility that cares for people who will be dying is definitely a little emotional and stressful for me.But I do feel a lot more comfortable (Himanshu, UNECOM 2 nd yr Medical Student, 2014).This theme had a high number of representative quotes.Although both students agreed upon the theme "Clinical Pearls" and Andrea and Himanshu shared many of the same experiences at the Hospice home, their key learning points varied from time to time.For example, both students identified key learning points focused on the patient-physician relationship, Andrea recognizing the importance of being present and Himanshu acknowledging the value of human touch.
From these observations, I am reminded of the importance of being fully present in each encounter and sharing abundant care and compassion with every individual, regardless of whether it's the first patient of the day or the 100 th patient of the year and regardless of personal setbacks and daily distractions.(Andrea,UNECOM 2 nd yr Medical Student, 2014).Despite the debate about expressing emotions between physicians and patient's I believe that I would be emotionally invested in my patients and that would mean that I would like to implement the act of human touch wherever appropriate (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
Actually, one could argue that there are more similarities between these quotes than there are differences.The case can be made that as a physician, one needs to be present in order to foster the kind of physician-patient relationship that Himanshu mentions.
Andrea states that she wants to include embracing the here and now and foster patient quality of life; both requiring care and compassion.
I am reminded through this immersion experience and my reflective writing to appreciate each moment and embrace every encounter with care and compassion…I want to apply palliative care to all patients, and I will most certainly take that with me as I move forward in my medical career: to find out what quality of life means for each patient and find ways to provide that, to increase comfort and decrease suffering (Andrea, UNECOM 2 nd yr Medical Student, 2014).
As time since leaving the Hospice Home passes and their education at UNECOM continues, the learning from this immersion project surfaces again in Himanshu's journal as this quote was written two weeks after he left the Hospice home.
A lot of us being type A people, lose perspective and forget why we are doing medicine.School can get stressful and…personal issues can exacerbate our loss of perspective.This was one of the most powerful experiences that further drive my passion and motivation to go into Palliative and Hospice medicine.By speaking to the residents and family, it was such a good reminder of why we are doing this.Reasons include, learning about their struggles with the medical system, where things went wrong within the system, and how the healthcare staff at Gosnell are real life idols in terms of their demeanor and dedication to their patients for us to replicate…as we pursue our careers (Himanshu, UNECOM 2 nd yr Medical Student, 2014).

Discussion
Students who participate in this experience are interested in palliative and end of life care even though they may not be sure what kind of doctor they want to be.This Hospice Immersion project is extraordinarily difficult-the situation was new for everyone.Ironically the patients in the dying process and their families stepped into teaching roles whether it was consciously done or not.Additionally, by the very nature of the Hospice staff and volunteers doing their job, they too played a key role as teachers for the students.Despite the intensity of the immersion these students experienced and the challenges of dealing with dying and death while at the Home for 48 hours, there were expressions of excitement from the staff and the students.The staff were generous with sharing their world with students.It gave them a feeling of hope to have future physicians invest this much time and effort to learning about palliative and end of life care within the Hospice environment.These students were attentive to the skills, abilities, and attitude with which the staff exhibited care.The presence of these students heightened the vibrancy of the environment and validated the day to day work the staff and volunteers do.
The very nature of this project challenged the prevailing paradigm that dying and death are to be avoided in medical practice.Instead, it humanized dying and death, solidified student realization that dying is part of life and what an honor it is to be part of the care process that alleviates pain, increases comfort, and values communication and human connections.Students reported new found skills in patient care such as the 1) importance of physical touch; 2) significance of communication at the end of life for the patient, family, and staff; 3) the value of authenticity and sincerity that comes from being comfortable with oneself, which allows silence to communicate caring; 4) connection with and awareness of the person (rather than their terminal illness) and their family; and 5) the importance of speaking with patients and their families about end of life plans in advance.
Students' journals repeatedly included comments on how much of life they took for granted.How humbling it is to be with someone who is in the dying process and even more so to have conversations with a dying person and/or the family during those last days of life.Students repeatedly stated the significance of staff in assuring patients respect, dignity, and comfort.Both students have learned the importance and depth of person-centered care.This Immersion project resulted in remarkable lessons learned within a 48 hour span of time.

Conclusions
Whether it was the roller coaster of feelings, the knowledge that 30 minutes away we are in a completely different world where dying is accepted and celebrated, or my inability to know whether the resident in 101 has passed away; for these reasons I needed to find some closure, hence I read another chapter of Dying Well to end the day… (Himanshu, UNECOM 2 nd yr Medical Student, 2014).
To date, four students have completed the Hospice Immersion project and this experiential learning project provided life altering medical education in palliative and end of life care.The plan is to have the University of New England College of Osteopathic Medicine continue the Hospice Immersion project and have two second year medical students spend 48 hours at the Gosnell Home during the first semester and have a second pair of medical students admitted to the home in the spring semester.Longitudinal data will be collected each year as the students' progress through their UNECOM education and begin their professional careers.Such items as their ability to maintain patient-centered attitudes and skills such as the use of eye contact, touch, body position, and voice cadence with all patients will be collected as well as ascertain experiences of their self-assessed ability to work with patients that have a terminal diagnosis.
am a bit nervous as to what to expect.My experiences with terminally ill patients are close to none.So interacting in such a circumstance is what I am looking forward to… [I have] this sense of excitement but nervousness as well (Himanshu, UNECOM 2 nd yr Medical Student, 2014).As the start date draws closer my excitement is sustained, but I am growing increasingly nervous.I have the greatest concern regarding appropriate communication: saying the right thing and not saying the wrong thing.So, as I approach the hospice house immersion program, I wish I had…a greater understanding of the art of communication with terminally ill patients in a hospice setting (Andrea, UNECOM 2 nd yr Medical Student, 2014).
they were non-responsive or just briefly talking to them [if they] could communicate, was a lot to process.I needed to emotionally understand what was going on and I needed time to process and relax.I spent some time in the sanctuary just relaxing.Death just is… like the overnight nurse says "everyone does not have kids nor do they have significant others but they all die."Death is what binds us all… (Himanshu, UNECOM 2 nd yr Medical Student, 2014).