A ‘good death’ is an concept that underlies the practice of palliative care: that at end of life, the dying and their loved ones are cared for with dignity, trust, a sense of control, respectful communication, minimized burden, and maximized relationships. When rural Canadians are asked to describe a ‘good rural death’ there is an additional common descriptor: that the dying person is not removed from their home community.
Palliative care, a practice of compassion, can be complex and involve many layers of formal and informal care, care co-ordination and service agency access, including access to culturally appropriate rituals and practices, and a safe place to die.
Rural healthcare is generalist and practiced in low-resource environments where health human resources are few, and often stretched across a large and sometimes harsh geography. Access to specialized services often requires travel, resulting in patients and their families being separated from their home communities. Furthermore, we know that rural healthcare providers often work beyond their usual scope of practice to adapt to the needs of the communities they serve, and that, in general, rural healthcare infrastructure is more solidly based on relationships and communication as compared with the urban context.
In rural communities, the dying are cared for by family, friends, neighbors, and acquaintances who may also be formal caregivers, blurring the boundaries between professional, social and family relationships in a closely woven web of interconnectedness. How are the challenges and strengths of rural practice and context resolved to provide quality palliative care? Are Canadians living in small communities dispersed across our vast geography dying the ‘good rural death’?
As a family physician and educator, formerly urban and now rural dwelling, I am struck by the challenges faced by those providing healthcare in small communities. But, more often, I am awed and humbled by the strengths, adaptability and creativity that I see around me as communities provide care to people who are aging proportionately faster, have a higher incidence of chronic conditions, are generally poorer, geographically isolated, and face more transportation difficulties and unemployment when compared with urban Canadians. From the published literature we know that the practice of palliative care can be difficult to learn, to enact and to embody for experienced healthcare providers, novices and learners. How have healthcare providers in rural communities, who may have dual personal-professional relationships, a high burden of care and broad scopes of practice, learned to provide palliative care in their complex environment?
Learning can be thought of as a process of ‘becoming’: an entanglement between the individual and the workplace environment, each influencing the other. By considering learning in this manner that is broader than simply ‘acquiring’ knowledge, skill and attitude, what might we discover about how rural healthcare providers learn their compassionate practice of palliative care? Palliative care is a burgeoning domain of healthcare where demography dictates that Canadians will be dying at greater rates than any time in the past, and the practice of palliative care will assume a bigger place in the healthcare landscape. With the support of my AMS Phoenix fellowship, we will explore memorable learning experiences of palliative care for healthcare providers on rural Manitoulin Island, where Indigenous and non-Indigenous healthcare organizations provide care, sometimes side by side and often together, for multi-cultural communities. Through the use of qualitative methods, and with a framework of learning as a process of becoming, our goal is to deepen the understanding of palliative care learning in rural settings and to reflect on how to develop curriculum that assists future learners in their process of becoming compassionate healthcare professionals.
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