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Learning about death from the undergraduate: Evaluation of an educational intervention

How to cite this article: Álvarez-Del Río A, Torruco-García U, Morales-Castillo JD, Varela-Ruiz M. Learning about death from the undergraduate: Evaluation of an educational intervention. Rev Med Inst Mex Seguro Soc. 2015;53(5):630-7.



Received: January 22nd 2015

Accepted: June 2nd 2015

Learning about death from the undergraduate: Evaluation of an educational intervention

Asunción Álvarez-del Río,a Uri Torruco-García,b José Daniel Morales-Castillo,b Margarita Varela-Ruizb

aDepartamento de Psiquiatría y Salud Mental

bDepartamento de Investigación en Educación Médica, Secretaría de Educación Médica

Facultad de Medicina, Universidad Nacional Autónoma de México, Distrito Federal, México

Communication with: Asunción Álvarez-del Río

Telephone: (55) 5623 2300, extensión 43133


Background: From June to November 2013 an elective subject “The doctor before death” was held in a public medical school. The aim of this report is to assess the achievement of the objectives of this course.

Methods: The main objectives of the course were to develop competences, aptitude for reflection before death and encourage changes in attitude towards it. Each session was preceded by an article on the content; during sessions the interaction with physicians and patients facing the approach of death was favored; audiovisual, computer resources were used and conducted discussions. The evaluation of the course was a retrospective questionnaire as a quantitative source, and semi structured interviews and essays as qualitative sources.

Results: The development of competences, aptitude for reflection about death and attitude changes showed an increase after the intervention (p < 0.01); competence development had the smallest increase. With qualitative information 11 categories were integrated; all showed positive changes in attitude towards death, aptitude for reflection and developed competences (although in this respect the impact was minor).

Conclusions: The educational intervention evaluated met the objectives, however, for a future intervention is necessary to reinforce competence development.

Keywords: Death, Terminal care, Medical students, Evaluation, Mexico

In the current era an attitude of denial and silence on death dominates and prevents us from preparing to confront it.1 While people may die suddenly or inadvertently, in most cases they die from a disease or condition that will have required medical attention.2 Doctors have a great responsibility because they must tell their patients and families the situation and decide with them the medical actions to follow, but they are also part of this society that denies death and they usually receive no training to prepare to navigate this.3 Many find it very difficult to provide adequate care for their terminally ill patients, and often experience death as their failure or fault.4-6 Educating future doctors to face death benefits, firstly, patients because they take into account their concerns and wishes, care for their quality of life, and aid survivors in their grief;7 secondly, it promotes the doctors’ welfare so they can handle these situations without anguish or guilt.7-8

Fortunately, in different places the importance has been recognized of doctors and medical students receiving guidance to care for patients at the end of life. Courses have been developed and protocols aimed primarily at developing skills for communicating bad news.9-12 Some students have even developed educational activities to overcome the shortcomings that they find.13 In one of the reported experiences, students interviewed the terminally ill to get to know their needs with the opportunity to discuss after the experience in small groups with an instructor.14

According to the results of a study of Mexican physicians, only a minority had received any training to address terminal patients (28%) and most were in favor of having seminars or workshops on the subject (77%). This study confirms the need to prepare our future doctors to face death in their practice.15 To help meet this need, an elective course for the Escuela de Medicina was established; the description and evaluation of this subject is the focus of this article.


Educational and intervention in the study participants

The subject "The doctor facing death" was given to students of the Bachelor of Surgical Medicine who have started their practice in hospitals (starting the third year) at the Facultad de Medicina of the UNAM, in Mexico.16 The subject was available for the first 30 students who voluntarily opted for it. It was given by one of the authors (AAR), two hours a week, in the period from June to November 2013 (18 sessions). The contents of the program are listed in Table I

Table I Course contents
Talking about death
Medical decisions about end of life
Suicide, euthanasia and physician-assisted suicide
The doctors facing their death
When the doctor cannot cure
A patient's perspective
Children and death
The old man and death
Brain death and organ transplantation

The main objective of the course was to develop the skills and ability of reflection before death and to encourage changes in attitude towards it. In terms of competency, it is meant the set of interrelated knowledge and skills that enable efficient professional performance, in accordance with the state of art.17 By attitude it is meant the evaluation of a person, event, behavior or other social object that predisposes a person to respond to them in a certain way.18 Based on the conceptual framework of psychoanalysis, reflective practice, humanism, and taking elements of transformative learning according to Mezirow, during the course instructors emphasized: 1) self-knowledge of the motivations, attitudes and behavior in situations involving death; 2) analysis of the impact on both the terminal patient and the physician, management of information and medical decisions; 3) development of personality traits that help doctors have a better relationship with their patients, and 4) critical reflection on assumptions acquired during their training (for example, "the doctor should always make every effort to extend life", "the physician must remain cool with their patients", "the physician must always give hope, even if it means hiding the truth").19-20 Each session was preceded by a reading on the topic. During the sessions multiple resources were used: videos, looking at websites, participation in blogs, collaborative work, discussion of current news, and interaction with patients facing the approach of death and with practicing physicians.

Student assessment was based on the depth of the reflection of their participation and on reports presented by them during the course.

Course Evaluation

The evaluation of the course was performed with a mixed study design of triangulation, with a survey as quantitative source, and qualitative sources as semi-structured interviews and essays.

Quantitative assessment: this was done through a retrospective survey of perception, based on the course objectives (Annex 1). The items were made by the authors to investigate the perception of skills developed (items 1, 2, 7 and 8), changes in attitude (items 3, 5 and 6) and the ability to reflect before death (item 4). The instrument was given to all students who enrolled in the course and who attended the closing day of the course. Everyone who answered the questionnaire was informed of its purpose, were given the opportunity to refuse to answer it and were guaranteed anonymity. The data were initially collected on paper, then emptied into a Microsoft Excel database and processed statistically using the Statistical Package for Social Sciences (SPSS) version 21. To compare each item before and after the course, a Wilcoxon signed rank test was applied, with p <0.05 considered significant. To calculate the reliability of the instrument Cronbach's alpha was used.

Qualitative evaluation: On the closing day of the course attendees were asked to participate in focus groups, but for lack of participation, only three people were scheduled appointments. Two people were interviewed in the same session and the other independently, the three participants agreed to having the interview recorded and used for the purpose of educational research. The interviews were conducted by one of the authors (UTG), a physician trained in qualitative research, who had no personal or professional relationship with the participants. The purpose of the questions was to assess competencies developed, changes in attitude and aptitude for reflection before death. In interviews, teaching methods, conducting of groups, evaluation and other educational aspects that were not assessed with the questionnaire and the tests were also evaluated. Both interviews were recorded, transcriptions were analyzed and categorized by authors JDMC, UTG and AAR who used grounded theory.21

The essays were done by students at the request of the author AAR, who two weeks before the end of the course asked them to write a text with a general evaluation of the course (maximum of two pages) which also included information on their perception of developed skills, changing attitudes to death and their ability to reflect before it. The essays were analyzed by the author MVR (who was not involved in the analysis and categorization of the interviews) according to the method of Rojas-Soriano that provides information on attitudes, expectations and opinions of the information collected through open questions or, as in our case, essays. The information was classified by grouping the frequency and content of greater relevance in categories established according to the objectives of the study.


The retrospective questionnaire was answered by 22 students, semi-structured interviews were conducted with 3 people and 24 essays were analyzed. Table II shows general data of each evaluation strategy.

Table II general characteristics of students
Survey Interviews Essays
Number of students 22 3 24
Percentage of women 79 100 70
Year in school (3rd / 4th) 21/1 2/1 23/1
Median age 22 22 22

The results of the survey are presented in Table III. The items of self-perception of skills developed and changes in attitude and aptitude for reflection before death, were higher then than before taking the course. Cronbach's alpha was 0.88.

Table III Retrospective questionnaire results
N Before After
Median (interquartile range) Median (interquartile range) Difference
1 Prepared to discuss terminal diagnosis with a patient 22 1(1) 3.5(1) 2.50 p< 0.001
2 Prepared to accompany a patient in their terminal diagnosis 22 1(1) 4(2) 3.00 p< 0.001
3 Aware of the importance of suspending treatment that will not help a terminal patient 22 2(1) 5(1) 3.00 p< 0.001
4 Convinced that reflecting upon my own death improves care of terminal patients 22 1(1) 5(1) 4.00 p< 0.001
5 Aware of the importance of palliative care
in end of life care
22 2(1) 5(0.25) 3.00 p< 0.001
6 Aware of the emotional needs of a terminal patient (beyond the purely physical) 22 2(1.2) 5(0) 3.00 p< 0.001
7 Prepared to discuss death with my family 22 1.5(1.2) 4.5(1) 3.00 p< 0.001
8 Was prepared to talk about death withmy friends 22 2(2) 5(1) 3.00 p< 0.001

The lowest scores at the beginning of the course were Items 1, 2 (on competencies developed) and 4 (on the aptitude to reflect). At the end of the course the aptitude to reflect reached the maximum score and items 1 and 2, although increased, remained the lowest.

The results of the qualitative evaluation are summarized in Table IV, where the categories generated from the interviews and essays are synthesized in a central column of final categories.

Table IV synthesis of qualitatively obtained categories
Interviews Final categories: Essays
Initial categories Subcategories Synthesis and definition of the categories (essays and interviews) Initial categories
Expectations Talking Expectations: Refers to what students expect from the course There was no relevant testimony
Seeing patients
Unmet educational needs
Self-perception of learning:
It refers to what the students interpreted from acquired learning
Acquired learning
Transfer of learning
Relationship with patients, recognition of affections in this relationship, communication, message of the words, bad news, building trust
Attitudes Attitudes: Refers to the predisposition to approach or reject the theme of death In peace/fear facing death
Changes in thinking, abandonment of prejudices, personal development
Skills There was no practice in the clinical field Self-perception of skills acquired:
refers to what the students interpreted of the skills acquired
There was no relevant testimony
Utility Importance:
refers to the relevance the student attributes to the subject for their training.It primarily condensed curricular aspects.
Dehumanized relationship with patients in the health care environment.
Current curriculum No reflection
Flexibility Death is a subject uncomfortable or ignored in medical education
Optional Unequal motivation Recommended course or would it take again
Mandatory for its importance Expand the course to a greater number of students

Personal development
Personal development:
Refers to the course not only to expand knowledge on the topic of study but it helps them be "better people" and therefore "better doctors"
Personal reflection, changes in thinking, abandonment of prejudices, personal development
Contents Revised topics:
refers to the opinion of the student on the contents of the course
They suggest greater depth in the course, say that the dynamic is very positive.Add topics like unexpected death and abortion,
ethical and legal questions surrounding death
Didactics Patient Educational flexibility:
refers to the use of resources and support to encourage reflection and interaction in the classroom
Didactic material that allowed reflection (videos, guest speakers, patient's experience)
Personal reflections Importance of listening to different points of view on death
Relationship between life and death
Handling of emotions
Guided discussion
Evaluation Reflection Evaluation:
Refers to the criteria and instruments used to acquire information about the learning of students
There was no relevant testimony
More general
In the center column are the definitive categories, synthesized from the results in the side columns, where the categories obtained are listed independently through interviews (left side) and essays (right side)

The table "Definitive qualitative categories and their corresponding evidence," not included in this article, is available and can be obtained from the author.

Discussion and conclusions

The purpose of this study was to describe and evaluate an educational experience about the role of the physician towards death, addressed to medical students who have started their clinical practice. To our knowledge, this is the first study in our country that assesses an undergraduate educational program on medical care at the end of life, with the additional advantage of doing it with a mixed design.

In all the areas assessed the quantitative and qualitative results were positive. The area that received the least improvement was the perception of skills developed, according to the questionnaire (questions 1, 2, 7 and 8) and testimonials (Table III); the following is one of them:

I wish I had had more practice. Perhaps giving them space, to do it and say how you felt in practice [...] AF / E2 / 281113

As for the perception of changes in attitude, quantitative assessment (questions 3, 5 and 6 of the questionnaire) was also positive and its relevance was confirmed when triangulating testimonies:

At first, well, I had the misconception that the doctor saves and the doctor doesn’t save, the doctor just changes the time when a person will die, also I had not worked much on some of the personal aspects of death, (??) how are you going to be an example and how are you going to talk about something you have not yet assimilated, that you have not worked out for yourself, feelings that you don’t know how to handle at that time. AF / E2 / 281113

The category most improved at the end of the experience was the aptitude for reflection about death, as reflected in the questionnaire (question 4) and testimonies in different categories; for instance:

I learned things I thought I knew, but I had never really taken the time to deeply reflect on. AF / E1 / 281113

As proposed by other authors, reflection of the doctor facing death is more relevant than the theoretical knowledge of the subject, which is observed in this study.23 This reflection involves looking closely at one’s own actions to go deep into it them and, therefore, modify one’s future actions. Reflective practice is therefore "... the support not only of the quality of medical care, but the continuing education of those who practice it, because identifying one’s own shortcomings generates the need to resolve them."24

Several results were obtained through qualitative evaluation that could hardly be collected by questionnaire, of which the most important are seen below. Since the students recognized that in the future they would face situations involving death, they assessed the need for training in this regard, hence some argued that the subject should be mandatory:


... I think it should be mandatory because it is understood that any medical student has mastered this, but when studying this subject, I realized that there are very few, including myself, who have knowledge about it. AF / E1 / 281113


This suggestion becomes important because students have learned about death through the hidden curriculum and from their experiences so far in their training. The dominance of the biomedical approach over the humanistic does not prepare students adequately to face death, as expressed by one of the testimonies:


The lack of humanistic part in the program and the purely biological approach, will make doctors practice from the essence of medicine. How to deal with people, with the sick, and if you do not know these issues in depth, how you intend to be a good doctor who has both the science and the humanistic parts. AF / E1 / 281113


The lack of preparation of doctors to deal situations related to death in their practice causes them, first, to be emotionally affected when the situations arise, and secondly, to confirm the prejudice that they should avoid an emotional approach with their patients and not show empathy with them. This has been reported in other studies and is an obstacle to adequately addressing the needs of patients and their families.25 The following testimony illustrates these statements:


It changed me a lot and I think I would have continued with my misconception of not getting close to the patient, because I thought that you cannot have a conversation with the patient that goes beyond, or you cannot see something more than all doctors see in a patient, but yes you can, and yes you can get closer. AF / E2 / 281113


In this sense, the course "the doctor facing death" made great approaches to transformational learning, as defined by Mezirow:


"The process by which we transform our frames of reference, taken for granted (perspectives of meaning, mental habits, mindsets), to make them more inclusive, demanding, open, emotionally capable of changing and reflective, and to generate beliefs and opinions that will prove more true or justified to guide action".26


The participation of a patient as a visiting professor in the course was rated as very positive and enriching for the students. This assessment coincides with what has been confirmed in other experiments, the terminal patient being the best teacher in education about death.27

It is worth mentioning that in both essays and testimonies, there was little mention of the teacher, a feature supported by pedagogical frameworks focusing on the student, who takes responsibility for their learning. An additional strength of the intervention is that the teacher encouraged the capacity for reflection and critical paradigms and assumptions made from the free expression of ideas and sharing experiences.28

Because the study was conducted only on those who opted for the course, one can hardly generalize the results obtained here, but they may be useful to enrich other similar experiences. Another limitation was the little quantitative information obtained due to the small number of students involved. A limitation of the qualitative evaluation was that only three students agreed to participate, which is probably explained by preference or rejection because of the subject to be evaluated; anyway, triangulation of methods allowed us to have a more objective view.

Based on the results of this study there are plans to add practical activities to the course syllabus to encourage the application of the issues addressed, especially those related to communication with the terminal patient. The use of role plays, simulations and other activities that support skill development will be considered.

Thanks to the work and reflection encouraged by the educational intervention evaluated, students changed their attitudes towards death, increased their aptitude for reflection and to a lesser degree, developed skills related to proper medical care at the end of life. This is important to help them develop skills so they feel better prepared to act according to the new responsibilities they assume. With that we conclude that we can learn about the death starting at the Escuela de Medicina.

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Annex 1 Retrospective self-perception questionnaire
Universidad Nacional Autónoma de Mexico
Facultad de Medicina
Optional course: the doctor facing death
Professor: Dr. AAR
Demographic information
Name _________________________________________________________
Age ___________________________________________________________
Sex (Male) (Female)
Year enrolled in medical school___ The following statements describes activities relating to the subject "The doctor facing death".
Please estimate what was your level of mastery of the activities of the left columnBeforeattending the course and what it isCurrently.
Mark your answer with an "X" on a scale of 1 to 5 according to the percentage mastery of the activity:

2.20-40% 3.40-60% 4.60-80% 5.80-100%
1 2 3 4 5
1 Was ready to tell a patient their terminal diagnosis Before
Am ready to tell a patient their terminal diagnosis Currently
2 Was ready toaccompanya patient in their terminal diagnosis Before
Am ready to accompany a patient in their terminal diagnosis Currently
3 Was aware of the importance ofsuspending treatmentsthat do nothelp a terminal patient Before
Am aware of the importance of suspending treatments that do not  help a terminal patient Currently
4 Was convinced thatthinking about my own deathimproves the care of terminal patients Before
Am convinced thatthinking about my own deathimproves the care thatI give terminal patients Currently
5 Was aware of theimportance of palliative carein
end of life care
Am aware of theimportance of palliative carein end of life care Currently
6 Was aware of theemotional needsof a terminal patient
(beyond the purely physical)
Am aware of theemotional needsof a terminal patient
(beyond the purely physical)
7 Was ready to speak about deathwith my family Before
Am ready to speak about deathwith my family Currently
8 Was ready to speak about deathwith my friends Before
Am ready to speak about deathwith my friends Currently

Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.

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