Changes in Medical Students’ Attitudes Towards End-of-Life Decisions Across Different Years of Medical Training

Abstract

BACKGROUND

Decisions to forgo life-sustaining medical treatments in terminally ill patients are challenging, but ones that all doctors must face. Few studies have evaluated the impact of medical training on medical students’ attitudes towards end-of-life decisions and none have compared them with an age-matched group of non-medical students.

OBJECTIVE

To assess the effect of medical education on medical students’ attitudes towards end-of-life decisions in acutely ill patients.

DESIGN

Cross-sectional study.

PARTICIPANTS

Four hundred and two students at The Chinese University of Hong Kong.

MEASUREMENTS

Completion of a questionnaire focused on end-of-life decisions.

MAIN RESULTS

The number of students who felt that cardiopulmonary resuscitation must always be provided was higher in non-medical students (76/90 (84%)) and medical students with less training (67/84 (80%) in year 1 vs. 18/67 (27%) in year 5) (p < 0.001). Discontinuing life-support therapy was more accepted among senior medical students compared to junior medical and non-medical students (27/66 (41%) in year 5 vs. 18/83 (22%) in year 1 and 20/90 (22%) in non-medical students) (p = 0.003). An unexpectedly large proportion of non-medical students (57/89 (64%)) and year 1 medical students (42/84 (50%)) found it acceptable to administer fatal doses of drugs to patients with limited prognosis. Euthanasia was less accepted with more years of training (p < 0.001). When making decisions regarding limitation of life-support therapy, students chose to involve patients (98%), doctors (92%) and families (73%) but few chose to involve nurses (38%).

CONCLUSIONS

Medical students’ attitudes towards end-of-life decisions changed during medical training and differed significantly from those of non-medical students.

Appendix

Questionnaire

Part A: Demographic features

• 1) Age:

• 2) Sex:

• 3) Religion:

• 4) Year:

• 5) Medical student ❑ Non-medical student ❑

Part B: Questionnaire

1) In your opinion do you think doctors should admit to ICU the following patients?	Yes	No
a) with no hope of survival for more than a few weeks	❑	❑
b) who may live for several years but whose quality of life is very poor according to the doctors opinion	❑	❑
c) who may live for several years but whose quality of life is very poor according to the patients opinion	❑	❑
d) with limited chances of survival	❑	❑
2) Medical information (diagnosis, treatment) given to the patient and family should: (Choose one)
a) Always include everything we know so far, without exception	❑
b) Depend on the type of disease and chance of survival	❑
c) Depend on the type of patient (e.g. personality, wishes, education level, etc.)	❑
d) Depend on both b and c	❑
3) Do you think doctors should tell the patient and family if an avoidable mistake occurs? (Choose one)
a) yes, exactly what happened, including problems that were probably due to human error	❑
b) yes, that problems occurred but limit the information given to avoid unnecessary distress and blame	❑
c) no, nothing should be mentioned	❑
4) If a sufficiently capable person refuses surgery that a doctor considers necessary and life-saving, do you think the doctor should? (Choose one)
a) try to convince the patient but if he/she still refuses, accept the patient’s decision	❑
b) treat the patient according to what the doctor thinks is right, contrary to the patient’s wish	❑
c) Inform the patient that he/she (the doctor) is no longer be able to look after them	❑
5) If a sufficiently capable person refuses surgery that a doctor considers necessary but not life-saving, do you think the doctor should? (Choose one)
a) try to convince the patient but if he/she still refuses, accept the patient’s decision	❑
b) treat the patient according to what the doctor thinks is right, contrary to the patient’s wish	❑
c) Inform the patient that he/she (the doctor) is no longer be able to look after them	❑
The last event in any terminal illness is when the heart stops beating. Cardiopulmonary resuscitation (CPR) involves pushing on the chest to compress the heart and giving electrical shocks to the heart to try and restart the heart when the heart has stopped beating. The success rate of CPR to restart the heart is low and the patient, at best, may return to the same state of illness as before the event.
	Yes	No
6) Must CPR always be provided to try and restart the heart?	❑	❑
If your answer is yes, please go to Q 10.
7) Do you think doctors should discuss with patients (if they are conscious and mentally capable) before deciding whether to withhold CPR?	❑	❑
8) Do you think doctors should discuss with families of patients before deciding whether to withhold CPR even if the patient is conscious and mentally capable?	❑	❑
9) Do you think doctors should discuss with families of patients who are unconscious or mentally incapable before deciding whether to withhold CPR?	❑	❑
10) For patients who have no real chance of recovering good quality of life, do you think it is acceptable for doctors to withhold (not increasing level of support) sophisticated life support treatments (e.g., breathing machines)?	❑	❑
11) For patients who have no real chance of recovering good quality of life, do you think it is acceptable for doctors to discontinue (reducing level of support) sophisticated life support treatments (e.g., breathing machines)?	❑	❑
If your answers to 10 and 11 are yes, please answer Q 12. Otherwise, please go to Q 13.
12) Would you feel more comfortable with 10 rather than 11?	❑	❑
13) For patients who have no real chance of recovering good quality of life, do you think it is acceptable for doctors to deliberately administer large doses of drugs (e.g., morphine) to ensure that death occurs
a) after discussing with the patient/the patient’s family and obtaining their consent?	❑	❑
b) without obtaining the consent of the patient/the patient’s family?	❑	❑
14) For patients who have no real chance of recovering good quality of life, do you think doctors should continue life support treatments regardless of the consequence?	❑	❑
15) For patients who have no real chance of recovering good quality of life, if the family insists on maximal medical treatment, do you think doctors should (Choose one):
a) continue maximal medical treatment including CPR if the heart stops	❑
b) continue maximal medical treatment excluding CPR if the heart stops	❑
c) continue present care but withhold sophisticated treatment (e.g., operations)	❑
d) continue present care but withhold additional treatment (e.g., antibiotics)	❑
e) discontinue the breathing machine to allow the patient to die	❑
f) discontinue all treatments (e.g., feeding) except the breathing machine	❑
g) continue maximal therapy pending a judge’s decision	❑
16) In a conscious and sufficiently capable person should the decision regarding limitation (withhold/withdrawal) of medical treatment involve:	Yes	No
a) the patient	❑	❑
b) the family	❑	❑
c) doctors	❑	❑
d) nurses	❑	❑
17) In an unconscious or mentally incapable person should the decision regarding limitation (withhold/withdrawal) of medical treatment involve:
a) family	❑	❑
b) doctors	❑	❑
c) nurses	❑	❑
18) If you take a group of people whose hearts have stopped where doctors have managed successfully to restart the heart. What do you think their chances of leaving hospital alive are?		%
19) What % of deaths do you think are preceded by some limitation (withhold/withdrawal) of medical treatment in ICU?		%