Psychosomatics 40:205-211, June 1999
© 1999 The Academy of Psychosomatic Medine
Changing Attitudes About End-of-Life Decision Making of Medical Students During Third-Year Clinical Clerkships
Risa P. Hayes, Ph.D.,
Alan S. Stoudemire, M.D.,
Kathy Kinlaw, M.Div.,
Mary Lynn Dell, M.D., Th.M., and
Amy Loomis, A.B.
Received July 14, 1998; revised September 18, 1998; accepted October 7, 1998. From Emory University Center for Clinical Evaluation Sciences, Atlanta, Georgia; Kerr L. White Institute for Health Services Research, Decatur, Georgia; Emory University Department of Psychiatry and Behavioral Sciences, Atlanta, Georgia; Emory University Center for Ethics in Public Policy and the Professions, Atlanta, Georgia; and Emory University, Atlanta, Georgia. Dr. Dell is currently with the University of Pennsylvania, Department of Psychiatry, Philadelphia. Address correspondence and reprint requests to Dr. Hayes, 101 W. Ponce de Leon Avenue, Suite 610, Decatur, GA 30030–2542; e-mail: rhayes{at}klwi.org Requests for reprints of the ethics course syllabus should be directed to Kathy Kinlaw, M. Div., Emory University Center for Ethics, Dental Building, 1462 Clifton Road, Suite 302, Atlanta, GA 30322.
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ABSTRACT
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To better define the learning objectives of ethics curricula and evaluate changes in medical students' attitudes about end-of-life decision making, enrolled students (N=96) of a pilot medical ethics program were surveyed at the beginning and end of their third-year clinical clerkship about their experiences and attitudes about end-of-life decision making. At the end of their clinical clerkship year, the majority of students had participated in end-of-life decisions, prioritized patient autonomy and quality-of-life issues, were concerned about legal liability, were polarized over issues such as physician-assisted suicide, and gained confidence in their ethical decision-making ability. To train future physicians such that clinical practice is consistent with ethical guidelines and legislation on end-of-life care, medical ethics curricula should focus on symptom relief, clarification of legal issues, and resolution of conflicts between personal beliefs and public opinion about such issues as physician-assisted suicide. Appropriate role-modeling and mentoring by residents and attending physicians should also be emphasized.
Key Words: Ethics Education • End-of-Life Care • Medical Students
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INTRODUCTION
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Experts agree that experientially based and developmentally appropriate ethics education is needed by medical students during their clinical training to prepare them to provide excellent end-of-life care.1–3 For most medical students, the third year is their initiation into clinical care. With this clinical initiation comes the potential for medical students to participate in end-of-life medical decision making as part of a medical team. A large number of third-year students will participate in decisions on the limits of medical intervention.2–4 Moreover, a small but meaningful proportion will encounter a patient who requests assistance in dying.2,4
As medical students become involved in end-of-life decision making, they are faced with the challenges inherent in these decisions.2 Guidelines, policy, legislation, and accepted ethical theory exist that outline a set of basic principles for the care of patients at the end of life, but the integration of these principles into clinical practice has not kept pace with the development of national recommendations.5 One reason suggested for the gap between policy and clinical practice is that personal values and/or professional attitudes act as a barrier to policy implementation.1 For example, research has shown that physicians value the concept of patient autonomy, but several factors compete with their respect for patient autonomy. These factors include physicians' views of their roles as physicians, physicians' personal moral beliefs, physicians' perceptions of the societal and legal implications of their decisions, and physicians' concerns about "killing patients" vs. "allowing them to die."2,4,6,7
To facilitate the development of an experience-based, clinically relevant ethics curriculum that focuses on end-of-life decision making for medical students, we examined changes in medical students' attitudes about end-of-life decision making during their third-year clinical clerkship. All of the students in this study participated in an ethics education program that focused on solving ethical dilemmas, especially those involving end-of-life decision making during their third year. A large majority of the students also participated, as part of a medical team, in some type of clinical experience related to end-of-life medical decision making. We first examined the attitudes about end-of-life patient care as medical students began their third-year clinical clerkships. We then compared these preclerkship attitudes with the students' attitudes after they had finished their third-year clinical clerkships.
To our knowledge, there has been little-to-no systematic, longitudinal investigation into medical students' attitudes about end-of-life care during their initial exposure to patient care. Understanding the factors that are important to third-year medical students, including their concerns related to end-of-life patient care prior to their clinical experience, as well as the changes that may occur in their attitudes as they gain clinical experience, may have important implications for the goals and learning objectives of medical education in clinical ethics.
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METHODS
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Study Participants
All third-year students at the Emory University School of Medicine are required to enroll in a medical ethics course during their clinical clerkship year of training. The overall goal of the course is to improve the knowledge base and skills of future physicians in ethical decision making, particularly end-of-life decision making. The principal text used in the course was Clinical Ethics by Jonsen, Seigler, and Winslade.8 A four-quadrant model of ethical decision making based on this text was a primary component of the teaching methodology (Figure 1). This model stressed the importance of the consideration of the relationships between medical indications, patient preferences, quality of life, and contextual features in any ethical dilemma. Other clinically oriented texts were used more selectively.9 Students attended about 40 hours of predominantly case-oriented preceptorial seminar time during their clinical clerkship year, with the time equally distributed among the five clerkship rotations (internal medicine, surgery, psychiatry, obstetric-gynecology, and pediatrics). About 50% of the dilemmas and educational content of the ethics course was devoted to end-of-life decision making, with the remainder of the content divided between various topics and ethical dilemmas in abortion, duty to warn, reproductive technologies, refusal of care, informed consent, "whistle blowing" on colleagues, confidentiality, distribution of limited medical resources, and determination of competency. A syllabus for the medical ethics class used in this study is available upon request. The participants in this study were the third-year medical students enrolled in the course during the 1995–1996 academic year.
Procedures
The directors of the medical ethics course administered a survey to medical students during the orientation period of their third year (i.e., precourse) and again at the end of the clerkship year (i.e., postcourse). The results of the survey were used to assist in the course evaluation and to further guide the learning goals and objectives of the ethics curriculum.
Instrument
The first section of the survey asked for information about student participation, as a member of a medical team, in seven clinical situations related to care of patients at the end of life. The second section of the survey presented 15 factors. Students were asked to rate the level of importance they placed on each factor when they made decisions about beginning or continuing life support using a scale ranging from "very important" (5) to "very unimportant" (1). This section of the survey was adapted with permission from a survey previously used by Caralis and Hammond2 to measure the attitudes of physicians, residents, and medical students toward euthanasia and termination of life-sustaining treatment. The third section of the survey presented nine statements about ethical medical decision making. Students were asked to indicate their level of agreement with each statement on a five-point scale ranging from "strongly agree" (5) to "strongly disagree" (1).
Analysis
Pre- and postcourse survey response distributions were tabulated. To test the hypotheses that there were no differences between students' pre- and postcourse clinical experiences and survey item-response distributions, the appropriate nonparametric tests for related samples (e.g., McNemar chi-square test or Wilcoxon matched-pairs signed-ranks) were used. An alpha level of 0.05 was used for all analyses.
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RESULTS
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Of the 104 students initially enrolled in the third-year medical class, complete pre- and postcourse survey data were obtained for 96 (92%) students. The majority of students were less than 26 years of age (96%) and male (60%), and 71% reported having had no prior formal ethics coursework (e.g., undergraduate course in medical ethics). The pre- and postcourse percentage of students who had participated in experiences related to end-of-life medical decision making as part of a medical team are presented in Table 1. At precourse, only 16% of the students reported that they had participated in at least one of the listed experiences. In contrast, at postcourse, 93% of the students reported participating in one or more of the clinical experiences. The most frequently experienced clinical situation involved questioning the benefit of further medical intervention followed by making a determination that the patient was not capable of making informed decisions (experienced by 83% and 69% of the students, respectively).
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TABLE 1. Medical student's clinical experiences related to end-of-life decision making at the beginning and end of their third-year clerkship(N=96)
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Factors Influencing Decision Making
Students were asked how much importance they placed on 15 factors when considering beginning or continuing life support (Table 2). At precourse, the majority of medical students considered 1) a patient's right to choose, 2) quality of life viewed by a patient, 3) pain and suffering, 4) a patient's decision-making capacity, 5) the likelihood of a patient's surviving hospitalization, and 6)reversibility of an acute illness as very important factors to consider in their decisions to begin or end life support. In contrast, the majority of students considered bed availability in the intensive care unit and patients' socioeconomic statuses to be very unimportant to student decision making. The amount of importance that students placed on eight of these factors significantly increased from pre- to postcourse. The factor for which the increase in importance was the greatest (40% to 66%) was "relief of symptoms."
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TABLE 2. Medical students' response distribution for 15 factors when making decisions about life support at the beginning and end of their third year (N=96)
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Attitudes About EthicalMedical Decision Making
Students were asked to indicate the extent to which they agreed with nine statements about ethical issues and their behavior related to medical decision making (Table 3). At precourse, nearly all of the medical students agreed that 1) respecting patient confidentiality is a moral obligation; 2) physicians should tell patients the truth about health findings; and 3) they would express ethical concerns about decisions regarding a patient's care. The majority of students also agreed that legal liability was an important consideration in their treatment decisions and that senior residents and attending physicians served as role models for them in the determination of how to proceed in an ethical dilemma. In contrast, fewer than half of the students agreed that 1) assisting a patient to die is morally justified; 2) their own safety and welfare should be secondary to providing patients with needed treatment; 3) some actions are right or wrong regardless of patient outcome; and 4) they had significant exposure to the field of ethical decision making.
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TABLE 3. Medical students' response distributions for attitude statements about ethical decision making at the beginning and end of their third year (N=96)
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Statistically significant differences between the students' pre- and postcourse response distributions were found for five statements. At the end of the year, a significantly greater proportion of the students agreed that 1) physicians should tell patients the truth about health findings; 2) they would express ethical concerns about decisions regarding a patient's care; 3) legal liability is an important factor to consider in their treatment decisions; and 4) they had significant exposure to the field of ethical decision making. At the end of the year, a significantly greater proportion of students disagreed that their safety and welfare must be secondary to providing patients with needed treatment.
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DISCUSSION
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Nearly all of the students in this study reported participating, as part of a medical team, in some type of clinical experience related to end-of-life care during their third-year clinical clerkship. The students' most common experiences involved questioning the benefit of further medical intervention and determining whether or not patients had decision-making capacity. Therefore, the results of this study confirm the importance of addressing end-of-life issues as a component of both preclinical and clinical medical education curriculum.
While this study was limited in its scope by the fact that the medical students participating in the study are from one institution and may not be representative in their characteristics or clinical experience to other third-year medical students nationwide, the study results provide insight into the areas related to end-of-life care that will be of most importance and concern to the majority of medical students during their introduction to clinical medicine. To ensure the relevancy of medical ethics curricula, medical educators will need to address these issues directly and effectively in their curricula.
Changes in Factors Influencing End-of-Life Decision Making
At both pre- and postcourse, the students considered factors related to patient autonomy and quality of life as the most important factors to consider when making medical decisions about life support. Patients' right to choose was ranked as the most important factor, with 93% of the students ranking this factor as very important.
The results of a 1988 survey of medical students (with at least 1 year clinical experience), residents, and faculty on the factors that influence their decisions to withhold or withdraw therapy indicated that only 69% of the respondents considered patients' right to choose as very important.2 During the about eight years between the 1988 survey and this study, there has been a significant increase in the published literature and public interest in end-of-life issues,10 particularly the role of patient autonomy; a national debate about physician-assisted suicide;11 and regulatory efforts (e.g., Patient Self-Determination Act12) that may have served to raise the consciousness of the students of this study about patient autonomy.2 Medical ethics education should provide students with structural learning experiences that reinforce this awareness and appreciation throughout the clinical training of residents and medical students. Such an approach is necessary to decrease the potential for other factors such as future physicians' views of their roles as physicians becoming a barrier to honoring patient autonomy.2,4,6,7
The most striking pre- to postcourse change in students' perceptions of the influence of factors in making decisions about life support was for the factor "relief of symptoms." Through their clinical experiences and/or ethics education, the students may have become more aware of the relationship between the relief of symptoms (e.g., pain) and patients' quality of life. Medical ethics education curricula should emphasize the importance of symptom relief, particularly pain relief, for maintaining quality of life for the terminally ill patient.
Changes in Attitudes About Ethical Medical Decision Making
At postcourse, the students were significantly more concerned about the legal liability associated with their decision making than at precourse. In another study, Fried et al.7 discovered that practicing physicians had misconceptions about the legality of actions (e.g., discontinuation of life-sustaining treatments). The authors expressed concern that physicians' insecurities about their legal liability might prevent them from honoring appropriate requests of competent patients. Medical ethics education that includes clarification of legal policy may reduce this insecurity.
Both at pre- and postcourse, the students were polarized over the issues of the moral justification of assisting a patient to die and the categorization of some actions as right or wrong, regardless of patient outcome. The medical ethics course in which the students were enrolled attempted to present students with multiple perspectives and to approach every ethical dilemma by considering the medical indications along with patient preferences; quality-of-life issues; and contextual issues, such as family wishes, financial constraints, and legal liability.8 Thus, students were discouraged from automatically defining situations as "black or white" or as simply "right or wrong." Other studies of physician attitudes have emphasized that the lack of consensus within medicine about ethical issues such as physician-assisted suicide will continue to pose a barrier to the development and implementation of policy protecting patient autonomy4,7 To move closer to consensus may require medical ethics education to provide medical students with experiences that assist them in resolving conflicts between their personal beliefs and patient preferences. This type of experience could be particularly valuable to future physicians who wrestle with the perception that certain actions constitute killing a patient as opposed to allowing a patient to die.
Surprisingly, no change occurred in students' attitudes on the role modeling of senior residents and attending physicians' proceedings with ethical dilemmas. At postcourse, about one-third of the students did not know or disagreed that their potential mentors were influential. Other studies provide insight into students' lack of confidence in their mentors. White et al.13 found that pediatric residents perceived attending physicians to be more distant from the patients and, therefore, less knowledgeable about patient preferences. Two other studies found that while some individual attending physicans and residents can substantially facilitate the ethical development of medical students, other attending physicians and residents may hinder students' development.3,14
The medical students of this study were not queried as to why residents and attending physicians did or did not serve as role models for them. It may be that some of these students had reasons to believe that their knowledge of the patient better positioned them to make decisions than their attending physicians or residents and/or that the students otherwise questioned the ethics of some of the medical decision making they observed. Even without knowledge of specific reasons, it is evident that residents and attending physicians may be less than ideal role models for learning about ethical issues and end-of-life care. The implication for medical educators is that an effective medical ethics program will depend not only on offering a relevant curriculum but also on providing appropriate role modeling and mentoring and continuing education in ethical decision making for resident teachers and attending physicians.
The dramatic increase at the end of the year in the proportion of students who agreed with the statement about having significant exposure to the field of ethical decision making and understanding their moral reasoning suggested that students' confidence in facing ethical dilemmas increased over their third year. This increase in confidence may have been the result of the opportunity to gain experience as part of a medical team dealing with ethical dilemmas. Sulmasy et al.15 found a positive association between residents' reported quality of previous ethics training in medical school and their confidence in dealing with ethical dilemmas. Therefore, the third-year medical ethics course may have also contributed to students' confidence.
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CONCLUSIONS
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The results of this study indicate that despite the fact that third-year medical students receive relatively limited experience in end-of-life decision making during their introductory clinical clerkships, this exposure affects their attitudes and concerns about patient care. In particular, ethical issues and dilemmas related to patient autonomy, quality of life, and legal liability are important issues for third-year medical students during this critical year of training. The polarization among students on the issue of physician-assisted suicide suggests that third-year students struggle with conflicts between personal values and patient preferences. Medical students may seek role models for assistance in ethical medical decision making but may not find adequate models in their attending physicians or residents. This fact has important implications for medical ethics education, particularly for continuing education at the postgraduate level.
While our approach emphasized the intellectual ethical issues that physicians encounter in making end-of-life decisions, we did not specifically address the critical issues of effective communication between physician, patient, and family about palliative care planning. For example, physicians might have or gain the necessary knowledge and skills in medical ethics to arrive at an appropriate decision about the patient's terminal care, but this is no guarantee that the physician's decision will be transmitted to the patient and family in a manner that is clear, effective, and compassionate. For example, Phase I of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)10 identified opportunities for improvement in physicians' communication, decision making, and outcomes related to the care of patients with life-threatening illness. Despite an intense clinical intervention led by liaison nurses designed to improve communication among physicians, patients, and their families, the intervention failed to impact patient care, with patients experiencing no improvement in patient–physician communication. The SUPPORT principal investigators concluded that improvements in the experience of seriously ill and dying patients may come only with greater individual and societal commitment and more proactive and forceful attempts at change. Therefore, medical educators should strive to develop curricula that will provide a foundation for the individual commitment that is vital to effective and timely patient–physician communication.
The results of this study suggest that the ethics course curricula for third-year students could be enhanced by including opportunities for students to 1) reinforce their belief in the prioritization of patient autonomy in their decision making, 2) gain knowledge and understanding of the implications of legal policy for their practice, and 3) develop strategies to resolve conflicts between their personal beliefs and their patients' preferences about end-of-life care. In addition, the results suggest more training in clinical ethics for residents and attending physicians is needed to provide better teachers and role models in this area of education. The results of our survey will hopefully assist medical student educators to better focus their ethics curricula on the pragmatic issues that concern students as they begin practicing medicine and formulating the ethical component of their identities as physicians.
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ACKNOWLEDGMENTS
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The authors thank Erica Brody, Lynda Matthews, Lesley Wood, M.A., and Carissa A. Craig for their assistance in the preparation of this manuscript. The authors also thank an anonymous referee for valuable comments and suggestions.
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REFERENCES
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ABSTRACT
INTRODUCTION
