Medical students’ knowledge and attitude toward brain death and the influence of medical education: a cross-sectional study

Abstract

Background

The medical students’ knowledge and attitude toward brain death has not been investigated in China. The aims of this study were to assess the knowledge and attitude toward brain death among medical students in China and assess the influence of medical education on the knowledge and attitude.

Methods

An online questionnaire consisting of 17 questions was developed and completed by undergraduates majoring in clinical medicine in China Medical University. The students’ demographic data, knowledge and attitude toward brain death were collected and analyzed.

Results

A total of 1075 medical students participated in the survey, and 1051 of them completed the valid questionnaire. The exploratory factor analysis grouped the 17 items into four dimensions, which explained 63.5% of the total variance. These dimensions were named as knowledge (5 items), attitude (5 items), concern (3 items) and education (4 items) respectively. The global Cronbach α of the questionnaire was 0.845 and the Cronbach α of the four dimensions ranged from 0.756 to 0.866. The mean dimension scores of knowledge, attitude, concern and education was 3.67 ± 0.89, 3.67 ± 0.87, 3.10 ± 1.03 and 4.12 ± 0.12 respectively. The clinical students had a better knowledge than the preclinical students (P < 0.001). The clinical students had a more favorable attitude in stopping the treatment for a brain-dead family member and using the organs and/or tissues of brain-dead patients for transplantation (P < 0.001). The clinical students showed more concerns than the preclinical students (P < 0.001). There was no significant difference in the education between the clinical and pre-clinical students.

Conclusions

Most medical students in China had insufficient knowledge about brain death. Although their knowledge of brain death increased with their university degree, their attitude toward organ donation after brain death did not evolve accordingly. Their concerns about brain death increased with seniority. Most students had great education need about brain death.

Background

Organ shortage is a worldwide problem, and this problem is especially serious in China [1, 2]. The ratio of patients who are awaiting organ transplants to organ donors in China is about 150:1 while the number of organ donors per million population was only 2.0, which means that many people are dying on the waiting list [3]. Brain death is recognized by the law in most countries as the death of a person. However, there is no legislation on brain death in China. In west countries, most deceased donors were brain dead donors[4]. In China, however, nearly all of the deceased donors were from donation after cardiac death. Cultural and religious traditions have been referenced to explain that Asians are less likely to approve of brain death or organ transplant from brain dead donors [4, 5]. However, the lack of knowledge about brain death and organ donation among health professionals and the public in China might be another important factor [6, 7]. As the new generation of physicians, the medical students might be responsible for making the diagnosis of brain death and identifying potential organ donors in the near future. What’s more, their knowledge and attitude might influence the public’s attitude toward brain death. Although medical students’ knowledge and attitude toward brain death have been reported in many countries [8–13], there is limited evidence about the influence of medical education on the knowledge and attitude. The aim of this study was to investigate the knowledge and attitude toward brain death among medical students and to assess the influence of medical education on the knowledge and attitude.

Methods

Results

Discussion

Medical students’ knowledge of brain death had been reported in many studies [8–13]. Since different tools were used to evaluate medical students’ knowledge, it is difficult to directly compare the knowledge among different studies. However, all of those studies had shown that there was a lack of knowledge of brain death among medical students. In a study in United States, only 33% of all medical students had an expert level of understanding brain death [8]. In a multi-center study performed on 9598 medical students in Spain, only 67% of the respondents understood the brain death concept [12]. In our study, the percentage of correct responses for each question about brain death ranged from 50.6–66.7%, which also showed medial students’ knowledge of brain death was insufficient in China. Previous studies have shown that medical students’ knowledge can evolve over their university degree [8, 9, 12]. Similarly, in this study, students in the clinical years had better knowledge than students in the pre-clinical years. In China, although there is no specific brain death course in the medical curriculum, brain death-related knowledge is scattered in several different courses. The concept of brain death is first mentioned in the course of medical ethics in the third study year. The diagnosis of brain death and organ donation is taught in the course of critical care medicine and surgery in the fourth and fifth study year. Therefore, it is reasonable that students in the clinical years had a better knowledge of brain death. However, the topics of brain death and organ donation is only briefly introduced in these courses, which means that clinical students might not have sufficient knowledge to make the diagnosis of brain death and identify potential organ donors [9].

Since the clinical students had a better knowledge, we had expected that they might also had a more favorable attitude toward brain death. However, the actual situation was not exactly the case. In this study, the clinical students were more favorable to stop the treatment for a brain-dead family member. This can be explained by that the clinical students were more likely to accept the concept of brain death, and further treatment would not bring benefits to their brain-dead family member. Although the clinical students were more in favor of using organs and/or tissues from brain-dead patients for transplantation, their attitudes toward donating or accepting organs and/or tissues after brain death were not more favorable than the pre-clinical students. This means that the attitude towards organ donation is not entirely determined by the knowledge. In this study, although most students would donate their own organs after brain death, less than half of the students would donate their family member’s organs. This means family factor might also be an important determinant. Although family overrule donation intentions is an issue in many countries [14–16], this issue is especially true in China. Without the permission of the family, it is almost impossible to donate the organs after death in China [17].

In this study, we also found that there were great concerns about brain death among medical students and the concerns increased over their university degree. Almost half of the clinical students were worried that they might be misdiagnosed as brain dead and more than half of them were worried that their treatment might be terminated prematurely if they had declared to donate organs after brain death. This reflects their mistrust of medical staff regarding brain death diagnosis, while medical education might deepen this distrust. In fact, the brain death criteria in the Chinese guideline are among the strictest in the world [18]. However, since there is no legislation on brain death, any clinically declared brain death is actually ‘illegal’. Therefore, the diagnosis of brain death is rarely implemented in China. Since clinical students are more accustomed to cardiac death, they might not have enough trust in the diagnosis of brain death.

Similar with previous studies, most medical students in China had great education needs about brain death [9, 10, 12, 19]. What's more surprising is that most medical students would like to disseminate the knowledge to their family members or friends and the public. Previous studies have showed that education can improve the attitude of medical students and physicians about brain death and organ donation [20, 21]. Therefore, it is necessary to add courses related to brain death and organ donation in medical education. However, some studies have shown that there was only mild correlation between knowledge and attitude about brain-death organ donation [8, 12], while the attitude was also influenced by cultural and family factors [4, 5, 17]. Therefore, the courses about brain death should not only focus on the knowledge of brain death. The courses should also include the knowledge of ethics and law related brain death and be adapted to the cultural background. More importantly, family discussions should be encouraged in the process of education about brain death [22, 23].

There are several limitations in this study. First, since this is an online survey, students who are interested in the topic about brain death might be more willing to participate in survey, which might lead to selection bias. Second, because this is a cross-sectional study, we can only assess the relationship between medical education and students’ knowledge and attitude toward brain death. Therefore, further prospective studies are needed to clarify the impact of education. Finally, this study was conducted at a single medical university in China, so the results from this study might not be generalized to medical students in other regions of China. Therefore, a multi-center study is needed to investigate medical students’ knowledge and attitude toward brain death in China.

Conclusions

Most medical students had insufficient knowledge about brain death. Although their knowledge of brain death increased with their university degree, their attitude toward organ donation after brain death did not evolve accordingly. Their concerns about brain death increased with seniority. Most students had great education need about brain death.

List Of Abbreviations

BD, brain death; IIC, inter-item consistency; IDV, item-discriminant validity; IDC, inter-dimension correlation.

Declarations

Ethics approval and consent to participate

This study was performed in accordance with the Declaration of Helsinki and approved by the institutional review board (IRB) of Shengjing Hospital of China Medical University(2020PS747K). Informed consent was obtained from all of the participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by the Foundation of Liaoning Province Education Administration under Grant (number QNRW2020008) and Doctoral Start-up Foundation of Liaoning Province under Grant (number 2020-BS-095).

Authors' contributions

CL and SQL conducted the literature review, development of the questionnaire, analysis of the data and writing the manuscript. CL and SQL revised the manuscript and approved it for publication. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank all the experts for the generation of the questionnaire and the coordinators for the implement of the study. The authors would like to thank all of the students for participating in the study.

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