Some Medical Students Cannot Face Death Rationally and Have a Negative Death View
Medical students will play an essential role in the professional medical care team in the future. Their cognitive attitude towards death, their knowledge reserve of death, and their mastery of end-of-life care skills are mainly related to whether patients can improve their quality of life[15]. The survey shows that most medical students have a rational cognition of death, but at the same time, some medical students have anxiety, fear, and escape reaction to the death. There is a certain degree of ambivalence. At present, China’s aging population problem has become increasingly severe. Cancer, chronic disease incidence increased year by year. However, because of the fear of death in the general public, most of the dying patients at the end of life tend to be “meaningless” excessive treatment, this not only consumes health resources that could be used to meet other needs, but also results in inevitable economic loss on individuals, familial, social and national level. Studies show that health care costs in the last 30 days before death were disproportionately high compared with those in the 6 months before death. It is questionable whether these increases in the last month of life provide benefit for patients and their families, or whether they may in fact be increasing suffering[9]. Influenced by the traditional Chinese view of death, many patients and their families believe that doctors must have a duty to cure patients after they have spent money. However, there are very few severe diseases that doctors can treat. In most cases, doctors can only relieve the pain of patients. The relationship between doctors’ and patients’ excessive expectations and limited abilities has led to chilling doctor-patient disputes. Medical staff is the people who contact the most death, especially in the hospice care post. Their attitude towards death and hospice care directly affects the development of hospice care, and medical staff will grow from medical students[16]. The attitude of accepting death with equanimity helps the students to digest the negative emotions brought by facing death in clinical practice[17]. Therefore, medical students need to have a favorable view of death to guide patients correctly and their families in the future, better develop hospice care services, build a harmonious and stable doctor-patient relationship, and avoid the waste of medical resources.
The traditional Chinese Confucian culture may influence medical students’ fear, anxiety, and escape towards death. Confucian culture advocates “unknown life, how to know death”, and the view of death in Confucian culture is evil death, taboo death, careful death, mourning death[18]. Influenced by this traditional culture, taboos have become a standard mode for people to face death. However, this has increased the mystery of death, expanding people’s fear of death[19]. This fear of death further aggravates the death anxiety of medical students, which is easily activated by the reminder of death. Death reminder is a psychological process in which individuals pay more attention to the inevitability of death by paying attention to some death-related reminders in the environment[20]. Medical students, however, are far more likely to be exposed to such death reminders in their academic and future careers. For example, during the COVID-19 epidemic, the daily increase in diagnoses and deaths is the reminder of death that currently surrounds us. At the same time, influenced by this thought, the development of the career of body donation in China has been hindered to a certain extent. When medical students choose organ or body donation, their choice will be influenced by the restriction of the traditional concept of “Preserving the body” and lead to their lack of enthusiasm. It also reflects that the immature view of death will hinder the development of medical and health undertakings to a certain extent. The results of this survey are similar to those of Wu, R.W. [21] and others.
Medical Students’ View of Death Is Influenced by Many Factors Such As Level, Specialty, and Family Atmosphere
Suicidal ideation helps to understand the fundamental value orientation of medical students towards death or suicide. In reality, quite a number of medical students have weak awareness of life, depression, self-harm, suicide becomes a significant factor endangering students’ health[13]. The death attitude can influence the suicide attitude of the college students through social support, and the college students who have the attitude of escaping from and accepting death are more likely to have a positive attitude toward suicide[22]. It was found that the suicidal thoughts of postgraduates were much higher than those of undergraduates. The reason may be that postgraduates have higher requirements on themselves and are under tremendous pressure from study, life, and emotion, so that they are easy to feel frustrated when self-task is not completed and arouse suicidal thoughts.
Medical students of different majors have different degrees of fear of death and suicidal thoughts due to their different academic pressure and career planning. The investigation shows that the frequency of suicidal ideation of clinical medical students is much higher than that of other majors, and the reason is analyzed because clinical medical students will be the first staff in clinical work in the future, it may be influenced by the violent medical incidents propagated by some media, coupled with a heavier academic load than other majors, resulting in a higher incidence of suicidal thoughts. This suggests that medical colleges and universities should carry out death education in different majors and grades, which can change the negative view of the death of some medical students and improve their attitude towards suicide. At the same time, pay attention to the combination of medical courses and psychological counseling, especially for medical students with abnormal behavior, psychological counseling should be given.
The more openly the family talks about death, the more rational the medical students’ view of death is, and the greater their natural acceptance of death. The results are consistent with former studies[23–25]. According to the survey, more than 1/5 of medical students acquired their view of death from their parents and elders, that is, the family environment is one of the important places for medical students to form their view of death. The analysis may be that the open family environment is more conducive to medical students forming a positive attitude towards death. Nevertheless, in general, because of the influence of traditional Confucian culture, most families still choose to avoid or only when necessary to talk about death, which shows that medical students’ understanding of death is not mature, this phenomenon is not conducive to the construction of healthy China 2030 - human health, so we should make death education popular and help more people establish a correct view of death, and the first step of popularization should be carried out in medical students.
Some medical students from single-parent families have a deeper understanding of death and can personally feel the impact of death because of the experience of one of their parents passing away. As a result, they have a deeper understanding of death and value life more, so their suicidal thoughts are lower than those of medical students from two-parent families.
Death Education in the Form of Elective Courses
Death education is through the way of education, to guide students to recognize the essence of death, to clarify the value of life, overcome the fear of death, anxiety, and to set up the correct view, comfortable in the face of death, to better deal with all kinds of setbacks and suffering in life, belongs to a kind of preventive education “to view life by death”. Studies at home and abroad indicated that death education for medical students can significantly improve their attitude towards death, reduce their death anxiety, strengthen their reflection on life and death [26], promote medical students to actively face dying patients [21, 27–28], and also be used to educate people about suicide prevention[29] and enhance professional identity [30]. At the moment of the normalization of COVID-19’s epidemic situation, medical students who have received death education can better face the problems of disease and death[31–32]. Therefore, it is vital to actively carry out theoretical and practical research on death education for medical students to promote their mental health and better deal with future clinical work[33].
The investigation found that the formation of the death view of medical students is mainly derived from school education, parents and elders or film, and television works. Therefore, schools should seize the school time of medical students and strengthen the correct death education for them, help medical students establish a positive view of death. Students who have been exposed to mass media reports on death are more likely to accept death and have less fear and avoidance of death[25, 34], which suggests that the valuable guidance of the view of death should also be strengthened through new media such as television and the Internet, together with the whole society.
In China, Qingming Festival is a traditional festival about paying respects to ancestors (on April 5 every year), which has a history of thousands of years. Nowadays, more and more marketing websites, companies, public welfare groups and schools have started to hold activities on this day to call attention to death. Although some success has been achieved, the influence is not enough to expand to the whole country, because the middle-aged and elderly people in China are mostly low-educated, and they may not receive such cutting-edge propaganda. Therefore, we try to influence medical students and patients through death education, so as to achieve the goal of making the whole society pay attention to and face death squarely.
Timely and appropriate intervention in the most acceptable way of death education can help medical college students break the taboo of death, achieve genuine humanistic care for students, perfect the quality education system, improve the personal accomplishment of medical students. Wilson[35] investigated pre-clinical students through experience-based learning (EBL) and found that medical students had difficulty in managing their emotions when experiencing end-of-life scenarios in clinical practice. This problem also exists among Chinese medical students. Currently, there is a lack of independent curriculum, single teaching form, and insufficient teachers in death education in medical schools in China[36]. Death education in the medical field is mainly carried out in the nursing profession, but it is still in the primary stage in general[37]. There are many discussions on death education, most of which refer to death education abroad. However, due to the cultural differences between the East and the West, national conditions are different, so a little effect has been achieved. Based on the results of the investigation, it is suggested that medical colleges and universities can help medical students establish a positive view of death by developing death education as an elective course. If there is a condition, visiting the intensive-care unit, hospice wards, Crematoria, and other places, inviting experienced hospice practitioners to give seminars on death education, offering performance classes (such as role-play, simulation of special situations) and so on can be included as practical courses in the elective, constructing the death education system suitable for China’s national conditions together.