Medical Students ’ Knowledge about End-of-life Decision-Making Conhecimento de Estudantes de Medicina sobre Tomada de Decisão no Fim da Vida Anielli PinheiroI

– Euthanasia ABSTRACT The influence of medical students’ knowledge concerning end-of-life care, considering ethical theories and clinical practice, remains controversial. We aimed to investigate medical students’ knowledge of bioethical concepts related to moral kinds of death (euthanasia, disthanasia, and orthothanasia) and to analyze the influence of their clinical experience on practicing such approaches in a tertiary hospital in the state of São Paulo, Brazil. We interviewed 180 medical students [distributed in Group 1 (G1) — first to thirdyear students, and Group 2 (G2) — fourth to sixth-year students] to evaluate the influence of the course on “medical ethics” on ethical theories and clinical practice, using a closed questionnaire. The course on “medical ethics” did not distinguish the groups (P=0.704) in relation to bioethical concepts. Neologisms such as “cacothanasia” and “idiothanasia” were incorrectly viewed as bioethical concepts by 28% of the interviewees. Moreover, 45.3% of the sample considered health care professionals incapable of managing terminally ill patients, especially G2 (29%) as compared to G1 (16.5%, P=0.031). The concept of euthanasia was accepted by 41% of sample, as compared to 98.2% for orthothanasia. Among medical students that accepted ways to abbreviate life (22.9%), 30.1% belonged to G1, and only 16.1% to G2 (P=0.049). These medical students were unfamiliar with common bioethical concepts. Moreover, they considered healthcare professionals incapable of managing terminally ill patients. The ethical ideal of the “good death” reflects better acceptance of orthothanasia by medical students, suggesting a tendency to apply it in their future clinical practice.


INTRODUCTION
Several goals have guided end-of-life medical decisions, considering the relief of suffering and improvement of quality of life for terminally ill patients and their families [1][2][3] .Substantial legal, ethical, and clinical consensus currently exists about end-of-life care, yet myths and misconceptions persist concerning what is ethically and legally permissible 4 .In this case, medical practice in relation to advanced and terminal illnesses remains controversial, although nearly 30 years have transpired since Karen Ann Quinlan's case, the first famous public discussion on end-of-life care 5 .
In this context, bioethical concepts were suggested in order to standardize medical practice concerning moral kinds of death.Euthanasia derives from the Greek (eu-thanatos) and literally means "good death".The term has come to refer to the effort to avoid prolonged and useless suffering, considering the relief of pain or other symptoms with a possible life-shortening effect 6 .In contrast, disthanasia (dis-thanatos, "death with difficulty") refers to futile treatment that prolongs the process of dying.In other words, it is medically futile that even with no expectation of cure, the treatment draws out the patient's agony 7 .Between these two is orthothanasia (ortho-thanatos, "normal or natural death"), in reference to the natural process of dying after interruption of futile clinical treatment.These are controversial topics not only in the medical field but also in the social, political, philosophical, and religious domains 8,9 .
The debate on euthanasia and assisted suicide has grown remarkably in the last 20 years, attracting widespread attention by medical experts.Analyses on the moral classification of death are common in the literature, taking into account the opinions of health care professionals on bioethical values 3,[10][11][12] .Medical schools in Brazil have included courses on medical ethics in the curriculum.Course objectives include increasing medical students' understanding of ethical terms and standards, as well as dilemmas in clinical settings [13][14][15][16] .Given the priorities in medical education, it is thus not surprising that medical students struggle to apply such ethical knowledge to clinical cases and sometimes confuse technical facts, personal or professional values, or clinical consensus with reasoned argument and justifiable clinical ethical decision-making 17 .Some recent studies have found that the curriculum can influence the students' ethical values during courses, considering the concurrent contact with clinical practice 2,18 .
In this context, the present study was designed to investigate the medical students' knowledge concerning bioethical concepts related to the moral classification of death (euthanasia, disthanasia, and orthothanasia) and to analyze the influence of their clinical experience in managing such types.

METHODS
A total of 180 medical students from the São José do Rio Preto School of Medicine participated (27 first-year, 26 second-year, 30 third and fourth-year, 27 fifth-year, and 30 sixth-year students).They were matched for gender and age.All individuals received a closed questionnaire, including 22 questions eliciting views on the moral classification of death and performance by health care professionals.Responses were returned anonymously by mail.The survey was conducted from July to September 2004.The study was approved by the Institutional Review Board of the School of Medicine in São José do Rio Preto, São Paulo State, Brazil (case review 302/2004).All subjects were informed in writing about the study, and all signed consent forms.
In Brazil, undergraduate medical school lasts six years, and students enter directly after high school.This medical school's fourth-year curriculum includes a short course on "medical ethics", consisting of lectures and discussions on bioethical concepts.A preliminary analysis considered the general responses by all the students.Next, the subjects were divided into two groups: Group 1 (G1), with first to third-year students, and Group 2 (G2), with fourth to sixth-year students, in order to evaluate the influence of the course on ethical theories in relation to their clinical practice.
Statistical analysis was performed comparing the groups in relation to gender and age using the t-test.Fisher's exact test was used for an exploratory analysis of medical students' knowledge concerning the moral classification of death, considering the absolute frequencies of the responses.Significance was set at p < 0.05.

RESULTS
Of the 180 individuals selected for the sample, 170 (94.4%) responded.Ten medical students refused to participate.G1 did not differ statistically (p=0.704)from G2 in relation to total number of correct responses on bioethical concepts such as euthanasia, disthanasia, and orthothanasia (Table 1).Regarding the definition of euthanasia, sixth-year students showed a higher rate of correct answers (93.3%).Meanwhile, fourth-year students showed better knowledge of disthanasia (73.3%).
The analysis of lemmas involving treatment of terminally ill patients and moral classification of death showed that euthanasia was accepted by approximately 41% of medical students.However, 75% (69% in G1 and 80% in G2) did not agree that euthanasia has been practiced by physicians in Brazil.Of the respondents, 7.7% accepted the use of drugs to relieve pain, but with a possible life-shortening effect, and 27.6% agreed with interruption of futile clinical treatment (  being allowed to die at home, and 2.3% were unaware of any illegal practice of euthanasia in Brazil.Among the total sample of medical students, 22.9% agreed with ways of abbreviating life (30.1% in G1 and only 16.1% in G2; p=0.049).Moreover, 27% acknowledged the patient's right to instruct the physician on how to act in the case of a terminal condition.Sixty-two percent favored explaining patients' diagnosis to them, and 50% considered this the physician's obligation.However, 45.3% of the sample (16.5% in G1 and 29% in G2, p=0.031;Table 3) considered physicians and other health care professionals unable to properly manage terminally ill patients.
Although 89% stated regularly practicing a religion, only fourth-year of the students felt that it influenced their end-of--life decisions.Among these, 55% stated that euthanasia is a violation of Divine laws, while 19% accepted the idea, despite not following any religious dogma.

DISCUSSION
The analysis of both groups of medical students' bioethical knowledge on moral kinds of death showed their unfamiliarity with the common concepts of euthanasia, disthanasia, and orthothanasia [19][20][21] .The high frequency of responses concerning the neologisms "cacothanasia" and "idiothanasia" as authentic bioethical terms confirms that short courses in medical ethics do not suffice to orient qualified future professionals in clinical settings, even in a university hospital 9 .This highlights the importance of organizing the curriculum towards better integration between learning and medical practice 17,22 , considering the laws in force in Brazil.
The process of dying is not always self-evident in clinical practice.The Terri Schiavo case reveals the controversy and unfamiliarity of moral kinds of death and their actual definitions and legal parameters 24 .Some students in this study had difficulty distinguishing between ethical and social issues, particularly those involving justice and health care allocation 25 .The important task of devising teaching strategies to assist students in integrating their ethical knowledge and enabling them to systematically analyze and manage ethical aspects in clinical practice is still necessary 17,21 .In this context, the discussion on euthanasia and futile medical treatment 26 reveals medical students' insecurity towards end-of-life care.
The higher level of acceptance of euthanasia among first to third-year medical students as compared to fourth to sixth-year students confirms that their ethical reasoning skills change over time, considering the ability to recognize and assess the ethical problems found in clinical practice 2,18,27 .This suggests that contact with terminally ill patients reduces the acceptance of euthanasia.Similar situations have been observed in surveys that included lawyers, social sciences students, or engineers along with physicians and health care professionals 12,28 .
In our series, most respondents felt that patients should have knowledge regarding their terminal condition, and that attending physicians should explain their perspective, even though they considered them unprepared for this ethical attitude and for proper clinical management of terminally ill patients 9,21,22 .In this context, one important aspect of providing better care for dying patients is to understand their symptoms and concerns, with a view towards better communication in the physician-patient relationship 4,29 .This suggests that discussing topics related to death and dying may actually be helpful for many terminally ill patients who are unable to accept their own death, while allaying their related fears and anxiety 30 .
Our data suggest that religious affiliation does not directly influence medical students' ethical reasoning on moral classification of death.In this case, half of the respondents stated that religious dogmas had not determined their ethical positions, corroborating Ramírez-Rivera et al. 31 and Cohen et al. 32 .The latter authors concluded that guidance by religious institutions has some influence on end-of-life decision-making but is certainly not blindly accepted by physicians.Most people allow adaptations to particular situations, for instance to the needs and wishes of the dying and considerations of humaneness 3 .
In short, these medical students proved to be unfamiliar with common bioethical concepts.Moreover, they considered health care professionals unable to manage terminally ill patients.However, the ethical ideal of the "good death" appears to better reflect the acceptance of orthothanasia, suggesting a tendency to apply it to their future clinical practice.

Table 2 )
. 98.2% of respondents were in favor of terminally ill patients 173 Anielli Pinheiro et al.Medical Students' Knowledge About End-of-life Care

TABLE 1 :
Medical students' views on bioethical concepts concerning moral classification of death

TABLE 2 :
Medical students' agreement with bioethical concepts and clinical practice

TABLE 3 :
Medical students' agreement with ethical theories and their use in clinical practice