Medical students' first clinical experiences of death.

摘要

OBJECTIVES: Many medical students feel inadequately prepared to address end-of-life issues, including patient death. This study aimed to examine medical students' first experiences of the deaths of patients in their care. METHODS: Final-year medical students at the Schulich School of Medicine & Dentistry, University of Western Ontario were invited to share their first experience of the death of a patient in their care. The students could choose to participate through telephone interviews, focus groups or e-mail. All responses were audiotaped, transcribed verbatim and analysed using a grounded theory approach. RESULTS: Twenty-nine students reported experiencing the death of a patient in their care. Of these, 20 chose to participate in an interview, five in a focus group and four through e-mail. The issues that emerged were organised under the overlying themes of 'young', 'old' or 'unexpected' deaths and covered seven major themes: (i) preparation; (ii) the death event; (iii) feelings; (iv) the role of the clinical clerk; (v) differential factors between deaths; (vi) closure, and (vii) relationships. These themes generated a five-stage cyclical model of students' experiences of death, consisting of: (i) preparation; (ii) the event itself; (iii) the crisis; (iv) the resolution, and (v) the lessons learned. 'Preparation' touches on personal experience and pre-clinical instruction. 'The event itself' could be categorised as referring to a 'young' patient, an 'old' patient or a patient in whom death was 'unexpected'. In the 'resolution' phase, coping mechanisms included rationalisation, contemplation and learning. The 'lessons learned' shape medical students' experiences of future patient deaths and their professional identity. CONCLUSIONS: A tension between emotional concern and professional detachment was pervasive among medical students undergoing their first experience of the death of a patient in their care. How this tension was negotiated depended on the patient's clinical circumstances, supervisor role-modelling and, most importantly, the support of supervisors and peers, including debriefing opportunities. Faculty members and residents should be made aware of the complexities of a medical student's first experience of patient death and be educated regarding sympathetic debriefing.