Abstract

Introduction

Each individual constructs their representation of death and attributes to it personifications, qualities and different forms by means of culture, family traditions, or even through personal investigation¹1 Eizirik CL, Polanczyk GV, Eizirik M. O médico, o estudante de medicina e a morte. Rev AMRIGS. 2000; 44(1-2):50-5..

Death represents an invisible, intangible, untamable and unknown power, over which we do not have any governability. We fear death because we do not know how our encounter with it will be¹1 Eizirik CL, Polanczyk GV, Eizirik M. O médico, o estudante de medicina e a morte. Rev AMRIGS. 2000; 44(1-2):50-5..

Although death and birth are part of the human being’s biological life process, they are permeated by symbolisms, meanings and values that have varied throughout history and among diverse cultures¹1 Eizirik CL, Polanczyk GV, Eizirik M. O médico, o estudante de medicina e a morte. Rev AMRIGS. 2000; 44(1-2):50-5..

In the current sociocultural context, death is described as something undesired, and this generates denial behaviors such as trying to escape from its occurrence and speeding up things in order to return to the activities of the hospital unit as if nothing had happened. This denial of death, mainly in Western society, makes it difficult to include it as part of life²2 Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998..

Many authors have discussed the attitude that has been adopted to avoid the theme. A historical analysis reveals that death has ceased to be a social phenomenon in which everybody used to participate and has become hidden and masked, with the justification of protecting life – it is the inverted death³3 Ariès P. O homem diante da morte. São Paulo: Unesp; 2014.. Death has become a hidden, undesired phenomenon, and confronting it is carefully avoided⁴4 Marcílio ML. A morte na história. In: Martins JS, organizador. A morte e os mortos na sociedade brasileira. São Paulo: Hucitec; 1983. p. 61-75..

In the current Western tradition, death has left houses and has moved into hospitals, which sometimes are not prepared to approach this theme, especially when health professionals assist patients who will die, or when they need to communicate a patient’s death in places that have no privacy, such as hospital corridors⁵5 Klafke TE. O médico lidando com a morte: aspectos da relação médico-paciente terminal em cancerologia. In: Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998. p. 25-49..

Inside the hospital environment, there is the conspiracy of silence: no one talks about death, and when someone does, inappropriate expressions are used⁶6 Boemer MR. A morte e o morrer. 3a ed. Ribeirão Preto: Holos; 1998.. The denial of death translates into attitudes like not knowing how to behave in this situation and the doctor’s distance in relation to terminal patients⁷7 González LC, Fernández RG, Fuentes PS, Medina CV. Negación de la muerte y su repercusión en los cuidados. Med Paliat. 2012; 19(4):148-54.. Many times, such patients are submitted to aggressive types of curative treatment, even when it becomes impracticable⁸8 Brandão C. Câncer e cuidados paliativos: definições. Rev Prat Hosp. 2005; 7(42):54-6..

A study on the views about death and dying held by healthcare professionals whose experience ranged from one month to 27 years has revealed that they recognize their lack of training to deal with death⁹9 Mallory JL. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduated nursing students. J Prof Nurs. 2003; 19(5):305-12.. A phenomenological study with cardiac resuscitation teams (nurses and doctors) has shown that the process of dying generates feelings of impotence, failure and pain in professionals. To "protect" themselves, they "get used" to death as something typical of their daily routine¹⁰10 Saloum NH, Boemer MR. A morte no contexto hospitalar – as equipes de reanimação cardíaca. Rev Latino-Am Enfermagem. 1999; 7(5):109-19..

A phenomenological study carried out with Medicine and Nursing students has found that their first contact with death in the anatomy class already generates suffering, which is gradually mitigated as the students get used to it¹¹11 Valente SH, Boemer MR. A sala de anatomia enquanto espaço de convívio com a morte. Rev Bras Enferm. 2000; 53(1):99-108.. Studies whose subjects are Nursing students have shown that dealing with death and dying generates anxiety⁹9 Mallory JL. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduated nursing students. J Prof Nurs. 2003; 19(5):305-12., and the professionals feel unprepared to provide care for terminal patients¹²12 Johnson A, Chang E, O’Brien L. Nursing the dying: a descriptive survey of australian undergraduated nursing curricula. Int J Nurs Pract. 2009; 15(5):417-25.^-1313 Gillan PC, Riet PJ, Jeong S. End of life care education, past and present: a review of literature. Nurse Educ Today. 2014; 34(3):331-42.. In view of this, the question is: how do Medicine students deal with situations that involve death?

To answer this question, this study aims to describe how students in the fourth and sixth years of the undergraduate program in Medicine of the School of Medicine of Botucatu/UNESP deal with situations that involve death.

Investigating this theme is justified by the lack of research that focuses on Medicine students’ experience of situations that involve death. In addition, this study can provide subsidies to the adoption of strategies to improve end-of-life teaching and care.

Method

We decided to employ Alfred Schutz’s social phenomenology because its principles are pertinent to the Medicine students’ experience of dealing with death situations in the academic context. According to Schutz, the subject experiences and consolidates their experiences through communication with other men. In this process, the subject constructs their knowledge baggage, their "biographical self", what differentiates them from others, including conducts, fears, joys and motives¹⁴14 Shultz A. Sobre fenomenologia e relações sociais. Petrópolis: Vozes; 2012..

Social action is practiced among two or more people in their natural attitudes. It is projected by man in a conscious and intentional way, and carries with it a subjective meaning. The "reasons for" instigate the performance of the action; therefore, they are directed towards the future. The "reasons why" are evident in facts that have occurred but have not been forgotten, and they can influence present actions¹⁴14 Shultz A. Sobre fenomenologia e relações sociais. Petrópolis: Vozes; 2012..

Thus, social phenomenology aims to learn and organize what individuals experience in their daily lives, as elements that act, interact and complement one another, configuring a social group with typical characteristics.

In this study, what matters are the reasons that impelled the action of the Medicine students. Thus, they were heard about their experiences related to death or to situations that evoke it.

The research participants were students in the fourth and sixth years of the undergraduate program in Medicine of the School of Medicine of Botucatu/UNESP. While the fourth-year students are in the beginning of internship, have just started clinical practice and have witnessed only a few life and death events, the sixth-year students are in the end of the undergraduate program and, therefore, have spent more time dealing with death or with situations that evoke it in the academic context.

The data were collected from February to August 2007. Theoretical saturation, which is a criterion of phenomenological research, occurred when the discourses showed convergences and repetitions¹⁵15 Holloway I, Wheller S. Phenomenology. In: Holloway I, Wheller S, organizadores. Qualitative research in nursing and healthcare. 3rd ed. Oxford: John Wiley & Sons; 2013. p. 213-31.. Overall, 17 fourth-year students and 9 sixth-year students participated in the study. This difference can be explained by the convenience of collecting data provided by the fourth-year students, as there were 20 students in the classroom and 17 accepted to participate. The sixth-year students were distributed across the hospital units and were contacted individually.

Data collection was performed after the study had been approved by the Research Ethics Committee (document no. 599/2006-CEP) and after the participants had signed a consent document.

After signing the consent document, the participants received, in writing, the guiding question: How do you feel when you deal with situations that involve death or with death itself? Please describe it to me.

The lecture to the students and the meetings with participants were conducted by the study’s supervisor because the researcher was a student in the Medicine program in question and her presence might influence her peers’ answers.

In accordance with ethical principles, the discourses received a numerical code according to the order of data collection.

For data analysis, units of meanings were constituted through the reading and identification of the subjects’ actions, expressed in their testimonies, in a search for what did not vary, that is, what was common to the group. Afterwards, we organized the data by searching, in the analysis of the testimonies, for what was typical of the action¹⁴14 Shultz A. Sobre fenomenologia e relações sociais. Petrópolis: Vozes; 2012.. Finally, we performed a comprehensive analysis of the groupings, guided by Schutz’s motivational theory¹⁴14 Shultz A. Sobre fenomenologia e relações sociais. Petrópolis: Vozes; 2012..

Results and discussion

The testimonies were analyzed according to the theoretical framework that was adopted. Seven thematic categories emerged: For the fourth-year students, death is a taboo; death evokes unpleasant feelings and sensations; the students lack academic training to deal with death; they deal with death in order to become a humanist doctor. For the sixth-year students, death continues to be a taboo; death is a difficult experience; and death becomes an element of the doctor’s daily routine.

The analysis showed that death, to the students, is revealed in many facets, which range from a very difficult experience to its incorporation as an element of professional exercise. During the undergraduate program, there is intellectual learning in order to deal with the theme of death, as we show below:

Fourth year of the undergraduate program

Death is a taboo

The fourth-year students perceive death as a matter that is little discussed during the undergraduate program.

According to the fourth-year students, healthcare professionals, including themselves, seem to avoid the confrontation with death. This corroborates Marcílio’s ideas⁴4 Marcílio ML. A morte na história. In: Martins JS, organizador. A morte e os mortos na sociedade brasileira. São Paulo: Hucitec; 1983. p. 61-75. when she states that death has been historically denied in Western society, which is revealed in people’s attitudes in different contexts. Thus, they seem to favor the conspiracy of silence⁶6 Boemer MR. A morte e o morrer. 3a ed. Ribeirão Preto: Holos; 1998.. No one talks about death or about situations that evoke it. Although the main stage of death is the hospital environment and in spite of the fact that death is intensely experienced by healthcare professionals, they do not face it, as they have not been taught how to develop personal strategies to do so. In addition, hospitals’ structures contribute to the denial of death⁷7 González LC, Fernández RG, Fuentes PS, Medina CV. Negación de la muerte y su repercusión en los cuidados. Med Paliat. 2012; 19(4):148-54.. In short, death can be characterized as a taboo²2 Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998..

Attributing a social value to death is a way of denying it³3 Ariès P. O homem diante da morte. São Paulo: Unesp; 2014.. When an old person dies, people say that she had already lived her life and death was expected. When a young person dies, they say that it was a pity, as he had his whole life ahead of him⁷7 González LC, Fernández RG, Fuentes PS, Medina CV. Negación de la muerte y su repercusión en los cuidados. Med Paliat. 2012; 19(4):148-54..

Death is admitted, among doctors, in the anatomy room and in necropsies. Denial is a consequence of the fact that it is treated as a taboo, a subject that is interdicted and avoided in the daily conversations of the members of the healthcare team¹⁶16 Consorte J. A morte na prática médica. In: Martins JS, organizador. A morte e os mortos na sociedade brasileira. São Paulo: Hucitec; 1983. p. 38-60..

Death evokes unpleasant feelings and sensations

The students’ choice for the Medicine course can be associated with fear of death, as they may aim to reach a certain degree of control over it and/or to fight against it²2 Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998.. To the fourth-year students, death evokes feelings and sensations that are predominantly negative and which mean, mainly, failure, impotence and lack of expertise, as shown by the discourses below:

It is possible to infer that, at this stage of the undergraduate program, the students nurture the idea of "doctors who are heroes" and fight to defeat death, valuing science and not recognizing its limits.

Medical schools provide the doctor with an organicist education, which focuses on life, with the main objective of fighting against death. Furthermore, it is possible to verify the absence of didactic books and contents about death in the curricula¹⁰10 Saloum NH, Boemer MR. A morte no contexto hospitalar – as equipes de reanimação cardíaca. Rev Latino-Am Enfermagem. 1999; 7(5):109-19.^-1111 Valente SH, Boemer MR. A sala de anatomia enquanto espaço de convívio com a morte. Rev Bras Enferm. 2000; 53(1):99-108.^,1313 Gillan PC, Riet PJ, Jeong S. End of life care education, past and present: a review of literature. Nurse Educ Today. 2014; 34(3):331-42.^,1717 Torres W, Guedes WC, Torres RC, Ebert T. Algumas contribuições à pesquisa sobre a morte. In: Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998. p. 131-44.. The school experiences the denial of death and transports it to teaching¹³13 Gillan PC, Riet PJ, Jeong S. End of life care education, past and present: a review of literature. Nurse Educ Today. 2014; 34(3):331-42.^,1717 Torres W, Guedes WC, Torres RC, Ebert T. Algumas contribuições à pesquisa sobre a morte. In: Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998. p. 131-44..

It is important to emphasize the need, in the education area, especially in formal education, of presenting ideas and methods to put them into practice, for when scientific concepts are insufficient, spontaneous concepts or common sense may prevail¹⁸18 Vigotski LS. Pensamento e linguagem. 3a ed. São Paulo: Martins Fontes; 2005..

Still in the context of fighting against death, Kubler-Ross¹⁹19 Kubler-Ross E. Sobre a morte e o morrer. São Paulo: Martins Fontes; 1969. reveals, in her experience, that society finds it difficult to view death as a natural phenomenon. An external factor is attributed to it and scientific advance is a strategy to fight it, to the point that death is denied as a reality.

"I’m afraid of these situations, mainly of how to communicate this fact to the relatives of the deceased patient". (5)

The students also reveal feelings of fear and anguish related to death experiences. This fact can be explained as a way of dealing with "failure" in the battle against death, which affects many aspects: learning the limits of the profession and experiencing intense suffering whenever a patient "is lost" ²2 Cassorla RMS, coordenador. Da morte, estudos brasileiros. 2a ed. Campinas: Papirus; 1998.^,1010 Saloum NH, Boemer MR. A morte no contexto hospitalar – as equipes de reanimação cardíaca. Rev Latino-Am Enfermagem. 1999; 7(5):109-19..

Only a few students related death to positive feelings and meanings. The discourse below is intimately connected with pre-undergraduate religious learning.

It is important to mention that, after years of exposure to death situations, without adequate conditions to deal psychologically with them, the result is the doctors’ desensitization regarding the theme²⁰20 Kovács MJ, coordenador. Morte e desenvolvimento humano. 4a ed. São Paulo: Casa do Psicólogo; 1992.. Since the first year of the undergraduate program, when they have contact with corpses in anatomy classes, the students, not without suffering, gradually acquire intellectual and emotional maturity concerning death, so that they can exercise the profession¹¹11 Valente SH, Boemer MR. A sala de anatomia enquanto espaço de convívio com a morte. Rev Bras Enferm. 2000; 53(1):99-108..

The feelings elucidate that the theme of death is seen with difficulty. This is revealed by the sensation of fear, lack of training and guilt. Death is hard and unpleasant; however, the school must favor the adequate elaboration of what death is.

Lack of academic training to deal with death

The students mention that some preparation takes place in the experiences and discussions that occur before and during the undergraduate course. It is important to explain that, in the curriculum of the fourth year, there is a lesson that focuses on the theme of death in the discipline of Psychology, as well as general discussions about humanization in the area of health. However, the students report that this is not enough for them to know how to deal with death.

"We haven’t had much contact with death during the course, so I think it’s still a taboo to be broken and discussed. It seems that the professors don’t want to talk about it (…). However, we know that it is unequivocally attached to our profession and that we’ll have to have a good psychological basis to bear the impact of such an important loss like that of a patient. Death, like life, is an object of study of medicine and should be viewed as such". (8)

The students attribute a great value to situations in which they must deal with death, and they think that the knowledge acquired in extra-curriculum activities or before their undergraduate course is not enough. They become scared, insecure, fragile, and this generates psychological suffering. They seem to want academic discussions during classes, with bibliographic references, and forget that experience itself favors learning.

Strategies to incorporate end-of-life care in undergraduate curricula have a positive impact on students’ attitude²¹21 Dobbins EH. The impact of end-of-life curriculum content on the attitudes of associate degree nursing students toward death and care of dying. Teach Learn Nurs. 2011; 6(4):159-66., enhance their communication skills and reduce their negative attitudes in relation to death²²22 Jo K-H, An G-J. Effect of end-of-life care education using humanistic approach in Korea. Collegian [Internet]. 2013 [acesso 2015 Abr 1]; 22(1):91-7. Disponível em: http://dx.doi.org/10.1016/j.colegn.2013.11.008
https://doi.org/10.1016/j.colegn.2013.11... . These studies have shown the possibility of including the theme of death in undergraduate curricula in the area of health, which enables to meet the students’ needs. When they witness the scene, they perceive the professional’s posture, ideals and manners, and this allows them to reflect on how to deal with death when their time comes.

Although the student mentions that "it’s all right" to deal with the theme, he contradicts himself when he says that, when he imagines the real situation, he thinks he would have difficulties and would not have the necessary courage. He seems to resist the feelings in relation to the theme and even to deny it in view of his difficulties. Experiencing deep contradictions that are unsuspected at first can be frequent¹⁶16 Consorte J. A morte na prática médica. In: Martins JS, organizador. A morte e os mortos na sociedade brasileira. São Paulo: Hucitec; 1983. p. 38-60..

Other students expressed themselves in this way. One possible explanation is the fact that, in this period of the undergraduate course, they are not requested to give the "bad news". This role is played by someone who is more qualified: residents, hired doctors or professors. Thus, the student does not face the situation, does not expose himself and does not discuss the theme.

"I believe that the task of giving bad news would not be assigned to me at this stage of the undergraduate course. Anyway, I wouldn’t have to do it alone; there would always be the support of a more qualified professional". (1)

The testimony below clearly annuls the apparent "it’s all right" that was mentioned above:

Dealing with death in order to become a humanist doctor

The fourth-year Medicine student perceives the event of death as something that is part of the doctor’s routine and that deserves to be treated with humanity, that is, with respect, feelings and suffering on the part of the doctor. Moreover, the students take into account the quality of the patient’s last moments of life.

The students resort to their daily personal and professional experiences to build judgements concerning how to deal with death situations without losing their humanity. Studies have shown that training to provide end-of-life care affects students’ attitudes⁹9 Mallory JL. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduated nursing students. J Prof Nurs. 2003; 19(5):305-12.^,1212 Johnson A, Chang E, O’Brien L. Nursing the dying: a descriptive survey of australian undergraduated nursing curricula. Int J Nurs Pract. 2009; 15(5):417-25.,and that learning promotes efficient and competent attitudes to care for terminal patients²³23 Leighton K, Dubas J. Simulated death: an innovative approach to teaching end-of-life care. Clin Sim Nurs. 2009; 5(6):223-30.. This strengthens the importance of including the death theme in formal education, that is, a significant amount of theoretical and practical (clinical) teaching in the training of Nursing students concerning end-of-life care⁹9 Mallory JL. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduated nursing students. J Prof Nurs. 2003; 19(5):305-12.^,1212 Johnson A, Chang E, O’Brien L. Nursing the dying: a descriptive survey of australian undergraduated nursing curricula. Int J Nurs Pract. 2009; 15(5):417-25..

The fact that the student mentions that the professionals need to unite so that they can help each other, and this is a way to cope with death situations, evokes primitive societies, in which the fear of dealing with death was not so great because the group met individual needs with the aid of rituals, thus inhibiting the idea of horror²⁰20 Kovács MJ, coordenador. Morte e desenvolvimento humano. 4a ed. São Paulo: Casa do Psicólogo; 1992..

The need of comforting the deceased’s relatives, as well as the doctor, is recognized¹⁶16 Consorte J. A morte na prática médica. In: Martins JS, organizador. A morte e os mortos na sociedade brasileira. São Paulo: Hucitec; 1983. p. 38-60..

According to the students, learning will be consolidated in clinical practice, either in or outside the undergraduate course, by experiencing real situations. They hope to be able to deal with death with little suffering on their part, while alleviating the patients’ and relatives’ suffering.

Thus, the fourth-year students experience death situations in their academic and personal reality, and characterize death as a taboo that brings discomfort. They reveals their lack of training and, at the same time, realize that the way of coping with this situation can contribute to their education as humanist doctors. According to Schutz¹⁴14 Shultz A. Sobre fenomenologia e relações sociais. Petrópolis: Vozes; 2012., human existence has a fundamental anguish, based on the fear of death, which is inevitable in the social reality. The occurrence of death is typified and absorbed by the relatively natural view of the daily world. At the same time, it requires a reflection on human finitude and its consequences to current experiences, that is, the world-life.

Sixth year of the undergraduate program

Death continues to be a taboo

Although the sixth-year students have completed almost all the stages of the undergraduate program in Medicine, they reveal that there is little discussion about death and about situations that evoke it.

Like in the fourth year, the consequence is the denial of death with the aim of reducing suffering: the students see it as a fatality; they sublimate their feelings, eliminate pain, and point to their possible growth in such situations, as it has been shown by cardiac resuscitation teams¹⁰10 Saloum NH, Boemer MR. A morte no contexto hospitalar – as equipes de reanimação cardíaca. Rev Latino-Am Enfermagem. 1999; 7(5):109-19..

In this testimony, the student differentiates the intensity of the suffering caused by a patient’s death according to his involvement with the patient. Having contact with death is part of the daily routine in the curricular medical activity, especially during internship. These experiences are configured as a learning process that contributes to efficient and competent attitudes²³23 Leighton K, Dubas J. Simulated death: an innovative approach to teaching end-of-life care. Clin Sim Nurs. 2009; 5(6):223-30..

"I see these situations as something natural, in the case of patients who are waiting for death. But in patients who have undergone traumas, death can be painful". (24)

The social value of death³3 Ariès P. O homem diante da morte. São Paulo: Unesp; 2014.emerges in the testimonies. There is a denial related to age and to the presence of a "fatality", which are justifications that help to accept death better. Unexpected versus expected death.

Sixth-year students still feel that death is a failure, and this generates the feeling of impotence. This is also revealed by doctors and nurses¹⁰10 Saloum NH, Boemer MR. A morte no contexto hospitalar – as equipes de reanimação cardíaca. Rev Latino-Am Enfermagem. 1999; 7(5):109-19.. In this period, the student could have the maturity to think that death is an inexorable process of life. This is what the educational school should accomplish: forming students who are able to realize that death is not a failure; it is part of life and, consequently, of the medical profession, as the testimony below shows:

It is important to mention the role of educational institutions in the area of health in relation to death. Students must receive theoretical and practical education regarding end-of-life care⁹9 Mallory JL. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduated nursing students. J Prof Nurs. 2003; 19(5):305-12.^,1212 Johnson A, Chang E, O’Brien L. Nursing the dying: a descriptive survey of australian undergraduated nursing curricula. Int J Nurs Pract. 2009; 15(5):417-25..

In these students’ education, the university, which is also immersed in the context of inverted death, contributes to form the thought of a "lost battle", allowing the emergence of the denial of death. Authors like Kovács call attention to the fact that healthcare professionals constantly deny death, which fosters cold and desensitized behaviors towards the human aspect in situations of death and suffering. This brings an immense psychological suffering to the professional²⁰20 Kovács MJ, coordenador. Morte e desenvolvimento humano. 4a ed. São Paulo: Casa do Psicólogo; 1992..

Death is a difficult experience

The sixth-year students report that they are still learning to deal with death and feel discomfort, but they recognize some progress in relation to their first contacts with death in the fourth year of the undergraduate program.

Even at the end of the course and after it, death remains a difficult situation to the medicine student. For this reason, we suggest that the themes of death and dying are approached in a longitudinal way in the curriculum²⁴24 Anders S, Fischer-Bruegge D, Fabian M, Raupach T, Petersen-Ewert C, Harendza S. Teaching post-mortem external examination in undergraduate medical education - The formal and informal curriculum. Forensic Sci Int. 2011; 210(1-3):87-90..

It can be noticed that learning gradually occurs in the academic experiences, even if the student who is already in the sixth year of university still feels unprepared to deal with end-of-life situations.

The successive actions in the students’ daily practice qualify them to deal with death. It is a continuous process during their education that probably begins in the anatomy classes¹¹11 Valente SH, Boemer MR. A sala de anatomia enquanto espaço de convívio com a morte. Rev Bras Enferm. 2000; 53(1):99-108.. Many times, this process is not perceived by the students, who are not aware that they attend many pedagogic spaces (technique; practice; internship; experience), the most important one being the learning that is based on the observation of the conduct of other professionals and masters. In addition to the education they receive, the students bring, as baggage, their life experience, which encompasses religion and their relationships with others. To Schutz¹⁴14 Shultz A. Sobre fenomenologia e relações sociais. Petrópolis: Vozes; 2012., man lives in a natural attitude and is influenced by his biography, which motivates him and directs his actions.

It is important to mention that, although all the students follow the same formal curriculum, the experience they have, with its significant facts, is individual. This explains why there are sixth-year students with discourses that deny death, based on the purpose of the medical profession, and exclude death as part of life and of comprehensive care.

To what extent can a doctor aim to maintain life at any cost? In Brazil, the Federal Council of Medicine, in its Resolution 1.805/06²⁵25 Conselho Federal de Medicina. Resolução 1.805/2006. Na fase terminal de enfermidades graves e incuráveis é permitido ao médico limitar ou suspender procedimentos e tratamentos que prolonguem a vida do doente, garantindo-lhe os cuidados necessários para aliviar os sintomas que levam ao sofrimento, na perspectiva de uma assistência integral, respeitada a vontade do paciente ou de seu representante legal. Diário Oficial da União. 28 Nov 2006. Seç. 1:169., has delimited to what extent the fight against death, obstinate and without limits, can no longer be considered a doctor’s absolute duty. Medical schools have the fundamental role of fostering discussions so that students reflect on the theme with the possibility of modifying their actions, not only to comply with laws and codes, but so that they make sense to the students.

Death as an element of the doctor’s daily routine

The sixth-year students seem to include death as part of medical care. They recognize that, in end-of-life situations, the doctor plays the role of assisting the patient and the family in an individual way, with resources derived from his/her experiences.

With their own resources, which come especially from their experiences, the students gradually learn how to deal with death, as it has been shown by a study carried out in 2003 and 2004, also with Medicine students at the same University²⁶26 Sadala MLA, Silva MP. Cuidar de pacientes em fase terminal: a experiência de alunos de medicina. Interface (Botucatu). 2008; 12(24):7-21., and by a study conducted with Medicine and Nursing students¹¹11 Valente SH, Boemer MR. A sala de anatomia enquanto espaço de convívio com a morte. Rev Bras Enferm. 2000; 53(1):99-108..

Although the students have not received formal learning about death and the relationship with terminal patients and their relatives, their experiences make them be concerned about not being limited to technical procedures, but not surrendering to sentimentalism, either.

Some initiatives that promote the development, in students, of competences related to coping with death and dying are highlighted below. A study carried out in Korea has revealed that, after attending a course on end-of-life humanized care, students enhanced their communication skills, their attitudes concerning death, and reduced their anxiety. The authors considered that students’ training in such questions is essential²²22 Jo K-H, An G-J. Effect of end-of-life care education using humanistic approach in Korea. Collegian [Internet]. 2013 [acesso 2015 Abr 1]; 22(1):91-7. Disponível em: http://dx.doi.org/10.1016/j.colegn.2013.11.008
https://doi.org/10.1016/j.colegn.2013.11... . Simulated clinical experiences are configured as a teaching strategy about death and dying, as students learn and develop the confidence and relational competences that are necessary to cope with death²³23 Leighton K, Dubas J. Simulated death: an innovative approach to teaching end-of-life care. Clin Sim Nurs. 2009; 5(6):223-30.. Another study has proposed the inclusion of a curricular discipline that welcomes the emotions of Medicine students, which are not usually part of the formal curriculum, as it focuses primarily on technical issues, to the detriment of emotions²⁷27 Leeuw S, Parkes MW, Thien D. Questioning medicine’s discipline: the arts of emotions in undergraduated medical education. Emot Space Soc. 2014; 11:43-51..

While the issue of death to the fourth-year student is difficult, but there is the possibility of learning from the situations, the sixth-year student continues to find it difficult, but they must have the posture of a doctor, with all the prerogatives of the profession, as there is no longer the perspective of learning during the undergraduate program.

Final remarks

Situations related to death and dying are present in the daily routine of the Medicine student, especially from the fourth year onwards. This is intensified in internship, during the fifth and sixth years, when students’ hours are dedicated to the provision of direct care for hospitalized patients. The teaching environment of the internship for the students analyzed here is a reference hospital for high complexity patients. Thus, independently of the hospital unit in which the student is, he/she has the possibility of interacting with terminal patients.

The students’ technical-scientific knowledge and affectivity in the daily routine of the assistance were fundamental elements of the care provided for terminal patients and their relatives. This study revealed the nature of this care and unveiled feelings and motives which are not visible in an objective observation and which influence the way of acting.

Fourth-year students described death as a taboo, as it is little approached and discussed in the course. It awakes unpleasant feelings and sensations. The students view death, frequently, as a professional failure, a feeling that is mitigated by the professor’s presence. This reveals that they are not prepared to deal with death and that they expect to learn relational and technical aspects in order to become humanist doctors.

To the sixth-year students, death continues to be a taboo, as they consider it a theme that is little discussed in medical education. Although they, too, believe that dealing with death is difficult, the fact that they act in end-of-life and death contexts promotes learning through the observation of the posture that is expected in these situations. Therefore, death and its interfaces become part of the doctors’ routine. The sixth-year students are required to give the news of the patient’s death to the family and to deal with feelings of loss and mourning.

This is a qualitative study; therefore, the results presented here describe and interpret the experience of Medicine students at the moment of data collection. It does not intend to generalize the findings to other medical schools.

The issues related to death and dying require that students have technical and emotional competences to cope with such situations. The undergraduate program must offer opportunities so that both competences can be enhanced, based on scientific, ethical and legal knowledge. In this sense, bioethics has contributed to the discussion of issues concerning different ways of dying by addressing euthanasia, dysthanasia, orthothanasia and humanization in hospitals. As the international literature has shown, there is a lack of experiences targeted at the teaching of communication skills and competences in the sphere of human sensitivity – types of knowledge that are also necessary to the doctor’s education, as they contribute to their own wellbeing and to the healthcare system as a whole.

References

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