Original Article

The Effects of an Early Observational

Experience on Medical Students
Attitudes Toward End-of-Life Care

American Journal of Hospice

& Palliative Medicine
2015, Vol. 32(1) 52-60
The Author(s) 2013
Reprints and permission:
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DOI: 10.1177/1049909113505760
ajhpm.sagepub.com

Elizabeth Wechter1, Denise Carter OGorman1, Mamta K. Singh2,

Pete Spanos1, and Barbara J. Daly1

Abstract
End-of-life care is paramount in maintaining the quality of life of the terminally ill, protecting them from unnecessary treatment,
and controlling costs incurred in their care. Training doctors to be effective end-of-life caregivers begins in medical school.
A survey design was used to collect data from 166 first-year medical students before and after exposure to hospice or palliative
care through an early clinical exposure program. Data demonstrated that students had a significant change in attitude scores after
the observational experience (P < .05). Providing students with the opportunity to observe and participate in end-of-life care has a
positive effect on attitudes toward the care of dying persons. We recommend that direct exposure to end-of-life care practices be
incorporated early in the medical school curriculum.
Keywords
hospice, palliative, curriculum, end of life, education, observation

Introduction
The quality of end-of-life (EOL) care is important in the terminally ill patients quality of life, the outcomes of the surviving
family members, and is a significant driver of health care costs
today.1-3 Studies have shown that introduction of early palliative care options, particularly hospice, helps to protect the
patient from ineffective and potentially harmful interventions
near the EOL, improve the quality of life of the surviving family members, and decrease costs associated with aggressive
EOL care.4-6 Physicians play an essential role in providing
patients with information necessary for making educated decisions regarding treatment options. Although discussions concerning EOL care can be difficult, they are associated with
better outcomes for the patient.3 These discussions can help the
patient more accurately evaluate the risks and benefits of
aggressive treatment versus focusing on palliation near the
EOL and help to ease the anxiety of family members.1,3,7
In 1997, the Institute of Medicines Committee on Care at
the End of Life published a review recognizing the need to
improve EOL care. The report highlighted that physicians
tend to overemphasize the use of aggressive treatment near
the EOL, underutilize hospice and palliative care, and are
deficient in the communication skills necessary to address
EOL concerns with patients.2 A more recent study by Miesfeldt et al continued to highlight a vast underutilization of
hospice services by showing that only 55.2% of the patients
accessed hospice within 30 days of death, with greater than

15% of those only accessing it within the final 3 days of life.8

Similarly, studies suggest that completion of advance directives remains low even though there is evidence that patients
appreciate the opportunity to discuss advanced care planning
with their physicians.9-12
Although physicians recognize the importance of providing high-quality EOL care, they also report feeling unprepared to effectively communicate potential options to their
patients.13-15 This perception may stem from deficiencies in
medical education, both in the preclinical and clinical
years.16,17 Sullivan et al reported that students and residents
in the United States feel unprepared to provide many key
components of quality care for terminally ill patients.13 In the
study, fewer than 20% of students and residents reported having received formal EOL care education.13 Similarly, a more
recent study showed that three-quarters of the residents and
nearly half of the attending physicians surveyed felt they were
insufficiently knowledgeable in the techniques related to delivering bad news.18 This may stem from the fact that there is
little emphasis on formal EOL care education in the medical

1
2

Case Western Reserve University School of Medicine, Cleveland, OH, USA

Louis Stokes VA Medical Center, Cleveland, OH, USA

Corresponding Author:
Elizabeth Wechter, 3702 Traynham Road, Shaker Heights, OH 44122, USA.
Email: ejw75@case.edu

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53

school curriculum. Although the Liason Committee for Medical Education (LCME) has stipulated that the curriculum of
a medical education program must . . . include the important
aspects of . . . end-of-life care in order for a school to be
accredited, it does not include any guidelines for actual EOL
care curriculum.19 In fact, a survey of medical school deans
across the country suggested that the LCME standards had
little impact on implementing more complete EOL care curriculum.20 Only 29% of the deans reported having dedicated
coursework related to EOL care, and only 15% of those
courses were required.20
Many efforts have been made to incorporate EOL care education into the medical school curriculum. However, these
courses are usually short-term clerkships that are not introduced until the third or fourth years of medical school or even
the first year of residency programs.21-26 Multiple studies have
suggested that more longitudinal exposure to EOL care experiences, throughout the medical education continuum, would
have a greater impact on medical students and help better prepare physicians in practice.15,20,27-29 However, there is little
evidence of the effects of the various approaches to EOL care
education, particularly experiences provided early in medical
school curriculum.
One unique approach to EOL care education was introduced at Case Western Reserve University School of Medicine in 2006. As part of an early clinical exposure program,
first-year medical students participate in the Rotating
Apprenticeships in Medical Practice (RAMP), which provides students with observational experiences in 3 patient
care settings including EOL care. Learning objectives for the
program include enhancing self-awareness through observation and reflection, recognizing integration of the values of
the patient, patients families, and physician as well as considering how cultural, religious, and ethical issues inform
talking with patients and families about death and dying. Students attend an afternoon session either at a large freestanding hospice or with 1 of 2 inpatient palliative care services.
Before the experience, students are expected to read articles
introducing concepts related to delivering bad news, conducting family meetings, and dealing with the emotions of
patients and their families. Students then meet with physicians in the field of palliative or hospice medicine to discuss
the readings as well as their personal and professional experiences with death and dying. When appropriate, students also
have the opportunity to interact with patients and their families. Upon completion of the RAMP program, students are
asked to reflect on their experiences and discuss how the
experiences affected their ideas concerning the doctor
patient relationship.
Given the lack of evidence regarding effective ways to introduce medical students to EOL and palliative care, we undertook an evaluation of the EOL component of RAMP. Our
purposes were (1) to evaluate whether or not the experience
affects students attitudes toward EOL care, (2) to determine
whether students found the experience helpful, and (3) to solicit
recommendations for improving the program.

Methods
Design
We conducted a descriptive correlational study, measuring
demographics and attitudes toward care of dying patients
before and after exposure to hospice or palliative care.

Sample
First-year medical students at Case Western Reserve University School of Medicine were invited to participate in the study.
Pre- and postexperience surveys were uploaded to the online
course evaluation system and made available to students via
links sent in an e-mail introducing the study and inviting participation. The presurvey was made available to students in
August 2012 before the program began, and postsurvey links
were made available upon completion of the experience.
Reponses were collected from August through December 2012.
The study site institutional review board determined that the
study met requirements for exemption under federal regulation.
We informed students that participation in the study was voluntary and would not affect grading. The data were deidentified,
and all students provided consent to participate.

Study Instrument
We developed pre- and postexperience questionnaires consisting of demographic data related to age and gender as well as
attitudes toward care of dying people. Both questionnaires
included 21 Likert-type items compiled from the Frommelt
Attitude Toward Care of the Dying scale (FATCOD, form B)
as well as 1 question from the Dickinson Attitude Towards
Care of Terminally Ill Patients scale.28,30
The FATCOD, form B, consisting of 30 Likert-type questions, was developed in 2003 to assess undergraduate student
attitudes toward caring for terminally ill people and their families. The form was evaluated for face validity by experts in
the field and testretest reliability was reported30 as .9269.
We utilized 21 of the 30 items on the FATCOD, form B, in our
surveys in order to make the questionnaire more applicable to a
medical student population.
In addition to the Likert items, the preexperience questionnaire contained close-ended questions related to previous education in death and dying as well as previous and current
personal experience with EOL care. This section was replaced
in the postexperience survey with close-ended questions evaluating the experience. Students were asked which experience
they attended, whether or not they had direct patient contact,
if the experience was helpful, and for improvement suggestions. Prior to distribution, the surveys were evaluated for
clarity and efficacy by informal peer review.

Analysis
Data were collected via the online course evaluation software
and were organized, paired, and analyzed using IBM SPSS

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American Journal of Hospice & Palliative Medicine 32(1)

54
version 20 statistical software. Cumulative pre- and postexperience attitude scores were calculated (items scored 1-5, 1
strongly disagree, 5 strongly agree, with negatively worded
items scored in reverse, maximum score 110). In order to
investigate whether or not there was a significant change in attitude score after the experience, we used only the paired data
(n 22). Paired as well as unpaired presurveys (n 61) and
postsurveys (n 44) were used to investigate relationships
between attitude scores and various demographic factors, previous education/experience as well as response to the program.
The t tests and analysis of variance were used to examine the
differences between subgroups, and chi-square was used to test
associations. For all tests, P < .05 was considered significant.

Results
Sample
Of the 166 students in the class, a total of 61 students responded
to the pretest for a response rate of 36.7%. The response rate for
the posttest was 26.5% with a total of 22 paired responses.
Table 1 presents the respondents demographic data. The majority of respondents were male and under age 28, which appears to
mirror the class demographics (53.6% male, average age 23.7).
As expected, few of the students in the class reported having
taken a course dedicated to issues surrounding death and dying
in the past, while more than half reported never having been
presented with material on the subject (Table 1). In terms of
personal experience, the majority of students, 85.2%, reported
having had experience with losing a friend or a family member
in the past, but less than 20% reported current experience with
impending loss of a loved one.

Program Experience and Responses

Table 2 presents data related to which experience students
attended and their responses and recommendations for the program. Almost two-thirds of the students spent the afternoon at
the hospice, while the remainder of the students had an experience with 1 of the 2 palliative care inpatient services. Nearly
75% of the students had direct interactions with patients during
the observation.
Ultimately, nearly 90% of the respondents found the experience helpful. While the majority of respondents had no suggestions for improving the experience, the next most common
suggestion was to make the experience more longitudinal with
repeated experiences throughout the curriculum (25%). Only 2
(4.5%) students wanted to eliminate the program, and 1 student
thought the program should be initiated later in the curriculum.

Attitudes
Only the paired data were used to evaluate whether there was a
significant change in the attitude score after the program. The
mean pretest score was 80.2, while the posttest score rose to
82.5 (P < .05). There was also a statistically significant increase
in the pretest (4.09) and posttest (4.36) scores on item #13,

Table 1. Demographic Variables of the Students Participating in the

RAMP EOL Experience Survey.
N (%)
Age
18-22
23-27
28-35
Gender
Male
Female
Previous education in death and dying
Took previous course
Exposed to material in other courses
No previous information
Experience with loss
Yes
No
Present experience with loss
Currently anticipating loss of someone close
Someone close is suffering from terminal illness
No impending loss

42 (50%)
38 (45.2%)
4 (4.8%)
50 (61%)
32 (39%)
7 (11.5%)
22 (36.1%)
32 (52.5%)
52 (85.2%)
9 (14.8%)
5 (8.2%)
5 (8.2%)
51 (83.6%)

Abbreviation: RAMP EOL, Rotating Apprenticeships in Medical Practice end of

life.

Table 2. Student Experiences, Evaluations, and Recommendations for

Improvement of RAMP EOL Program.
N (valid
percentage)
RAMP experience
Palliative care
Hospice
Direct patient contact
Yes
No
Was the experience helpful?
Yes
No
Recommendations
Have experience at later point in curriculum
Eliminate the experience
Make the experience more longitudinal with
repeated experiences throughout curriculum
Provide better preparation for the experience
Incorporate more debriefing/discussion after
No suggestions for improvement

18 (38.2%)
29 (61.7%)
35 (74.5%)
12 (25.5%)
42 (89.4%)
5 (10.6%)
1 (2.3%)
2 (4.5%)
11 (25.0%)
7 (15.9%)
6 (13.6%)
17 (38.6%)

Abbreviation: RAMP EOL, Rotating Apprenticeships in Medical Practice end of

life.

which stated that families need emotional support to accept the

behavior changes of the dying person. No significant differences occurred in the remainder of the individual items.
As expected, there was a statistically significant relationship between the posttest scores and whether or not the respondents found the experience helpful. Among those who found
the experience helpful the mean posttest score was 81.67,
while it was 75 among those who did not find the experience
helpful.

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Table 3. Student Recommendations for Improvement of the RAMP EOL Experience Versus Evaluation of Program Helpfulness, Exposure to
Direct Patient Contact, and Personal Experiences with Loss.
Postexperience recommendations (n 44)

Experience helpful
Yes
No
Direct patient contact
Yes
No
Current experience with loss
Anticipating
No impending loss

Eliminate

Repeat

Later

Prepare

Debrief

None

0
2

11
0

1
0

6
1

6
0

16
1

2
0

7
4

0
1

7
0

6
0

12
5

0
0

0
4

0
0

0
4

1
1

2
10

Abbreviation: RAMP EOL, Rotating Apprenticeships in Medical Practice end of life.

We also examined whether or not the type of experience or

direct patient contact affected postexperience scores in any
way. There were no significant differences in posttest scores,
helpfulness of the experience or recommendations between
those who had patient contact compared to those who did not,
nor among the various sites of experience. However, 40% of
the students who had no direct patient contact wanted to repeat
the experience, while 21% of the students with direct patient
contact thought the program should be more longitudinal
(Table 3).
We also examined the relationships between demographic
data and pretest attitude scores. The only statistically significant relationship was related to the respondents present experience with loss. The mean pretest score among those with
no current experience was 78.64, while that among people currently experiencing loss of a loved one was 85.8. There was no
relationship between present experience with loss and whether
the program was found helpful or specific recommendations;
however, only those students with no current experience recommended repeating the experience (Table 3).

Discussion
Our study is one of the first to examine a program introducing
direct observation of end-of-life care within the first year of
medical school. A variety of electives and professional development programs have been designed to help better prepare
students, residents, and faculty to provide care for dying
patients; however, they are primarily aimed at individuals further along in the study or practice of medicine.31 Although
these programs have been shown to be effective in improving
self-perceived communication skills and knowledge in the
field, they seem to be late answers to the problem of inadequate
training in how to effectively communicate end-of-life issues
with patients.11,12,14,26
An informal survey of the remaining 5 medical schools in
Ohio found that no other school in the state introduced direct
observational experiences in EOL care to students in the first
year of study. In fact, the programs varied greatly, with one
school having no required coursework in the subjectonly

optional electives in the third and fourth year. Another program

had an in-depth EOL care curriculum with multiple required
patient experiences in years 3 and 4, but with primarily lecture
and standardized patient-based programs in years 1 and 2.
One reason why programs may wait to introduce these
topics until later in the curriculum is a concern that early exposure may have a negative impact on young medical students
who may not be emotionally or professionally prepared to discuss these issues.13 However, our study demonstrated that a
program with direct site experience was associated with a positive effect on attitudes toward caring for patients at the EOL
and that the majority of students found the experience to be
helpful. These findings highlight the benefits of introducing
direct experience early in students careers. Early exposure to
hospice and palliative care settings may help to combat the
hidden curriculum, the idea that the sole focus of medicine
is on cure, and that by practicing palliative medicine or addressing complex emotions associated with treating terminally ill
patients one is an unsuccessful physician.13,32
Our study further demonstrated that attitudes were more
strongly affected by personal experience than by previous education in the subject. This suggests that curricula that are
merely case- or lecture-based may not be as effective in changing students attitudes toward end-of-life care as direct site
experience. This may be reflected in the positive change in attitude score to question 13 (families need emotional support to
accept the behavior of the dying person). This question is relevant to the understanding of the role of the physician, including
the responsibility to address the psychosocial aspects of illness.
This aspect of the physician role may not be fully appreciated
in a simple interaction with a standardized patient and may
require direct observation of family dynamics.
The study found that students, particularly those without
personal exposure to EOL care, were also interested in making
the experience more longitudinal as well as incorporating
greater preparation and debriefing before and after the site visit.
Incorporating small group discussions before and after the program could allow students to more fully reflect on the experience and its implications. An extended exposure could also
provide students with invaluable experience when they enter

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American Journal of Hospice & Palliative Medicine 32(1)

56
practice as residentshelping to combat the feeling of unpreparedness that residents and faculty continue to feel in discussing EOL issues today.
The study had several important limitations. First is the low
response rate and small sample size. It would be helpful to
repeat the study with a larger sample to better evaluate the
effectiveness of the EOL component of the RAMP experience.
Second, the potential for selection bias emerges as students
who completed both pretest and posttest may have had more
interest in the field initially. This may have skewed the posttest
score and artificially increased the change in attitude score.
Third, although we did not revalidate the survey used for the
study, the questions used were part of the FATCOD, form B,
which had been previously validated. Finally, we recognize

that it would have been helpful to expand the demographic

questions related to personal loss to include more specific
details related to timing of the death in order to more thoroughly evaluate the impact on student attitudes.
Ultimately, although the sample was small, the data suggest
that early exposure to a direct EOL care experience, as through
the RAMP program, had a positive effect on students attitudes
toward caring for the terminally ill. Although a more robust
evaluation is necessary to determine the outcomes of the program, this serves as promising preliminary data on a curricular
program that can be incorporated into the first year of study.
This would allow for early introduction to complex concepts
related to death and dying that may help better prepare students
for their future careers.

Appendix A
Rotating Apprenticeships in Medical Practice (RAMP) End-of-Life (EOL) Preexperience Survey
The purpose of this survey is to better understand medical students attitudes toward end-of-life care and to evaluate the CWRU
RAMP program as a means of introducing students to end-of-life care within the first year of medical education. Please complete
the short demographic profile and then complete the following scale that reflects your attitudes concerning the following
statements.

Demographics
1. Age:

2. Sex:

____18-22 years

____23-27 yrs

____36-45 years

____>46 yrs

____Male

____28-35 yrs

____Female

3. Last 4 digits of telephone#___________

4. Previous education on death and dying
____I took a course in death and dying previously
____I have never taken a specific course on death and dying, but material on the subject was included in other courses
____No information related to death and dying has ever been presented to me
5. Experience with loss:
____I have lost a friend or family member in the past
Present experience with loss:
____I am presently anticipating the loss of someone close to me
____I presently have someone close to me who is terminally ill
____I am not dealing with any impending loss at the present time

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The following questions2 ask about your beliefs and attitudes towards aspects of caring for and interacting with people who are
terminally ill and/or dying. Please select the option that best represents your own beliefs.
Strongly
Strongly
Disagree Disagree Neutral Agree Agree
1. Death is not the worst thing that can happen to a person.
2. I do not think about death very much.1
3. I would be uncomfortable talking about impending death with the dying person.
4. Caring for the patients family should continue throughout the period of grief and bereavement.
5. I would not want to care for a dying person.
6. I would be upset when the dying person I was caring for gave up hope of getting better.
7. I think it would be difficult to form a close relationship with the dying person.
8. There are times when the dying person welcomes death.
9. I hope the people I will care for wont die when I am present.
10. The family should be involved in the physical care of the dying person.
11. I am afraid to become friends with a dying person.
12. I think I will feel like running away when the person actually died.
13. Families need emotional support to accept the behavior changes of the dying person.
14. As a patient nears death, the physician should withdraw from his/her involvement with the
patient.
15. It is beneficial for the dying person to verbalize his/her feelings.
16. Care should extend to the family of the dying person.
17. Addiction to pain relieving medication should not be a concern when dealing with a dying patient.
18. I would be uncomfortable if I entered the room of a terminally ill person and found him/her crying.
19. Dying persons should be given honest answers about their condition.
20. Educating families about death and dying is not a physician responsibility.
21. Family members who stay close to a dying person often interfere with the professionals job
with the patient.
22. It is possible for physicians to help patients prepare for death.
1. Dickinson GE, Tournier RE, Still BJ. Twenty years beyond medical school: physicians attitudes toward death and terminally ill patients.
Arch Intern Med. 1999;159(185):1741-1744.
2. Frommelt KH. Attitudes toward care of the terminally ill: an educational intervention. Am J Hosp Palliat Care. 2003;20(1):13-22.

Appendix B
Rotating Apprenticeships in Medical Practice (RAMP) End-of-Life (EOL) Postexperience Survey
The purpose of this survey is to better understand medical students attitudes toward end-of-life care and to evaluate the CWRU
RAMP program as a means of introducing students to end-of-life care within the first year of medical education. Please complete
the short demographic profile and then complete the following scale that reflects your attitudes concerning the following statements.

Demographics
6. Age:

7. Sex:

____18-22 years

____23-27 yrs

____36-45 years

____>46 yrs

____Male

____28-35 yrs

____Female

8. Last 4 digits of telephone#___________

9. Previous education on death and dying
____I took a course in death and dying previously
____I have never taken a specific course on death and dying, but material on the subject was included in other courses
____No information related to death and dying has ever been presented to me

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American Journal of Hospice & Palliative Medicine 32(1)

58
10. Experience with loss:
____I have lost a friend or family member in the past
Present experience with loss:

____I am presently anticipating the loss of someone close to me

____I presently have someone close to me who is terminally ill
____I am not dealing with any impending loss at the present time
The following questions2 ask about your beliefs and attitudes towards aspects of caring for and interacting with people who are
terminally ill and/or dying. Please select the option that best represents your own beliefs.
Strongly
Strongly
Disagree Disagree Neutral Agree Agree
23. Death is not the worst thing that can happen to a person.
24. I do not think about death very much.1
25. I would be uncomfortable talking about impending death with the dying person.
26. Caring for the patients family should continue throughout the period of grief and
bereavement.
27. I would not want to care for a dying person.
28. I would be upset when the dying person I was caring for gave up hope of getting better.
29. I think it would be difficult to form a close relationship with the dying person.
30. There are times when the dying person welcomes death.
31. I hope the people I will care for wont die when I am present.
32. The family should be involved in the physical care of the dying person.
33. I am afraid to become friends with a dying person.
34. I think I will feel like running away when the person actually died.
35. Families need emotional support to accept the behavior changes of the dying person.
36. As a patient nears death, the physician should withdraw from his/her involvement with the
patient.
37. It is beneficial for the dying person to verbalize his/her feelings.
38. Care should extend to the family of the dying person.
39. Addiction to pain relieving medication should not be a concern when dealing with a dying
patient.
40. I would be uncomfortable if I entered the room of a terminally ill person and found him/her
crying.
41. Dying persons should be given honest answers about their condition.
42. Educating families about death and dying is not a physician responsibility.
43. Family members who stay close to a dying person often interfere with the professionals job
with the patient.
44. It is possible for physicians to help patients prepare for death.

Reflection on RAMP End-of-Life Care Experience

1. Which experience did you attend?
____________Palliative Care ______________Hospice
2. Did you have direct contact with patients and/or their families?
_____________Yes ______________No
3. Was this a helpful experience?
______________Yes ______________No

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59

4. What are your recommendations for future classes?

______________Have the experience at a later point in the medical school curriculum
______________Eliminate the experience
______________Make the experience more longitudinal (i.e. have repeated experiences throughout the curriculum,
rather than a single afternoon session)
______________Provide better preparation for the experience
______________Incorporate greater debriefing and discussion after the experience
______________No suggestions for improvement
1. Dickinson GE, Tournier RE, Still BJ. Twenty years beyond medical school: physicians attitudes toward death and terminally ill patients.
Arch Intern Med. 1999;159(15)L:1741-1744.
2. Frommelt KH. Attitudes toward care of the terminally ill: an educational intervention. Am J Hosp Palliat Care. 2003;20(1), 13-22.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

9.
10.

Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.

11.

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