{"paper_id":"2aa25b08-c1fa-488c-a4fe-765af43852a0","body_text":"Perceptions of palliative care among medical students: A thematic analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perceptions of palliative care among medical students: A thematic analysis Junji Chan, Tze Yuan Tee, Chee Loong Lam, Ee Chin Loh, Sheriza Izwa Zainuddin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2440713/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Palliative care (PC) needs are projected to increase and training future practitioners is an important response to this. While the specialty of PC has developed rapidly it is not yet universally integrated in healthcare. Advocacy has achieved improvements in this field but misperceptions of PC have remained in the general population. Methods : A qualitative study based on semi-structured interviews with medical students at a Malaysian university was conducted. Results were thematically analyzed. Results : Fifteen students were interviewed. Seven themes were generated: (1) Understanding palliative care (2) communication (3) spirituality (4) ethical issues (5 education. Conclusion : Perceptions of PC are relevant to the medical training and the development of PC. palliative care medical student perception hospice Introduction Palliative care (PC) improves the quality of life of patients with life-threatening illness by relieving suffering and improving quality of life through a holistic approach. It also supports their caregivers.[1] It is multidisciplinary, thus not only palliative care specialists, but healthcare workers of all specialties require a basic understanding about palliative care. Malaysia’s palliative care services has limited integration in the healthcare system.[2] However, the need of palliative care continues to rise despite there is lack of services to meet the acute needs in the country. Medical students play an important role in the development of PC as they undergo a transition from being members of the lay public to healthcare professionals. This is significant in several ways. Firstly their perceptions of PC at the beginning of their studies are more likely to resemble the general population and hence offer an opportunity to bridge gaps between the healthcare profession and the public. Secondly their socialization within the medical profession affects their perceptions of PC upon entering the workforce. While it has been shown that students feel poorly prepared to deal with end-of-life care, it is less well understood how they perceive PC. Previous studies have been done through questionnaires[3-10], reflective essays after clinical teachings[11, 12] and semi-structured interviews[13-16]. Factual knowledge about palliative care were mainly explored by using questionnaires and found deficiencies particularly with regards to psychosocial and spiritual care.[3-5, 7, 8, 10] The objective of this study was to qualitatively explore the perceptions of PC among Malaysian medical students. Methods Ethics approval had been obtained from the Ethics Committee at the University Malaya Medical Centre (MREC ID NO: 2022714-11381). We purposively sampled participants among undergraduate students at the faculty of medicine, University Malaya, Kuala Lumpur, Malaysia. Additionally we included two participants undergoing an attachment in palliative care as part of a postgraduate master’s degree. Recruitment was done through e-mail and personal contact among peer students and continued concurrently with data analysis until no further new themes were generated. Informed consent was obtained from all participants and semi-structured interviews according to the topic guide were conducted. The prompts used are listed in Table 1 . Between August and September 2022 13 undergraduate students and two postgraduate students were interviewed for a duration between 20 to 35 minutes in English language. Audio recordings were transcribed verbatim and thematic analysis performed on the transcripts. In the first two steps of thematic analysis the authors coded interviews and searched for themes individually. Findings were then compared within the author group and collaboratively themes were reviewed and defined prior to the preparation of the report. Interviews were re-read in the process to ensure the validity of the themes generated. Table 1: Topic guide to the semi-structure interview • Have you heard about palliative care? • Have you had experiences with patients under palliative care? • What are your thoughts about palliative care? • What should be the role of palliative care? • What issues in palliative care are you interested in? • How do you think palliative care will be related to your future practice of medicine? • Do you have concerns about palliative care? • How do you feel about delivering palliative care yourself? • What do you think should be included in palliative care teaching? Results Fifteen participants took part in this interview. The demographics of all participants are summarised in Table 2 . Table 2: Participant demographics Gender Female 8 (53.3%) Male 7 (46.7%) Age 21-30 13 (86.7%) 31-40 2 (13.3%) Year as medical student 3 9 (60.0%) 5 4 (26.7%) Post graduate student 2 (13.3%) Race Malay 4 (26.7%) Chinese 7 (46.7%) Indian 4 (26.7%) Religion Islam 4 (26.7%) Christian 6 (40%) Buddhism 3 (20.0%) Hindu 2 (13.3%) Family members received have received palliative care Yes 3 (20.0%) No 12 (80.0%) From the raw codes five themes were generated. Understanding of palliative care Palliative care is generally seen as an important part of medicine. Participants without previous contact with PC patients tended to offer a formal definition (centered on holism) when asked about their general understanding of the field. Those with a previous exposure to PC shared intuitions they had gained. So we want them to have as much control with their life as possible and then you, know respect. I mean in our… in our… in our subconscious we subconsciously might really respect or really care a bit more in terms of like their wishes and what else they wanted to do… things like that. Students saw PC as going beyond the routine process of making a diagnosis followed by treatment. I would say it is quite a different one because, you know, in medicine when we learn about many other different things we would say treat with this, treat with that. Treat,treat, treat, treat, treat . But then PC is more about. So what do you want more? I would say, a little bit more of a patient-centred although I know medicine in general should be patient-centred. PC responds to the particular needs of patients with life-limiting illness. Participants related PC to the special situations of patients they had clerked before. …they can feel their condition is getting worse, sometimes they like… just breakdown in front of me. I don’t know what to do, and I don’t know how to like, comfort them or… like make them feel better. I think like… that’s what palliative care do right? When following clinical staff as part of their training the participants noted that a previous PC exposure was reflected in a different approach to the care for patients. And I’m following one of the medical officer who previously did PC research. So I could really see how different she was, when she approached the patient, when she talked to the patient and try to understand the patient. As globally the importance of advocacy is gaining attention, medical students also mentioned the need to empower caregivers, for example through offering PC education. I think a lot can be learnt from PC, because I think everyone… the time will come when we have to take care of our parents or our loved ones. I think if this knowledge is available to everyone, not just me, (but) to everyone, I think it helps a lot la, yeah. I think we need to educate. The caregivers… need to spend some time to learn about this. Maybe we can do classes… classes about this… or make the information more readily available on the internet… maybe yeah. The role of caregivers in PC was seen as very important. As a student pointed out they are intimately acquainted with the patient, able to offer the ideal comfort in a familiar environment. Definitely need the family members, because they are the people that constantly give care to the patients and not their doctors, so I think it is definitely important that the family members are informed and know what they can do, how much they can do to inform the patients. Students also reflected on the importance of balancing hopes and expectations of both patients and their family members and argued that they are equally important. I think equally important because some may say eh, actually of course is the patient la, because it’s the patient’s life. I feel like afterwards, those who still be here is the family member to… help you to clean up after your… you passed away. Help you…. They are the ones who stay here. So I think is also in equally important that they know what is going on and they are okay with that. Yeah. Not just you… it’s equally important. Discussions in palliative care often center around realistic hopes and wishes to be fulfilled. In the absence of training in PC, the situations of patients are sometimes described in terms of “hopelessness” and cases “where nothing much could be done”. Therefore in order to foster and preserve hope one has to be very sensitive when these terms are used either by patients or other healthcare professionals and sensitively explore underlying intended meaning. Most of the people know when a person goes into palliative care it means there’s not much time for them anymore. And I think the patient also knows this, right? So emotionally you must make sure that the patient is not depressed, if they show signs of depression, maybe we as a doctor can uh… ask them to see a psychiatrist or anything. PC has also been associated with a job that is depressing and heart-breaking. However, relieving patients’ suffering holistically, be it physically or psychosocially, can offer important comfort to patients through the practice of humanistic medicine. I think sometimes it’s heart-breaking to see them, I think because we cannot do anything much to cure them anymore, and all we can do is just make them comfortable. Other students noted the importance of having the right attitude towards facing challenges in PC and gaining clinical experience from an increasing number of patient encounters. I guess it's just the way how we put things and how we break the news to them that it is. It's not the end of the world. It is still, there’s still hope there’s still challenge. They are a lot of people in the world that need palliative care. Hence, you know, it's all under our supervision. So there is no problem with that. You just have to bear with it. Communication: handling difficult situations Students were concerned about their communication skills in PC settings as prior teaching had not included it. The task of history taking was seen as stereotypically following a list of items from the biomedical domain and not including the patient perspective properly. When we clerk a patient our lectures don’t really focus on that part, they just want us to clerk the HOPI, all those PMH they want it to be uh.. like very detail, but for the patient’s expectation part and the ideas, expectations, what they are worried about, those kind of things, they don’t really spend time on them. There was a sense of missing out on an important element of the patient-doctor interaction as a consequence. Issues such as a poor prognosis and suffering were seen as sensitive and tended to be avoided. Students recognized this as a deficiency in their approach and had hope that more experience would equip them better. I’m not sure whether it’s a good way, because we sort of like… avoided the question itself and not really settle her problem. The way I should approach this patient, I mean , as times goes, I’m exposed to more patients like that, I think I would get my way, haha. I think it’s about experience. Communication around sensitive topics carried an emotional challenge which could sometimes lead to students actively avoiding PC patients. Precious time available on the wards was thus often spent clerking patients who were selected for the perceived learning benefit with regards to passing later exams. Some of us tend to just avoid straight up not talking to patients like this, you know, we can talk to other patients, why do I have to talk to this specific patient whose just gonna make me more sad and you know, yeah. Spirituality: dignity, suffering Students rarely used term spirituality, however many of their reflections on PC fit in the formal definition of spiritual concerns. Having seen patients losing their independence prompted students to consider PC as a way of re-establishing and preserving dignity when life-limiting illness threatened it. They empathically imagined the experience of the patients, taking on their perspective in hoping for PC to restore a lost sense of dignity. Hmm… from palliative care… dignity. Because what I can imagine from now, because when I clerked the stroke patients, sometimes they have uhm like, dribbling, and then they cannot feed themselves, and then sometimes they can have some incontinence, and then I cannot imagine if I’m in their position, so … uh… if, if I’m referred to the palliative, palliative care, I hope that they can help me to settle this problem? Make me look like I can .. I can like… make me look like my activity of daily living can be like, I can settle it independently. Yeah. Likewise, although students rarely used the term “suffering”, they have observed in their patients the effect of a threat to the intactness of the person, for example in cases of social isolation and lack of family support. Another one is, sometimes they might have challenges, like some social problems/ social issues where they don’t have any family members, or their family members couldn’t really take care of them. They are already dying … in a dying state and they know they are gonna die soon, but they have no one to hold on to. So that’s what makes me feel a bit… sad and yeah. Students offered rich descriptions of patient suffering. For example life itself seemed torturing to one patient and responding to patients’ feelings of helplessness meant having to face the limitations of medicine and healthcare professionals in relieving illness. I just saw patient cry in front of me because she’s a CKD patient, like late-stage CKD and then her family members also have CKD. She’s really stressed, then she don’t know what to do next, she feels like her life is like, very … torturing? Then she cried in front of me and my friends Patient encounters put students in immediate touch with existential concerns and the associated suffering. PC, one thing is that patients in PC, they know that they are gonna go, it’s the matter of when and how they gonna go. So you come to think of it, even I as a regular person thinking how and when I wanna go it’s quite daunting. Witnessing the journeys of patients with terminal illness gave students new perspectives on their own lives and personal spirituality. Having to face the end of life could be the real fear behind a patient’s variety of physical and psychosocial and spiritual complaints. The aspect of anticipatory grief is reflected in the concern about ceasing to exist as a person in the world. Students also distinguish between spirituality as an aspect of human existence which is relevant regardless of religious affiliation. Hmm… like their religion? And also if not religion, if they’re like, at least have any… what they know about death and what is the real fear behind all their situation, so like, yeah….Like one of my friend, she said like, she is fear of death because she is afraid of like, it would be nothing, she would be nothing in the world and she is fear of this. And this is nothing regarding the religion. This is her fear. Ethical issues: euthanasia Ethical issues surrounding the issue of euthanasia were mentioned repeatedly. Feelings surrounding this were very ambiguous and there was a tension between a strong desire to relieve patient suffering and a firm dedication to principles of ethics and religious conviction. Personally, I… I wouldn’t be comfortable with doing it, but I think it has some group room in terms of… In terms of, in people who think they really suffer a lot. And in terms of their personal wishes and their autonomy perspective. I would… I would… most sort of time… I think that part has some room for discussion from my part la. And…. but I… I… I, I do, I do acknowledge that law does not permit here and I do agree that we should not play God. Some people might put it that way, that euthanasia is… it’s like we are playing God. I do acknowledge that part and I think… I think it has some rooms in terms of patients who really suffer and they know what they’re doing in terms of their… they know their decision in this… in a sound person they have the…. They are making their informed decision Euthanasia is seen in the context of the patient suffering at the end of life and participants felt a need to understand in depth the situation of the patient and to what extent PC had been provided or could be improved. “ I wish to die.” I’ll definitely have a doubt, but of course we have to understand why … is it because of the disease burden, or the treatment is really making them suffer? So far I have no clue. And a thing there’s a lot more to improve on… as in not just the treatment, and also the very basic care for the patient. Students’ views generally very nuanced, highlighting the need to assess the individual situation of the patient. A spectrum of ethical opinions was held, where some students favoured euthanasia. R: Err… but… in my personal point of view like… in general my point of view for euthanasia? Personally, I support this idea, because like I said, if I were to die, I want to die with dignity. If by any chance, my life is out of my control, I would want to … I would want to like I said, die in a way I want. Others, while being receptive to opposing arguments, expressed disagreement. So my thought of euthanasia for now is if best, don’t do it. Maybe I should review into it more carefully and maybe I should see about it… but otherwise it’s a no for me la. Education: experience, self-care, self-reflection Following early exposures to PC participants considered experience as very important in their development of palliative skills. R: I think they need to show us examples like how they approach this with a real patient, so that I can see how the real patient react, the family members. So I think by that is the best way for me to learn. Improving communication skills was considered very significant, however students felt that earlier teaching outside the actual clinical context had done little to prepare them well. There was a preference towards increasing the amount of teaching in PC delivered in the actual context of patient care rather than in abstract lectures. I’m not sure whether it’s a good way, because we sort of like… avoided the question itself and not really settle her problem. The way I should approach this patient, I mean , as times goes, I’m exposed to more patients like that, I think I would get my way, haha. I think it’s about experience. Students noticed limitations with mnemonic based techniques and were instead understood communication as being shaped by factors related to the individual persons involved. we have a lot of mnemonics or protocol, things like that but people are different. Humans being humans, every human is different. How… how do we really understand what up Hu- What kind of people we are dealing with and what kind of approach we can… to deal with them. I think that… that would be some… something, which I am a bit concerned about. An empathic process of communication was described as using one’s own experiences in trying to understand the patient better. As in understanding what they are going through? It helps a lot with being more empathetic with the patient if you understand what they are going through. (There’s) a lot of things you can only learn from experience, either personal or from people around you, and if you can use your experiences to try to understand the patient better then I feel like you will be able to provide better care for them Developing a habit of reflection was seen as an important factor in developing PC skills, requiring time within a busy clinic schedule. You know, just don’t have the kind of emotions? I don’t know. Or maybe it’s just that it’s… it’s just that we don’t quite often, so might not be very comfortable with. Because you are not doing it often, so we don’t practice it enough and it’s a skill. Skills needs practice I think. At times severe emotional distress and doubt surfaced as well. These descriptions of personally struggling in the face of patient suffering were notable for an intense emotional involvement in the experiences of patients and carers. Because last time when I was in paediatrics onco ward, that was like my… first week of my clinical years. And I get really emotional, like the whole week I cry…. Like every time I clerk a patient I have to go out and ohhh… take a deep breath and then my tears just vroommm like that. So, uhh… I think it really looks not professional? And in a sense, patients are expecting some encouraging? Or comfort words from the…and reassurance from the doctors, and if the doctors are crying, like that, then… (sobs) it makes no sense. Discussion This study revealed a range of perceptions regarding PC among medical students. They included factual knowledge, attitudes, expectations as well as ethical issues. Generally students appreciate PC as an important part of care. They ponder the potential challenges it includes and how they can prepare for them. In agreement with previous work we found that aside from factual knowledge, students did not find theoretical teaching lectures and problem-based learning sessions effective enough to learn end-of-life competencies, such as cultural or spiritual aspects of end-of-life care, communication skills with dying patients and their families and critical reflection on experiences around death.[17] Medical students agreed that they would have a better understanding of palliative care with more clinical exposure, for instance, clinical rotations.[3, 12, 15, 18] Experience-based learnings allows medical students to be actively engaged[19] Experience-based learnings allows medical students to be actively engaged.[11] Similar to previous studies our participants sensed a strong degree of sensitivity around the topics of death and dying, occasionally even perceiving it as taboo topics[9, 13, 14] Some felt comfortable with palliative care patients.[15] Others prefer to avoid palliative care or approaching dying patients as they experience emotional difficulties. They stated that witnessing death, dying and suffering of a patient and the grief of their family was “emotionally destructive”. They felt stressed due to the emotional attachment with dying patients and their families and admitted that there might be a risk of burnout.[18] ] Older medical students tended to be less afraid of approaching such patients and had more positive attitudes about caring for them.[20] A study comparing UK and US medical students suggested that cultural differences towards death and dying seemed to affect students’ perception of palliative care. A culture within medicine that is more receptive towards palliative care could help students to appreciate the value of end-of-life care.[21] With regards to the ethics of end-of-life care the current study found that students were intensely engaging with the current discourse around euthanasia and assisted suicide, while they were generally reluctant to commit to a definite position in this question they were receptive to arguments from both sides. In comparison a previous study found that medical students tend to be more reluctant to withdraw and withhold therapies, however they found euthanasia and assisted suicide more acceptable than doctors.[22] Personal experiences and beliefs influence medical students’ perceptions too.[6, 9] This could be one of the reasons for varying attitudes and perceptions of palliative care from studies in different countries. Although students had admitted that they feel unprepared and not confident in delivering PC, they appreciated the importance of PC and welcomed more teaching.[4, 5, 13] A Taiwanese study showed that a 1-week multimodal curriculum of palliative care managed to help students who voluntarily attended to improve significantly in palliative care knowledge and beliefs about ethical decision-making.[23] Recommendations Understanding perceptions of PC among students is a vital part in the effort to expand PC in the future. Negative attitudes towards PC may lead to a nihilistic approach which fails to realise the potential to improve patients’ quality of life. It also entails the very significant risk of healthcare provider burnout due to a sense of helplessness in the face of life limiting illness.[24] Medical students were very engaged with the issue of suffering. The expectation to receive training in this area is an opportunity for curriculum design. For example the relevance of PC across the spectrum of medical specialties can be acknowledged by highlighting its multidisciplinary character in the curriculum. Emotional aspects deserve attention as well. The perception of PC as a last resort needs to be actively addressed as this can threaten the vital objective of supporting hope among patients. Students did appreciate this skill in particular among faculty during their attachments, underlining the significance of the hidden curriculum.[24] Our research highlighted the potential for transmitting vital skills and attitudes from faculty to students. Importantly it was motivating for students to witness experienced practitioners deliver PC which could be immediately seen as effective in relieiving patient suffering. This opportunity to demonstrate the value of PC in terms of the patient benefit can be helpful in clearing the perception of PC as a less important specialty of medicine. As has been shown for family medicine such misperceptions of apparently less meaningful specialties can have a pervasive influence on career decision making among junior doctors.[25] Cultural aspects of PC are yet another factor deserving attention. As we have shown, students realized that discussions about death and dying would need to respect cultural factors. While ethics are a universal set of principles it has to be acknowledged that ethical aims cannot be achieved while disregarding elements of culture. Hence there is a need to tailor the practice of PC to the relevant setting or else run the risk of compromising care by too narrow an understanding of the precepts of ethics. The awareness of ethical issues in PC among students is an opportunity for further learning. Exposure to clinical practice offers a realistic background which infuses otherwise abstract ethical discussions with practical relevance. Considering this in curriculum design would enable students to develop a practice of continuous ethical reflection and equip them with the competence to reason about ethical challenges and recognize the role of involving other professionals in addressing difficult deliberations. Finally our study revealed a degree of anxiety among students as they pondered having to face suffering in their career. This finding is relevant with regards to their future professional and personal well being as exposure to chronic and incurable illness is expected to increase and preparedness for this is essential in preservering their wellbeing and mental health. Limitations Our study has several limitations. Firstly it was done at a single university and hence does not reflect the wider population of Malaysian medical students. Secondly the topic guide was formulated in a broad fashion owing to the vastness of the topic. Further studies are warranted to explore the various topics in greater detail. Additionally we did not account for the possibility of students either having had prior teaching exposure to PC or not. Some students therfore were able to speak from previous experience with PC while others related their perceptions prior to any teaching. Conclusion Perceptions of PC among medical students significantly influence their attitudes towards care for patients with life limiting illness. In order to expand PC and increase doctors’ confidence in delivering PC a better understanding of existing perceptions is needed. Declarations Acknowledgements: The authors would like to express their thanks to all participants who generously shared their time and views on this matter. Authors’ contributions TYT and JC performed the interviews, JC completed the transcriptions. The manuscripted was collaboratively prepared by JC, TYT, CLL, ECL, SIZ and DPC. Funding This study was not supported by dedicated funding. Availability of data and materials The datasets obtained and analyzed are available from the corresponding author on reasonable request. Ethics approval and consent to participate Ethical approval was obtained from the Medical Research Ethics Committee at University of Malaya Medical Centre ( MREC ID NO : 2022714-11381). The study was conducted in accordance with the Declaration of Helsinki and relevant guidelines and regulations . Participants were given an information sheet about the study before completing the consent form. All participants have provided informed consent. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References World-Health-Organisation. Palliative care . 5 August 2020; Available from: https://www.who.int/news-room/fact-sheets/detail/palliative-care. Sivalingam, N., R.B.L. Lim, and L. Rampal, Palliative care in Malaysia: the need to do much more. Med J Malaysia, 2021. 76 (3): p. 279-283. 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Lewis, C., et al., The impact of a simulated intervention on attitudes of undergraduate nursing and medical students towards end of life care provision. BMC Palliat Care, 2016. 15 : p. 67. Lloyd-Williams, M. and N. Dogra, Caring for dying patients--what are the attitudes of medical students? Support Care Cancer, 2003. 11 (11): p. 696-9. Hammel, J.F., et al., End-of-life and palliative care education for final-year medical students: a comparison of Britain and the United States. J Palliat Med, 2007. 10 (6): p. 1356-66. Alminoja, A., et al., Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians? In Vivo, 2019. 33 (3): p. 903-909. Chang, H.H., et al., Reflections on an end-of-life care course for preclinical medical students. J Formos Med Assoc, 2009. 108 (8): p. 636-43. Sullivan, A.M., M.D. Lakoma, and S.D. Block, The status of medical education in end-of-life care: a national report. J Gen Intern Med, 2003. 18 (9): p. 685-95. Zainal, H. and H.E. Smith, Medical students' attitudes towards careers in primary care in Singapore. BMC Med Educ, 2020. 20 (1): p. 464. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-2440713\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":376223353,\"identity\":\"cf040d98-a9b5-4bcd-a332-890000270114\",\"order_by\":0,\"name\":\"Junji Chan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Malaya\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Junji\",\"middleName\":\"\",\"lastName\":\"Chan\",\"suffix\":\"\"},{\"id\":376223354,\"identity\":\"72955ffe-110a-4122-96d5-09212e19a7e9\",\"order_by\":1,\"name\":\"Tze Yuan Tee\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Ministry of Health\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tze\",\"middleName\":\"Yuan\",\"lastName\":\"Tee\",\"suffix\":\"\"},{\"id\":376223355,\"identity\":\"3d7c3813-da05-4ce7-a5f6-e34811afd28b\",\"order_by\":2,\"name\":\"Chee Loong Lam\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Malaya\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Chee\",\"middleName\":\"Loong\",\"lastName\":\"Lam\",\"suffix\":\"\"},{\"id\":376223356,\"identity\":\"1b656662-5ed2-4b8c-8695-2e09813f0872\",\"order_by\":3,\"name\":\"Ee Chin Loh\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Malaya\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ee\",\"middleName\":\"Chin\",\"lastName\":\"Loh\",\"suffix\":\"\"},{\"id\":376223357,\"identity\":\"0e88ec91-6f4d-4eb0-be3b-6d37aa206244\",\"order_by\":4,\"name\":\"Sheriza Izwa Zainuddin\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Malaya\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sheriza\",\"middleName\":\"Izwa\",\"lastName\":\"Zainuddin\",\"suffix\":\"\"},{\"id\":376223358,\"identity\":\"039a6dc1-37f4-438d-b0e3-6dbf2023b83a\",\"order_by\":5,\"name\":\"Capelle David Paul\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYDCCA0DEA2YxNx5gqACzDIjVwthwgOEMkVoY4FoY24jQwnf8jOGBNwx28ubsjQ0HPs47HM3A3rxNgjHnME4tkmdyDA7OYUg23NlzsOHgzG2Hcxt4jpVJMG7DrcXgQFrCYR6GA4wbbiQ2HOYFaZHIMcOv5fwzsBb7DfcfNhz+OweoRf4NAS03kg+AtCRuuMHYcBiIgLbw4NcieePxgYNzDJKTd/YkNhzsOZae28aTVmyRuC0dpxa+84nNH95U2NluZz988MGPGuvcfvbDG2983GaNUwvUeUhxwQYiEhiaCWhhwIy+OsJaRsEoGAWjYKQAAHNfY1x9fVa3AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"University of Malaya\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Capelle\",\"middleName\":\"David\",\"lastName\":\"Paul\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2023-01-04 00:59:21\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-2440713/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-2440713/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":68779833,\"identity\":\"dc49a141-f72c-4fac-a4ad-04099598c169\",\"added_by\":\"auto\",\"created_at\":\"2024-11-12 02:27:49\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":441237,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2440713/v1/982445cd-4386-4610-b51d-150126d66ddc.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Perceptions of palliative care among medical students: A thematic analysis\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePalliative care (PC) improves the quality of life of patients with life-threatening illness by relieving suffering and improving\\u0026nbsp;quality of life through a holistic approach. It also supports their caregivers.[1]\\u0026nbsp;It is multidisciplinary, thus not only palliative care specialists, but healthcare workers of all specialties require a basic understanding about palliative care. Malaysia\\u0026rsquo;s palliative care services has limited integration in the healthcare system.[2]\\u0026nbsp;However, the need of palliative care continues to rise despite there is lack of services to meet the acute needs in the country.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMedical students play an important role in the development of PC as they undergo a transition from being members of the lay public to healthcare professionals. This is significant in several ways. Firstly their perceptions of PC at the beginning of their studies are more likely to resemble the general population and hence offer an opportunity to bridge gaps between the healthcare profession and the public. Secondly their socialization within the medical profession affects their perceptions of PC upon entering the workforce.\\u003c/p\\u003e\\n\\u003cp\\u003eWhile it has been shown that students feel poorly prepared to deal with end-of-life care, it is less well understood how they perceive PC.\\u0026nbsp;Previous studies have been done through questionnaires[3-10], reflective essays after clinical teachings[11, 12]\\u0026nbsp;and semi-structured interviews[13-16]. Factual knowledge about palliative care were mainly explored by using questionnaires and\\u0026nbsp;found deficiencies particularly with regards to psychosocial and spiritual care.[3-5, 7, 8, 10]\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe objective of this study was to qualitatively explore the perceptions of PC among Malaysian medical students.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eEthics approval had been obtained from the Ethics Committee at the University Malaya Medical Centre (MREC ID NO: 2022714-11381).\\u003c/p\\u003e\\n\\u003cp\\u003eWe purposively sampled participants among undergraduate students at the faculty of medicine, University Malaya, Kuala Lumpur, Malaysia. Additionally we included two participants undergoing an attachment in palliative care as part of a postgraduate master\\u0026rsquo;s degree.\\u003c/p\\u003e\\n\\u003cp\\u003eRecruitment was done through e-mail and personal contact among peer students and continued concurrently with data analysis until no further new themes were generated. Informed consent was obtained from all participants and semi-structured interviews according to the topic guide were conducted. The prompts used are listed in \\u003cem\\u003eTable 1\\u003c/em\\u003e. Between August and September 2022 13 undergraduate students and two postgraduate students were interviewed for a duration between 20 to 35 minutes in English language. Audio recordings were transcribed verbatim and thematic analysis performed on the transcripts.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the first two steps of thematic analysis the authors coded interviews and searched for themes individually. Findings were then compared within the author group and collaboratively themes were reviewed and defined prior to the preparation of the report. Interviews were re-read in the process to ensure the validity of the themes generated.\\u003c/p\\u003e\\n\\u003cp\\u003eTable\\u0026nbsp;1: Topic guide to the semi-structure interview\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"602\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 100%;\\\"\\u003e\\u0026bull; Have you heard about palliative care?\\u003cbr\\u003e\\u0026bull; Have you had experiences with patients under palliative care?\\u003cbr\\u003e\\u0026bull; What are your thoughts about palliative care?\\u003cbr\\u003e\\u0026bull; What should be the role of palliative care?\\u003cbr\\u003e\\u0026bull; What issues in palliative care are you interested in?\\u003cbr\\u003e\\u0026bull; How do you think palliative care will be related to your future practice of medicine?\\u003cbr\\u003e\\u0026bull; Do you have concerns about palliative care?\\u003cbr\\u003e\\u0026bull; How do you feel about delivering palliative care yourself?\\u003cbr\\u003e\\u0026bull; What do you think should be included in palliative care teaching?\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eFifteen participants took part in this interview. The demographics of all participants are summarised in \\u003cem\\u003eTable 2\\u003c/em\\u003e. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTable\\u0026nbsp;2: Participant demographics\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"360\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003eGender\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e8 \\u0026nbsp;(53.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e7 (46.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003eAge\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003e21-30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e13 (86.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003e31-40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e2 (13.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003eYear as medical student\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e9 (60.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4 (26.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003ePost graduate student\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e2 (13.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003eRace\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eMalay\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4 (26.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eChinese\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e7 (46.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eIndian\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4 (26.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"4\\\" valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003eReligion\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eIslam\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4 (26.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eChristian\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e6 (40%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eBuddhism\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e3 (20.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eHindu\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e2 (13.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 181px;\\\"\\u003e\\n \\u003cp\\u003eFamily members received have received palliative care\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e3 (20.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 83px;\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e12 (80.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eFrom the raw codes five themes were generated.\\u003c/p\\u003e\\n\\u003ch1\\u003eUnderstanding of palliative care\\u003c/h1\\u003e\\n\\u003cp\\u003ePalliative care is generally seen as an important part of medicine. Participants without previous contact with PC patients tended to offer a formal definition (centered on holism) when asked about their general understanding of the field. Those with a previous exposure to PC shared intuitions they had gained.\\u003c/p\\u003e\\n\\u003cp\\u003eSo we want them to have as much control with their life as possible and then you, know respect. I mean in our\\u0026hellip; in our\\u0026hellip; in our subconscious we subconsciously might really respect or really care a bit more in terms of like their wishes and what else they wanted to do\\u0026hellip; things like that.\\u003c/p\\u003e\\n\\u003cp\\u003eStudents saw PC as going beyond the routine process of making a diagnosis followed by treatment.\\u003c/p\\u003e\\n\\u003cp\\u003eI would say it is quite a different one because, you know, in medicine when we learn about many other different things we would say treat with this, treat with that. Treat,treat, treat, treat, treat . But then PC is more about. So what do you want more? I would say, a little bit more of a patient-centred although I know medicine in general should be patient-centred.\\u003c/p\\u003e\\n\\u003cp\\u003ePC responds to the particular needs of patients with life-limiting illness. Participants related PC to the special situations of patients they had clerked before.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026hellip;they can feel their condition is getting worse, sometimes they like\\u0026hellip; just breakdown in front of me. I don\\u0026rsquo;t know what to do, and I don\\u0026rsquo;t know how to like, comfort them or\\u0026hellip; like make them feel better. I think like\\u0026hellip; that\\u0026rsquo;s what palliative care do right?\\u003c/p\\u003e\\n\\u003cp\\u003eWhen following clinical staff as part of their training the participants noted that a previous PC exposure was reflected in a different approach to the care for patients.\\u003c/p\\u003e\\n\\u003cp\\u003eAnd I\\u0026rsquo;m following one of the medical officer who previously did PC research. So I could really see how different she was, when she approached the patient, when she talked to the patient and try to understand the patient.\\u003c/p\\u003e\\n\\u003cp\\u003eAs globally the importance of advocacy is gaining attention, medical students also mentioned the need to empower caregivers, for example through offering PC education.\\u003c/p\\u003e\\n\\u003cp\\u003eI think a lot can be learnt from PC, because I think everyone\\u0026hellip; the time will come when we have to take care of our parents or our loved ones. I think if this knowledge is available to everyone, not just me, (but) to everyone, I think it helps a lot la, yeah. I think we need to educate. The caregivers\\u0026hellip; need to spend some time to learn about this. Maybe we can do classes\\u0026hellip; classes about this\\u0026hellip; or make the information more readily available on the internet\\u0026hellip; maybe yeah.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe role of caregivers in PC was seen as very important. As a student pointed out they are intimately acquainted with the patient, able to offer the ideal comfort in a familiar environment.\\u003c/p\\u003e\\n\\u003cp\\u003eDefinitely need the family members, because they are the people that constantly give care to the patients and not their doctors, so I think it is definitely important that the family members are informed and know what they can do, how much they can do to inform the patients.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eStudents also reflected on the importance of balancing hopes and expectations of both patients and their family members and argued that they are equally important.\\u003c/p\\u003e\\n\\u003cp\\u003eI think equally important because some may say eh, actually of course is the patient la, because it\\u0026rsquo;s the patient\\u0026rsquo;s life. I feel like afterwards, those who still be here is the family member to\\u0026hellip; help you to clean up after your\\u0026hellip; you passed away. Help you\\u0026hellip;. They are the ones who stay here. So I think is also in equally important that they know what is going on and they are okay with that. Yeah. Not just you\\u0026hellip; it\\u0026rsquo;s equally important.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDiscussions in palliative care often center around realistic hopes and wishes to be fulfilled. In the absence of training in PC, the situations of patients are sometimes described in terms of \\u0026ldquo;hopelessness\\u0026rdquo; and cases \\u0026ldquo;where nothing much could be done\\u0026rdquo;. Therefore in order to foster and preserve hope one has to be very sensitive when these terms are used either by patients or other healthcare professionals and sensitively explore underlying intended meaning.\\u003c/p\\u003e\\n\\u003cp\\u003eMost of the people know when a person goes into palliative care it means there\\u0026rsquo;s not much time for them anymore. And I think the patient also knows this, right? So emotionally you must make sure that the patient is not depressed, if they show signs of depression, maybe we as a doctor can uh\\u0026hellip; ask them to see a psychiatrist or anything.\\u003cbr\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ePC has also been associated with a job that is depressing and heart-breaking. However, relieving patients\\u0026rsquo; suffering holistically, be it physically or psychosocially, can offer important comfort to patients through the practice of humanistic medicine.\\u003c/p\\u003e\\n\\u003cp\\u003eI think sometimes it\\u0026rsquo;s heart-breaking to see them, I think because we cannot do anything much to cure them anymore, and all we can do is just make them comfortable.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOther students noted the importance of having the right attitude towards facing challenges in PC and gaining clinical experience from an increasing number of patient encounters.\\u003c/p\\u003e\\n\\u003cp\\u003eI guess it\\u0026apos;s just the way how we put things and how we break the news to them that it is. It\\u0026apos;s not the end of the world. It is still, there\\u0026rsquo;s still hope there\\u0026rsquo;s still challenge. They are a lot of people in the world that need palliative care. Hence, you know, it\\u0026apos;s all under our supervision. So there is no problem with that. You just have to bear with it.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch1\\u003eCommunication: handling difficult situations\\u003c/h1\\u003e\\n\\u003cp\\u003eStudents were concerned about their communication skills in PC settings as prior teaching had not included it. The task of history taking was seen as stereotypically following a list of items from the biomedical domain and not including the patient perspective properly.\\u003c/p\\u003e\\n\\u003cp\\u003eWhen we clerk a patient our lectures don\\u0026rsquo;t really focus on that part, they just want us to clerk the HOPI, all those PMH they want it to be uh.. like very detail, but for the patient\\u0026rsquo;s expectation part and the ideas, expectations, what they are worried about, those kind of things, they don\\u0026rsquo;t really spend time on them.\\u003c/p\\u003e\\n\\u003cp\\u003eThere was a sense of missing out on an important element of the patient-doctor interaction as a consequence. Issues such as a poor prognosis and suffering were seen as sensitive and tended to be avoided. Students recognized this as a deficiency in their approach and had hope that more experience would equip them better.\\u003c/p\\u003e\\n\\u003cp\\u003eI\\u0026rsquo;m not sure whether it\\u0026rsquo;s a good way, because we sort of like\\u0026hellip; avoided the question itself and not really settle her problem. The way I should approach this patient, I mean , as times goes, I\\u0026rsquo;m exposed to more patients like that, I think I would get my way, haha. I think it\\u0026rsquo;s about experience.\\u003c/p\\u003e\\n\\u003cp\\u003eCommunication around sensitive topics carried an emotional challenge which could sometimes lead to students actively avoiding PC patients. Precious time available on the wards was thus often spent clerking patients who were selected for the perceived learning benefit with regards to passing later exams.\\u003c/p\\u003e\\n\\u003cp\\u003eSome of us tend to just avoid straight up not talking to patients like this, you know, we can talk to other patients, why do I have to talk to this specific patient whose just gonna make me more sad and you know, yeah.\\u003c/p\\u003e\\n\\u003ch1\\u003eSpirituality: dignity, suffering\\u003c/h1\\u003e\\n\\u003cp\\u003eStudents rarely used term spirituality, however many of their reflections on PC fit in the formal definition of spiritual concerns. Having seen patients losing their independence prompted students to consider PC as a way of re-establishing and preserving dignity when life-limiting illness threatened it. They empathically imagined the experience of the patients, taking on their perspective in hoping for PC to restore a lost sense of dignity.\\u003c/p\\u003e\\n\\u003cp\\u003eHmm\\u0026hellip; from palliative care\\u0026hellip; dignity. Because what I can imagine from now, because when I clerked the stroke patients, sometimes they have uhm like, dribbling, and then they cannot feed themselves, and then sometimes they can have some incontinence, and then I cannot imagine if I\\u0026rsquo;m in their position, so \\u0026hellip; uh\\u0026hellip; if, if I\\u0026rsquo;m referred to the palliative, palliative care, I hope that they can help me to settle this problem? Make me look like I can .. I can like\\u0026hellip; make me look like my activity of daily living can be like, I can settle it independently. Yeah.\\u003c/p\\u003e\\n\\u003cp\\u003eLikewise, although students rarely used the term \\u0026ldquo;suffering\\u0026rdquo;, they have observed in their patients the effect of a threat to the intactness of the person, for example in cases of social isolation and lack of family support.\\u003c/p\\u003e\\n\\u003cp\\u003eAnother one is, sometimes they might have challenges, like some social problems/ social issues where they don\\u0026rsquo;t have any family members, or their family members couldn\\u0026rsquo;t really take care of them. They are already dying \\u0026hellip; in a dying state and they know they are gonna die soon, but they have no one to hold on to. So that\\u0026rsquo;s what makes me feel a bit\\u0026hellip; sad and yeah.\\u003c/p\\u003e\\n\\u003cp\\u003eStudents offered rich descriptions of patient suffering. For example life itself seemed torturing to one patient and responding to patients\\u0026rsquo; feelings of helplessness meant having to face the limitations of medicine and healthcare professionals in relieving illness.\\u003c/p\\u003e\\n\\u003cp\\u003eI just saw patient cry in front of me because she\\u0026rsquo;s a CKD patient, like late-stage CKD and then her family members also have CKD. She\\u0026rsquo;s really stressed, then she don\\u0026rsquo;t know what to do next, she feels like her life is like, very \\u0026hellip; torturing? Then she cried in front of me and my friends\\u003c/p\\u003e\\n\\u003cp\\u003ePatient encounters put students in immediate touch with existential concerns and the associated suffering.\\u003c/p\\u003e\\n\\u003cp\\u003ePC, one thing is that patients in PC, they know that they are gonna go, it\\u0026rsquo;s the matter of when and how they gonna go. So you come to think of it, even I as a regular person thinking how and when I wanna go it\\u0026rsquo;s quite daunting.\\u003c/p\\u003e\\n\\u003cp\\u003eWitnessing the journeys of patients with terminal illness gave students new perspectives on their own lives and personal spirituality. Having to face the end of life could be the real fear behind a patient\\u0026rsquo;s variety of physical and psychosocial and spiritual complaints. The aspect of anticipatory grief is reflected in the concern about ceasing to exist as a person in the world. Students also distinguish between spirituality as an aspect of human existence which is relevant regardless of religious affiliation.\\u003c/p\\u003e\\n\\u003cp\\u003eHmm\\u0026hellip; like their religion? And also if not religion, if they\\u0026rsquo;re like, at least have any\\u0026hellip; what they know about death and what is the real fear behind all their situation, so like, yeah\\u0026hellip;.Like one of my friend, she said like, she is fear of death because she is afraid of like, it would be nothing, she would be nothing in the world and she is fear of this. And this is nothing regarding the religion. This is her fear.\\u003c/p\\u003e\\n\\u003ch1\\u003eEthical issues: euthanasia\\u003c/h1\\u003e\\n\\u003cp\\u003eEthical issues surrounding the issue of euthanasia were mentioned repeatedly. Feelings surrounding this were very ambiguous and there was a tension between a strong desire to relieve patient suffering and a firm dedication to principles of ethics and religious conviction.\\u003c/p\\u003e\\n\\u003cp\\u003ePersonally, I\\u0026hellip; I wouldn\\u0026rsquo;t be comfortable with doing it, but I think it has some group room in terms of\\u0026hellip; In terms of, in people who think they really suffer a lot. And in terms of their personal wishes and their autonomy perspective. I would\\u0026hellip; I would\\u0026hellip; most sort of time\\u0026hellip; I think that part has some room for discussion from my part la. And\\u0026hellip;. but I\\u0026hellip; I\\u0026hellip; I, I do, I do acknowledge that law does not permit here and I do agree that we should not play God. Some people might put it that way, that euthanasia is\\u0026hellip; it\\u0026rsquo;s like we are playing God. I do acknowledge that part and I think\\u0026hellip; I think it has some rooms in terms of patients who really suffer and they know what they\\u0026rsquo;re doing in terms of their\\u0026hellip; they know their decision in this\\u0026hellip; in a sound person they have the\\u0026hellip;. They are making their informed decision\\u003c/p\\u003e\\n\\u003cp\\u003eEuthanasia is seen in the context of the patient suffering at the end of life and participants felt a need to understand in depth the situation of the patient and to what extent PC had been provided or could be improved.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo; I wish to die.\\u0026rdquo; I\\u0026rsquo;ll definitely have a doubt, but of course we have to understand why \\u0026hellip; is it because of the disease burden, or the treatment is really making them suffer? So far I have no clue. And a thing there\\u0026rsquo;s a lot more to improve on\\u0026hellip; as in not just the treatment, and also the very basic care for the patient.\\u003c/p\\u003e\\n\\u003cp\\u003eStudents\\u0026rsquo; views generally very nuanced, highlighting the need to assess the individual situation of the patient. A spectrum of ethical opinions was held, where some students favoured euthanasia.\\u003c/p\\u003e\\n\\u003cp\\u003eR: Err\\u0026hellip; but\\u0026hellip; in my personal point of view like\\u0026hellip; in general my point of view for euthanasia? Personally, I support this idea, because like I said, if I were to die, I want to die with dignity. If by any chance, my life is out of my control, I would want to \\u0026hellip; I would want to like I said, die in a way I want.\\u003c/p\\u003e\\n\\u003cp\\u003eOthers, while being receptive to opposing arguments, expressed disagreement.\\u003c/p\\u003e\\n\\u003cp\\u003eSo my thought of euthanasia for now is if best, don\\u0026rsquo;t do it. Maybe I should review into it more carefully and maybe I should see about it\\u0026hellip; but otherwise it\\u0026rsquo;s a no for me la.\\u003c/p\\u003e\\n\\u003ch1\\u003eEducation: experience, self-care, self-reflection\\u003c/h1\\u003e\\n\\u003cp\\u003eFollowing early exposures to PC participants considered experience as very important in their development of palliative skills.\\u003c/p\\u003e\\n\\u003cp\\u003eR: I think they need to show us examples like how they approach this with a real patient, so that I can see how the real patient react, the family members. So I think by that is the best way for me to learn.\\u003c/p\\u003e\\n\\u003cp\\u003eImproving communication skills was considered very significant, however students felt that earlier teaching outside the actual clinical context had done little to prepare them well. There was a preference towards increasing the amount of teaching in PC delivered in the actual context of patient care rather than in abstract lectures.\\u003c/p\\u003e\\n\\u003cp\\u003eI\\u0026rsquo;m not sure whether it\\u0026rsquo;s a good way, because we sort of like\\u0026hellip; avoided the question itself and not really settle her problem. The way I should approach this patient, I mean , as times goes, I\\u0026rsquo;m exposed to more patients like that, I think I would get my way, haha. I think it\\u0026rsquo;s about experience.\\u003c/p\\u003e\\n\\u003cp\\u003eStudents noticed limitations with mnemonic based techniques and were instead understood communication as being shaped by factors related to the individual persons involved.\\u003c/p\\u003e\\n\\u003cp\\u003ewe have a lot of mnemonics or protocol, things like that but people are different. Humans being humans, every human is different. How\\u0026hellip; how do we really understand what up Hu- What kind of people we are dealing with and what kind of approach we can\\u0026hellip; to deal with them. I think that\\u0026hellip; that would be some\\u0026hellip; something, which I am a bit concerned about.\\u003c/p\\u003e\\n\\u003cp\\u003eAn empathic process of communication was described as using one\\u0026rsquo;s own experiences in trying to understand the patient better.\\u003c/p\\u003e\\n\\u003cp\\u003eAs in understanding what they are going through? It helps a lot with being more empathetic with the patient if you understand what they are going through. (There\\u0026rsquo;s) a lot of things you can only learn from experience, either personal or from people around you, and if you can use your experiences to try to understand the patient better then I feel like you will be able to provide better care for them\\u003c/p\\u003e\\n\\u003cp\\u003eDeveloping a habit of reflection was seen as an important factor in developing PC skills, requiring time within a busy clinic schedule.\\u003c/p\\u003e\\n\\u003cp\\u003eYou know, just don\\u0026rsquo;t have the kind of emotions? I don\\u0026rsquo;t know. Or maybe it\\u0026rsquo;s just that it\\u0026rsquo;s\\u0026hellip; it\\u0026rsquo;s just that we don\\u0026rsquo;t quite often, so might not be very comfortable with. Because you are not doing it often, so we don\\u0026rsquo;t practice it enough and it\\u0026rsquo;s a skill. Skills needs practice I think.\\u003c/p\\u003e\\n\\u003cp\\u003eAt times severe emotional distress and doubt surfaced as well. These descriptions of personally struggling in the face of patient suffering were notable for an intense emotional involvement in the experiences of patients and carers.\\u003c/p\\u003e\\n\\u003cp\\u003eBecause last time when I was in paediatrics onco ward, that was like my\\u0026hellip; first week of my clinical years. And I get really emotional, like the whole week I cry\\u0026hellip;. Like every time I clerk a patient I have to go out and ohhh\\u0026hellip; take a deep breath and then my tears just vroommm like that. So, uhh\\u0026hellip; I think it really looks not professional? And in a sense, patients are expecting some encouraging? Or comfort words from the\\u0026hellip;and reassurance from the doctors, and if the doctors are crying, like that, then\\u0026hellip; (sobs) it makes no sense.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study revealed a range of perceptions regarding PC among medical students. They included factual knowledge, attitudes, expectations as well as ethical issues. Generally students appreciate PC as an important part of care. They ponder the potential challenges it includes and how they can prepare for them.\\u003c/p\\u003e\\n\\u003cp\\u003eIn agreement with previous work we found that aside from factual knowledge, students did not find theoretical teaching lectures and problem-based learning sessions effective enough to learn end-of-life competencies, such as cultural or spiritual aspects of end-of-life care, communication skills with dying patients and their families \\u0026nbsp;and critical reflection on experiences around death.[17]\\u0026nbsp;Medical students agreed that they would have a better understanding of palliative care with more clinical exposure, for instance, clinical rotations.[3, 12, 15, 18]\\u0026nbsp;Experience-based learnings allows medical students to be actively engaged[19]\\u0026nbsp;Experience-based learnings allows medical students to be actively engaged.[11]\\u003c/p\\u003e\\n\\u003cp\\u003eSimilar to previous studies our participants sensed a strong degree of sensitivity around the topics of death and dying, occasionally even perceiving it as taboo topics[9, 13, 14]\\u0026nbsp;Some felt comfortable with palliative care patients.[15]\\u0026nbsp;Others prefer to avoid palliative care or approaching dying patients as they experience emotional difficulties. They stated that witnessing death, dying and suffering of a patient and the grief of their family was \\u0026ldquo;emotionally destructive\\u0026rdquo;. They felt stressed due to the emotional attachment with dying patients and their families and admitted that there might be a risk of burnout.[18]\\u0026nbsp;] Older medical students tended to be less afraid of approaching such patients and had more positive attitudes about caring for them.[20]\\u003c/p\\u003e\\n\\u003cp\\u003eA study comparing UK and US medical students suggested that cultural differences towards death and dying seemed to affect students\\u0026rsquo; perception of palliative care. A culture within medicine that is more receptive towards palliative care could help students to appreciate the value of end-of-life care.[21]\\u003c/p\\u003e\\n\\u003cp\\u003eWith regards to the ethics of end-of-life care the current study found that students were intensely engaging with the current discourse around euthanasia and assisted suicide, while they were generally reluctant to commit to a definite position in this question they were receptive to arguments from both sides. In comparison a previous study found that medical students tend to be more reluctant to withdraw and withhold therapies, however they found euthanasia and assisted suicide more acceptable than doctors.[22]\\u0026nbsp;Personal experiences and beliefs influence medical students\\u0026rsquo; perceptions too.[6, 9]\\u0026nbsp;This could be one of the reasons for varying attitudes and perceptions of palliative care from studies in different countries.\\u003c/p\\u003e\\n\\u003cp\\u003eAlthough students had admitted that they feel unprepared and not confident in delivering PC, they appreciated the importance of PC and welcomed more teaching.[4, 5, 13]\\u0026nbsp;A Taiwanese study showed that a 1-week multimodal curriculum of palliative care managed to help students who voluntarily attended to improve significantly in palliative care knowledge and beliefs about ethical decision-making.[23]\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRecommendations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eUnderstanding perceptions of PC among students is a vital part in the effort to expand PC in the future. Negative attitudes towards PC may lead to a nihilistic approach which fails to realise the potential to improve patients\\u0026rsquo; quality of life. It also entails the very significant risk of healthcare provider burnout due to a sense of helplessness in the face of life limiting illness.[24]\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMedical students were very engaged with the issue of suffering. The expectation to receive training in this area is an opportunity for curriculum design. For example the relevance of PC across the spectrum of medical specialties can be acknowledged by highlighting its multidisciplinary character in the curriculum.\\u003c/p\\u003e\\n\\u003cp\\u003eEmotional aspects deserve attention as well. The perception of PC as a last resort needs to be actively addressed as this can threaten the vital objective of supporting hope among patients. Students did appreciate this skill in particular among faculty during their attachments, underlining the significance of the hidden curriculum.[24]\\u0026nbsp;Our research highlighted the potential for transmitting vital skills and attitudes from faculty to students. Importantly it was motivating for students to witness experienced practitioners deliver PC which could be immediately seen as effective in relieiving patient suffering. This opportunity to demonstrate the value of PC in terms of the patient benefit can be helpful in clearing the perception of PC as a less important specialty of medicine. As has been shown for family medicine such misperceptions of apparently less meaningful specialties can have a pervasive influence on career decision making among junior doctors.[25]\\u003c/p\\u003e\\n\\u003cp\\u003eCultural aspects of PC are yet another factor deserving attention. As we have shown, students realized that discussions about death and dying would need to respect cultural factors. While ethics are a universal set of principles it has to be acknowledged that ethical aims cannot be achieved while disregarding elements of culture. Hence there is a need to tailor the practice of PC to the relevant setting or else run the risk of compromising care by too narrow an understanding of the precepts of ethics.\\u003c/p\\u003e\\n\\u003cp\\u003eThe awareness of ethical issues in PC among students is an opportunity for further learning. Exposure to clinical practice offers a realistic background which infuses otherwise abstract ethical discussions with practical relevance. Considering this in curriculum design would enable students to develop a practice of continuous ethical reflection and equip them with the competence to reason about ethical challenges and recognize the role of involving other professionals in addressing difficult deliberations.\\u003c/p\\u003e\\n\\u003cp\\u003eFinally our study revealed a degree of anxiety among students as they pondered having to face suffering in their career. This finding is relevant with regards to their future professional and personal well being as exposure to chronic and incurable illness is expected to increase and preparedness for this is essential in preservering their wellbeing and mental health. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLimitations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOur study has several limitations. Firstly it was done at a single university and hence does not reflect the wider population of Malaysian medical students. Secondly the topic guide was formulated in a broad fashion owing to the vastness of the topic. Further studies are warranted to explore the various topics in greater detail. Additionally we did not account for the possibility of students either having had prior teaching exposure to PC or not. Some students therfore were able to speak from previous experience with PC while others related their perceptions prior to any teaching.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003ePerceptions of PC among medical students significantly influence their attitudes towards care for patients with life limiting illness. In order to expand PC and increase doctors\\u0026rsquo; confidence in delivering PC a better understanding of existing perceptions is needed.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors would like to express their thanks to all participants who generously shared their time and views on this matter.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTYT and JC performed the interviews, JC completed the transcriptions. The manuscripted was collaboratively prepared by JC, TYT, CLL, ECL, SIZ and DPC.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was not supported by dedicated funding.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets obtained and analyzed are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval was obtained from the Medical Research Ethics Committee at University of Malaya Medical Centre (\\u003cstrong\\u003eMREC ID NO\\u003c/strong\\u003e: 2022714-11381).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eThe study was conducted in accordance with the Declaration of Helsinki and relevant guidelines and regulations\\u003c/strong\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eParticipants were given an information sheet about the study before completing the consent form. All participants have provided informed consent.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eWorld-Health-Organisation. \\u003cem\\u003ePalliative care\\u003c/em\\u003e. 5 August 2020; Available from: https://www.who.int/news-room/fact-sheets/detail/palliative-care.\\u003c/li\\u003e\\n\\u003cli\\u003eSivalingam, N., R.B.L. Lim, and L. Rampal, \\u003cem\\u003ePalliative care in Malaysia: the need to do much more.\\u003c/em\\u003e Med J Malaysia, 2021. \\u003cstrong\\u003e76\\u003c/strong\\u003e(3): p. 279-283.\\u003c/li\\u003e\\n\\u003cli\\u003ePandey, S., et al., \\u003cem\\u003ePerception of Palliative Care among Medical Students in a Teaching Hospital.\\u003c/em\\u003e JNMA J Nepal Med Assoc, 2015. \\u003cstrong\\u003e53\\u003c/strong\\u003e(198): p. 113-7.\\u003c/li\\u003e\\n\\u003cli\\u003eIbrahim, H., et al., \\u003cem\\u003eMedical student experiences and perceptions of palliative care in a middle eastern country.\\u003c/em\\u003e BMC Med Educ, 2022. \\u003cstrong\\u003e22\\u003c/strong\\u003e(1): p. 371.\\u003c/li\\u003e\\n\\u003cli\\u003ePieters, J., et al., \\u003cem\\u003ePalliative care education in the undergraduate medical curricula: students' views on the importance of, their confidence in, and knowledge of palliative care.\\u003c/em\\u003e BMC Palliat Care, 2019. \\u003cstrong\\u003e18\\u003c/strong\\u003e(1): p. 72.\\u003c/li\\u003e\\n\\u003cli\\u003eBarros-Garcia-Imhof, J., et al., \\u003cem\\u003ePerception of Medical Students on the Need for End-of-Life Care: A Q-Methodology Study.\\u003c/em\\u003e Int J Environ Res Public Health, 2022. \\u003cstrong\\u003e19\\u003c/strong\\u003e(13).\\u003c/li\\u003e\\n\\u003cli\\u003eSadhu, S., N.S. Salins, and A. Kamath, \\u003cem\\u003ePalliative Care Awareness among Indian Undergraduate Health Care Students: A Needs-Assessment Study to Determine Incorporation of Palliative Care Education in Undergraduate Medical, Nursing and Allied Health Education.\\u003c/em\\u003e Indian J Palliat Care, 2010. \\u003cstrong\\u003e16\\u003c/strong\\u003e(3): p. 154-9.\\u003c/li\\u003e\\n\\u003cli\\u003eJahan, F., \\u003cem\\u003ePerception of Undergraduate Medical Students in Clinical Years Regarding Palliative Care.\\u003c/em\\u003e ME J of Family Medicine, 2013. \\u003cstrong\\u003e10\\u003c/strong\\u003e.\\u003c/li\\u003e\\n\\u003cli\\u003eDaud S, A.A., Bhatti BK, \\u003cem\\u003ePerceptions of Medical Students about End of Life Palliative Care.\\u003c/em\\u003e Pak J Med Health Sci, 2013. \\u003cstrong\\u003e4\\u003c/strong\\u003e: p. p. 812-816.\\u003c/li\\u003e\\n\\u003cli\\u003eAbuhammad, S., et al., \\u003cem\\u003eKnowledge of pediatric palliative care among medical students in Jordan: A cross-sectional study.\\u003c/em\\u003e Ann Med Surg (Lond), 2021. \\u003cstrong\\u003e64\\u003c/strong\\u003e: p. 102246.\\u003c/li\\u003e\\n\\u003cli\\u003eWilson, H., S. Warmington, and M.L. Johansen, \\u003cem\\u003eExperience-based learning: junior medical students' reflections on end-of-life care.\\u003c/em\\u003e Med Educ, 2019. \\u003cstrong\\u003e53\\u003c/strong\\u003e(7): p. 687-697.\\u003c/li\\u003e\\n\\u003cli\\u003eRoj\\u0026iacute;, R., et al., \\u003cem\\u003ePalliative Care Bedside Teaching: A Qualitative Analysis of Medical Students' Reflective Writings after Clinical Practices.\\u003c/em\\u003e J Palliat Med, 2017. \\u003cstrong\\u003e20\\u003c/strong\\u003e(2): p. 147-154.\\u003c/li\\u003e\\n\\u003cli\\u003eReigada, C., et al., \\u003cem\\u003eInterdisciplinary discussions on palliative care among university students in Spain: giving voice to the social debate.\\u003c/em\\u003e Int J Qual Stud Health Well-being, 2021. \\u003cstrong\\u003e16\\u003c/strong\\u003e(1): p. 1955441.\\u003c/li\\u003e\\n\\u003cli\\u003eAndrea Augusta Castro, S.R.T., Caio Assun\\u0026ccedil;\\u0026atilde;o Rocha Pereira, Natan I\\u0026oacute;rio Marques, \\u003cem\\u003ePalliative care in medical education: the students\\u0026rsquo; perception. .\\u003c/em\\u003e Revista Brasileira de Educa\\u0026ccedil;\\u0026atilde;o M\\u0026eacute;dica, 2022. \\u003cstrong\\u003e46\\u003c/strong\\u003e((1)): p. p. e024.\\u003c/li\\u003e\\n\\u003cli\\u003eKriesen, U., A. 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Pfeifer, \\u003cem\\u003eSenior medical students' perceptions of the adequacy of education on end-of-life issues.\\u003c/em\\u003e J Palliat Med, 2001. \\u003cstrong\\u003e4\\u003c/strong\\u003e(3): p. 337-43.\\u003c/li\\u003e\\n\\u003cli\\u003eDobrowolska, B., et al., \\u003cem\\u003ePredicted difficulties, educational needs, and interest in working in end of life care among nursing and medical students.\\u003c/em\\u003e Nurse Educ Today, 2019. \\u003cstrong\\u003e83\\u003c/strong\\u003e: p. 104194.\\u003c/li\\u003e\\n\\u003cli\\u003eLewis, C., et al., \\u003cem\\u003eThe impact of a simulated intervention on attitudes of undergraduate nursing and medical students towards end of life care provision.\\u003c/em\\u003e BMC Palliat Care, 2016. \\u003cstrong\\u003e15\\u003c/strong\\u003e: p. 67.\\u003c/li\\u003e\\n\\u003cli\\u003eLloyd-Williams, M. and N. 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Block, \\u003cem\\u003eThe status of medical education in end-of-life care: a national report.\\u003c/em\\u003e J Gen Intern Med, 2003. \\u003cstrong\\u003e18\\u003c/strong\\u003e(9): p. 685-95.\\u003c/li\\u003e\\n\\u003cli\\u003eZainal, H. and H.E. Smith, \\u003cem\\u003eMedical students' attitudes towards careers in primary care in Singapore.\\u003c/em\\u003e BMC Med Educ, 2020. \\u003cstrong\\u003e20\\u003c/strong\\u003e(1): p. 464.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"palliative care, medical student, perception, hospice\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-2440713/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-2440713/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e: Palliative care (PC) needs are projected to increase and training future practitioners is an important response to this. While the specialty of PC has developed rapidly it is not yet universally integrated in healthcare. Advocacy has achieved improvements in this field but misperceptions of PC have remained in the general population.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e: A qualitative study based on semi-structured interviews with medical students at a Malaysian university was conducted. Results were thematically analyzed.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: Fifteen students were interviewed. Seven themes were generated: (1) Understanding palliative care (2) communication (3) spirituality (4) ethical issues (5 education.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e: Perceptions of PC are relevant to the medical training and the development of PC.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Perceptions of palliative care among medical students: A thematic analysis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-11-12 02:19:42\",\"doi\":\"10.21203/rs.3.rs-2440713/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"54a89691-6594-4cd9-a3c5-2c68152f5aeb\",\"owner\":[],\"postedDate\":\"November 12th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-11-12T02:19:42+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-11-12 02:19:42\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-2440713\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-2440713\",\"identity\":\"rs-2440713\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}