Reflexões sobre a Terminalidade da Vida com Acadêmicos de Medicina

Abstract: Introduction: Death and dying are daily relevant themes for health care professionals and medical students. Nonetheless, since their first years of graduation, students are contrived to supplant the holistic conception of human beings and life in favor of enhancing the technical aspects of the medical profession. Methods: Therefore, in face of the few opportunities to enquire about these future professionals’ feelings and comprehensions toward life terminality, we pursued their perceptions through the application of a semi-structured questionnaire. Ten students from each year of the medical course at UNIVAS were interviewed, encompassing 60 scholars. Students should be regularly enrolled in the medical course, as well as give their consent, by signing the Consent Term, to participate in the study. The interviews took place at the institution and the material containing students’ responses was fully destroyed afterwards. Their responses were analyzed based on the Discourse of the Collective Subject Method. Results: The idea of terminality being properly the “end of life” was paramount among the years, situation with which a great amount of the scholars (58%) admitted not being prepared to deal with, due to the lack of reflections about death, its psychological aspects and repercussions in the academic context. Interestingly, about 16% of the scholars considered themselves prepared to deal with someone’s death, although they were not prepared to intervene in the actual process. This is reinforced by the fact that students must deal with the real scenario of giving undesirable news without previously being prepared to do so, by means of reflecting upon a hypothetical related to the “life-death binomial”. Conclusion: Thus, it seems necessary to create spaces in the curriculum that yield not only theoretical-practical but also affective support in situations related to terminality. The proposal of a theoretical-practical education based on palliative care amid the learning programs would shape confident attitudes of future health care professionals towards care.


INTRODUCTION
Death and dying are relevant topics to the daily lives of health professionals and the learning process of undergraduate medical students. Since the first years of medical school, the student is induced to value the technical-scientific foundations of the profession, and to leave the holistic conception of the human being and of life in the background 1 . Therefore, any feelings of anxiety or anguish, which may eventually arise during medical school, about the inevitability of the end, must be overcome in favor of their formation 2 .
The intensity of the struggle to find a cure for diseases, encouraged since the first years of medical school, guides future professionals into a death-denying culture 2,3 : dying is seen, since the beginning, as a symbol of failure. Moreover, medical students, during the years of clinical practice, sometimes assume omnipotent attitudes, of "saviors of the other" 4 , relegating patients to the role of mere receptors of procedures, disregarding their autonomy over their own lives.
Therefore, a demand has been observed towards rescuing the patient' s participation in their death process 5 , especially terminally ill patients. In this context, Leonard Martin 6 highlights three possibilities for terminal care, among them orthothanasia, which brings with it the issue of palliative care, providing relief from pain and other distressing symptoms, without rushing or postponing death, but seeing it as a part of life 7 , which must be faced in a human and dignified manner, associating technological and scientific knowledge to the psychological and spiritual aspects of patient care 8 .
During their education, the student is committed to life, and all their training is based on purely technical aspects 9 ; only a modest part of the curriculum, when present, includes specific content aimed at the end of life 10 , but even so, they are not prepared to deal with scenarios of anguish and ambivalence when facing the inevitability of the end, even if they have so many resources at their disposal. Therefore, given the scarcity of reflections on the terminality of life in the medical academic context, it is necessary to know how familiar the students are with the topic, comparing perceptions, experiences and personal preparation, from the first to the last year of medical school, to deal with death, this being the objective of the study carried out at Univás' medical school, in the city of Pouso Alegre/MG, Brazil.

METHOD
This study was carried out at Univás, being a descriptive, crosssectional, non-controlled study with an intentional sampling, including ten students from each year of the medical course, totaling 60 students.
The following eligibility criteria were adopted for inclusion in the study: being a student from the 1 st to the 6 th year of medical school, regularly enrolled in the medical course, freely accepting to participate in the research by signing the Free and Informed Consent.
The interviews were recorded and took place at the institution' s premises. The material containing the participants' speech was discarded.
For data collection, the following instruments were used: Sociodemographic questionnaire: consisting of questions related to gender, age, year of the course, religion and contact with topics related to bioethics up to the time of the interview.
Semi-structured interview script: an instrument consisting of four questions: "For you, what is the meaning of the end of life?", "How would For the analysis of the interviews, the Collective Subject Discourse (CSD) method was used, based on three methodological figures: key expressions (KE), central ideas (CI) and the Collective Subject Discourse (CSD) itself, according to the following steps: First step: the answers to the questions were listened to several times and, only after obtaining a general idea and a better understanding of the discourse, they were literally transcribed.
Second step: careful reading of all the transcribed material, at two different moments: first, the responses of each participant were read; then, each answer was read separately, that is, the first question of all respondents, then the second, the third and finally the fourth.
Third step: an integral copy was made of all answers to question 1 in the Discourse Analysis Instrument 1 (DAI1), marking the KE in italics and identifying the CI, so that it represented the description of the KE and not its interpretation. The same procedure was applied to the other questions.
Fourth step: creation of the Discourse Analysis Instrument 2 (DAI2), which brings together, separately, each central idea with their respective KE, similar or complementary.
Fifth step: extracting the topic from each of the questions; they were grouped with their respective CIs, the subjects (represented by the number of respondents) and the frequencies of ideas, using charts.
The comparison between the views of the groups comprised by students belonging to each year of the medical course was carried out, finally creating the CSDs that represented them.
The study was performed with the assistance of the Vale do Sapucaí Education Foundation following the provisions of Resolution N. 466

RESULTS
The study sample consisted of 60 undergraduate students from the 1 st to the 6 th year of the medical course at Univás, consisting of 10 students from each year, of both genders. Of the total of 60 students, 36 (60%) were females and 24 (40%) were males; 50 (83%) stated they had already had contact with issues related to the end of life and topics related to bioethics during the undergraduate years, emphasizing that they were brief and scarce.
Representative concepts for each year of the course were attributed to each question, which reflected the intensity of contact with the subject. Regarding the topic "terminality of life", when asked about its meaning, the predominant ideas in all the years of the medical course were: end of life and transition from the physical to the spiritual body. However, in the third and fourth years of the course, two new conceptions about the end of life were observed, one of proximity to death (3 rd year) and that of the separation of body-mind-soul (4 th year), as shown in Chart 1.
Regarding the students' feelings towards a hypothetical situation of having to deal with a terminal patient, at that very moment when they

• Third central idea Proximity of death (3 rd year) CSD "I think it is a moment in life when you know that death is near, and you are aware of it."
The separation of body-mind-soul (4 th year) DSC

"... that is when the person is no longer able to be present, their body is here but they no longer have a 'mind'. For me, life really ends when the person's soul is no longer there, when the spirit is no longer there."
Source: Authors were being interviewed, the following CI predominated: not feeling prepared and acting for the patient' s well-being. Three students (from the 1 st , 5 th and 6 th years) reported that they would have no difficulties in the face of the event (Chart 2).
After that, the students were asked if they felt prepared to deal with death and the process of dying. The idea "am not prepared" prevailed in all years, with its variants "one is never prepared" and "more or less prepared" appearing in one year or another. Predominantly in the first years, the idea "depends on the relationship" arose, which associated the intensity of the relationship between the student and the individual who was going through the process of dying. Ten students (from the first to the last years) said they felt prepared; one student said they did not know (Chart 3).
Finally, the students were asked to give their opinion on the approach to the topic of death and terminal patients during medical training in general. The ideas that the approach is "superficial" and that "it should be approached more frequently" showed relevant frequencies; there is a report stating that the topic was not addressed (Chart 4).

• Second central idea
Acting for the patient's well-being CSD "I would do anything to ensure that they had the best possible end of life. If it is a case that cannot be recovered, there is no way to go back, I think we have to support the patient, reduce their pain, so that they can go through that period in the best possible way." -3 rd year students.

Chart 3
Prepared or not to deal with death and the process of dying Source: Authors

• First central idea I am not prepared CSD
"It is very difficult to be truly prepared to deal with death." -5 th year students • Second central idea I am prepared CSD "I am prepared, life and the experiences teach us." -5 th year students.

• Third central idea Depends on the relationship CSD
"If it were a person who was not very close to me, maybe I would be prepared." -2 nd year students.

Chart 4 Death and terminal patients during medical training • First central idea Superficial approach CSD
"The approach is very deficient, I think that doctors are unprepared, and this has a great impact on professional life." -4 th year students.
"Little discussed topic. The medical course is prepared mainly for diagnosis and treatment." -5 th year students.

• Second central idea
It should be more frequently addressed CSD "It is of the utmost importance that this topic be addressed; 99% of the workload is about life." -3 rd year students. "It has been little discussed in my training until now. It should have a greater focus."-4 th year students.

DISCUSSION
Based on the analysis of the data obtained by the sociodemographic questionnaire, it was observed the predominance of the female gender and the Catholic religion among the participating students, and that little over 80% of the interviewees had already had contact with subjects related to bioethics at some point during the medical course.
The first aspect addressed in this study was regarding the meaning of the end of life for students in each year of the course; the ideas of "terminality/end of life" and "transition from the physical to the spiritual body" were prevalent in all years, and, therefore, consistent with literature; a bibliographic review of 47 articles sought to identify the concepts of palliative care published over six years, finding as one of the main ideas precisely the finitude of life, which is experienced according to the beliefs and values of the individual, the family and the health professional 11 .
Another focus of this study was the analysis of the students' feelings regarding a hypothetical situation of caring for terminally ill patients. It was observed that 35% of the students said they were "not prepared" and that 25% were certain that they would take an "approach always aiming at the patient' s well-being", being possible to identify in their speech the idea of dying with dignity, providing pain relief, from the perspective of a good doctor-patient relationship 12 .
Corroborating the analysis of the previous question, the third question assessed the personal training of students in the face of death and the comprehensive process of dying; again, a considerable portion of respondents (58%) said they were not prepared for the issue; interestingly, approximately 16% of students considered themselves prepared to face someone' s death, but not to be interventionists in the process (that is, dealing directly with a patient).
A study carried out by Whyte, Quince, Benson, Wood and Barclay 13 concluded that the experience of grief lived by students at some point in their lives can be seen, for instance, as a negative influence on the doctor-patient relationship, and that it should be taken into account during medical training. That is because students can avoid situations involving death and the process of dying (such as communicating the death of a loved one to the family), in addition to being more likely to develop anxiety and other disorders.
On the other hand, Lima and Machado 14 concluded that the difficulty in dealing with finitude is frequently related not only to the formal technical incapacity of professionals and caregivers, but also to an affective dimension: it was observed that when professionals had personal experiences of death and remembered them, instead of it being a negative factor, as pointed out in the study by Whyte 13 , it was possible to circumvent the suffering associated to the concept of death, allowing the caregiver to assign meaning to the patient' s life and their own history.
Finally, the students were encouraged to give their opinion on the approach given to the death and dying topics during the medical undergraduate course. Two aspects were observed: those that considered the course itself and the ones that considered medical training in general; it was possible to verify that the medical course depicts unpreparedness and superficiality to face death.
For Marta et al 14 , most of the medical training is focused on the production of "seres tanatolíticos". Biotechnological developments since the 1970s ended up associating the term "life" with constant human intervention, which ceased to be something dependent only on nature, but rather, mainly, dependent on medical performance 15 .
However, what we observe is that health professionals and studentswho are being introduced to the hospital environment at an increasingly early period -often have to deal with the real scenario of transmitting bad news, without first going through hypothetical and reflective situations involving the "life and death binomial" 16 during their formation. The unpreparedness makes them suffer in a dysfunctional way and, as shown by the study by Mason and Ellershaw 17 , the proposal for theoretical and practical education related to palliative care included in the curriculum would improve the confidence and attitude of future health care professionals.

CONCLUSION
Based on the analysis of the obtained results, the present study unexpectedly showed that the conceptions of the undergraduate students in the first years are little different from those of the interns. This is because both have deficiencies in both technical and emotional knowledge, being exposed to death daily since the first learning experience with a corpse, without a foundation, a reflection within the theoretical / cognitive scope. Therefore, given the scarcity of reflections on death, its psychological aspects and its effects on the medical-academic context, it seems necessary to create spaces in the curriculum that provide not only theoretical and practical support, but also emotional support for issues involving the terminality of life.