Table 2 Suggested Interventions to Improve Medical Students’ Management of Dying Patients

Clinical attachment with direct interaction with dying patients is an effective way to learn [86].

Integrate direct clinical care of dying patients into mandatory curriculum [11].Actively encourage interdisciplinary and interprofessional collaborations with nurses, medical social workers, pharmacists and other healthcare professionals who bring with them unique experiences and insights into the care for the dying and their families [137,138,139,140,141]

Lack of debrief, death acknowledgement, and closure. Need for psychological support.• “Often being ‘on their own’” [107].• “Little or no time for discussion or reflection on patient’s death” [16, 101, 118].• “Experiencing ‘a small form of PTSD’ every time he thought of a patient’s death for several weeks after it happened, because no one on his team had acknowledged it.” [107].

• Schedule routine [16] reflective discussions (E.g. Focus group discussions) and debriefs [16, 18, 21, 22, 78, 89, 101] with clear guidelines [90], as well as after every death including rounding on those who died.• Provide counselling and access to a psychologist to medical students who require more support [18, 21].• Incorporating death rounds into attachment programs.    • Provides an opportunity to explore strong emotions that arise from caring for dying patients with colleagues in a supportive environment.

Medical students found it difficult to address and reconcile conflicts in personhood:• Dilemma of being professionally detached yet still able to display empathy and care towards patients [13, 87].• Conflict between personal values and professional ideals.• Belief that patients under the care of doctors should not die.• Conflict between non-maleficence and having to triage decisions [24, 134, 142].

• Facilitate uptake of professional ideals into individual ring of personhood.    • Minimizes ‘dyssynchrony’ between the rings of personhood leading to newfound self-confidence and empowerment [84].• Incorporate discussions of professionalism in palliative care.• Provide advice and standards on how best to calibrate emotional attachment in the care of dying patients, and also to balance seemingly conflicting ideals.• Encourage medical students to express any internal conflicts they have during debriefs, death rounds, or privately with a trained mentor.• Establish ethics teams to support and be consulted on ethical decision making.

Inconsistent or weak medical student-doctor relationship with lack of support and guidance [16, 22, 87, 101, 102, 107].• Felt seniors were not ideal role models [102].• Gave conflicting accounts of professionalism [102].• Felt disempowered and discouraged from actively participating in the care of the patient [12, 99, 102].• Some medical students feel uncomfortable approaching superiors for help [14, 16, 21, 79, 101, 107].

Train doctors to mentor effectively:• Role model skills, such as communication with the dying [78], through explicit demonstrations [12].• Routinely inquire of trainees about their and acknowledge their feelings [16].• Discuss and attend to emotional aspects of death with team [16].• Observe medical students and provide feedback [114].• Provide a standardized guide of professionalism milestones.• Provide a safe learning environment.• Identify medical students who need support.• Train healthcare workers to spot signs of psychological distress in their colleagues.

The experiences, reactions, and preferred support systems of medical students to be varied.• While some preferred to seek support from within their relational ring [12, 100], others preferred to turn to peers and clinicians from their societal ring [12, 14, 86, 90] possibly because of the shared experience amongst members of the medical community [12, 14] that made them feel better understood [14].

Adopt a tailored approach to intervention to individualize support for medical students.• Ensure different options are available to medical students to help cope.