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Development, implementation and evaluation of a terminal and hospice care educational online module for preclinical students
  1. Chung Sang Tse1 and
  2. Matthew S Ellman2
  1. 1Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Dr Chung Sang Tse, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Tse.Chung{at}


Objectives To explore the application of an online learning tool to teach preclinical medical students terminal and hospice care in a blended curricula.

Methods We created and evaluated a 30 min interactive online module at the Yale School of Medicine. Second-year medical students were randomly assigned to complete the online module or not (control group) prior to attending a required half-day hospice clinical experience. We assessed the students' knowledge and attitudes with a 23-item survey.

Results 152 students (response rate 51%) participated in this study from 2012 to 2014. 56% (n=85) completed the online module, 37% (n=56) did not and 7% (n=11) did not indicate whether they had completed the module or not. Students who completed the online module prior to the hospice experience scored higher (p<0.05, two-way analysis of variance) on 5 out of 8 of the multiple choice questions pertaining to hospice and palliative care, but their attitudes were similar to those who did not complete the online module. Overall, the students felt somewhat uncomfortable caring for dying patients although they regarded it as a physician's duty and felt that palliative/hospice care education is important in medical school.

Conclusions When combined with a mentored clinical hospice experience, an online module appears to enhance the teaching of the dying process and terminal care for preclinical medical students. This online module may prove useful for other institutions.

  • Hospice care
  • Terminal care
  • Education and training

Statistics from


Modern medicine is today more successful than ever at treating diseases and managing illnesses. In the early 1900s, the average life expectancy was 50 years, and people often experienced a relatively quick death, many due to infectious diseases or accidental injuries.1 By comparison, people living in the 21st century often die after a substantial period of disability, living for years to decades with a gradual decline from chronic diseases.2 Medical advances have made it possible to keep patients alive without necessarily improving their quality of life.3 Amidst an expanding ageing population, it is important for physicians to recognise and reconcile with the potentials and limitations of modern medicine. Although the goals of care have traditionally been directed towards curing and prolonging life,4 ,5 there has been a growing emphasis on ensuring patient comfort and maximising quality of life. Hospice care provides care to patients with a life expectancy of 6 months or less. The goals are to minimise pain and distress, enhance quality of life, integrate psychological and spiritual care, support patients and their families through illness and bereavement.6 Hospice services can be provided at home, at a hospice facility, in the hospital, or at a skilled nursing facility. In the USA, the costs of these services are covered by Medicare under the Hospice Benefit Act.7

While usage of hospice care has increased in recent years, more than a million Americans die of chronic, life-limiting illnesses without the benefit of receiving hospice services.8 ,9 In a study that examined non-traumatic deaths at a tertiary care centre, only 14% of the hospice-eligible patients had documented discussions about hospice care with their inpatient physician provider.9 Even among patients with advanced cancer with a median survival of 4.4 months, only 37% recall having end-of-life care discussions with their physicians.10 Consistent with this, 78% of physicians at a large non-profit health maintenance organisation in the USA believed that hospice care was underused, and 84% were unable to identify appropriate hospice diagnoses.11 Similarly, a recent survey in the greater New York metropolitan area showed that 87.7% of internal medicine residents and fellows agreed that knowledge of hospice care was an important competence for internal medicine physicians though many still relinquished end-of-life care discussions to emergency medicine physicians (53.2%) or the palliative care team (27.3%).12 A physician's knowledge and attitudes about hospice has been found to be positively related to the rates of hospice referral for terminally ill patients.13 ,14 Consequently, enhancing future physicians' knowledge about hospice eligibility and services would help decrease the number of patients dying without the benefits of hospice care.14 ,15

With the growing use of online teaching tools in the 1990s, e-learning has been shown to be an effective, flexible method in diverse areas of medical education.16–18 At the University of Alberta, third-year medical students piloted an interactive computer simulation of a virtual terminal patient and had significant increases in knowledge scores and self-assessed comfort levels.19 At Baylor College of Medicine, Morrison et al20 implemented a MS3 palliative care blended curricula comprised of a workshop, a patient interaction experience and an online module on pain management. Third-year medical students showed attitudinal improvements after completing the workshop. Knowledge improvements were observed after completion of the online module and the patient interaction experience. At the Yale School of Medicine, third-year students who completed a blended curricula comprising an online module and a workshop focused on the spiritual, cultural and interprofessional aspects of palliative care emerged with a better understanding of the contributions of all health professionals and more readily identified the spiritual and cultural needs of patients.21

To our knowledge, a blended curriculum for teaching preclinical medical students end-of-life care principles has not yet been reported in the literature. Given the success of blended curricula in the undergraduate medical education of physiology,22 anatomy,23 radiological anatomy24 and primary care,25 we hope to test its applications for education in hospice and terminal care.


We hypothesised that an online module will increase the students' knowledge on (1) the dying process, (2) terminal care and (3) hospice care, but not have a significant effect on the students' attitudes about self-perceived efficacy in caring for dying patients.

Given the promising research of other e-learning initiatives in improving knowledge, we postulated that a well-researched and well-designed online module will likewise improve the students' knowledge in the specific topic areas corresponding to the designated learning objectives. However, we were sceptical as to whether a short, one-time use of an online module would have substantial impact on the students' self-perceived efficacy in providing end-of-life care.

We hoped that this new educational intervention would complement and enrich an existing curriculum in palliative and end-of-life care curriculum at the Yale School of Medicine,21 ,26 ,27 and could prove useful for other institutions.


Online module development

In 2012, we used the Qualtrics software to develop the online module entitled Life, Death, and Medicine: the Dying Process, Terminal Care, and Hospice Care. The learning objectives of the modules were:

  • To identify the associated key physiological and psychosocial features in the early, mid-stages, and late stages of the active dying process.28

  • To recognise five common symptoms that may accompany the dying process (anxiety, fatigue, pain, dyspnoea, and anorexia) and be introduced to treatment options.

  • To describe the qualifications for and provisions of hospice care.

The module was 30–45 min in duration and contained 15 web pages, 29 in-text questions, a 30 s video clip (Cheynes-Stokes breathing) and a 20 s sound clip (death rattle). The module included three case studies: an 87-year-old Asian woman with end-stage renal disease to illustrate the three stages of the active dying process; a 54-year-old Hispanic man with end-stage chronic obstructive pulmonary disease to introduce treatments options for symptoms that may be experienced during the last days or hours of life; and a 70-year-old African-American man with metastatic bladder cancer to explain hospice care eligibility and services. The interactive features of the module included in-text multiple choice questions with immediate feedback, mix-and-match pairing, scripted dialogues and multimedia audiovisual clips. The primary references for this module were End-of-Life Care: A Practical Guideline29 and A Practical Guide to Palliative Care.28 These references were chosen because they covered the basics on terminal care and hospice care at a level appropriate for preclinical students.

Hospice clinical experience rotation

The hospice clinical experience was established in 2011 as a mandatory component of the Pre-Clinical Clerkship with the following learning objectives:

  • To define the key elements of a hospice assessment, and compare this with an acute care assessment.

  • To discuss the professional and personal challenges of caring for patients at the end of life.

Groups of three to four students spent an afternoon with a hospice care physician or nurse (the preceptor) in an inpatient or home hospice setting. As a group, they spent about 2 hours visiting one or two hospice patients and interviewed the patients and/or their families. At the conclusion of the interviews, the preceptor held a 1 hour structured debriefing session with the students to discuss their experiences, lessons learned and emotional reactions. The hospice clinical rotations occurred over a 6-week period in which 16–17 students (subdivided into groups of three to four) attended the rotation each week.

Study design

In the fall semesters of 2012, 2013 and 2014, the second-year medical students at the Yale School of Medicine were invited to voluntarily participate in this study that was offered in conjunction with the pre-existing mandatory hospice clinical experience. In the pilot year (2012), all the second-year medical students received an email invitation to complete the new module via an embedded web link 1 week prior to their hospice clinical experience. After completing the clinical hospice experience, all students received a second email that invited them to anonymously complete a posthospice survey. At the end of 6 weeks, once all the students completed their hospice visits, a third email was sent to all the students reminding them to complete the survey. During the pilot year (2012), we empirically collected the participation rate for completion of the online module and/or the survey. In subsequent years of the study (2013 and 2014), 70% of students were randomised to the Yes module group and received access to the online module 1 week prior to their hospice experience, while the remaining 30% comprised the No module (control) group who did not receive access to the online module until they completed the posthospice survey. This 70/30 ratio of randomisation was employed in an effort to obtain survey results from a balanced proportion of Yes module and No module students, since only a proportion (∼50% in the pilot year) of students who received the module link actually completed it. A schematic diagram depicting the flow of the randomised study is shown in figure 1.

Figure 1

Students were randomly assigned to the Yes module group and the No module (control) group. Those who were in the Yes module group received a link to the online module 1 week prior to their hospice rotation, whereas those in the No module group did not. All students participated in the clinical hospice rotation for one afternoon, after which they received a link to an anonymous online survey.

Module assessment

Survey development

We assessed the online module's effect on the students' attitudes and knowledge using a 23-item survey created and administered via Qualtrics. Ten attitude-assessing statements were adapted from the Frommelt Attitude Toward Care of the Dying (FATCOD), a validated instrument with 30 Likert-type statements used to assess attitudes towards dying patients.30 The statements were chosen based on their relevance to the three areas corresponding to the learning objectives: the students' self-perceived comfort level, their views on the physician's responsibility, and their perspective on the role of medical education in the care of dying patients. To each statement, the students indicated their degree of agreement or disagreement on a sliding scale from 0 (completely disagree) to 100 (completely agree). For knowledge assessment, we created eight multiple choice questions each with four answer options. We focused on assessing knowledge towards terminal care and end-of-life care in the areas of the dying process, terminal symptoms and their management, and hospice care. Of the five terminal symptoms introduced in the module, three were chosen at random to be tested in the knowledge questions; testing of additional symptoms were omitted in order to keep the survey short and succinct. The survey questions were reflective of the content in the online module.

Survey administration

A web email was sent to all second-year students inviting them to participate in the study via an anonymous survey web link. Access to the survey was by invitation only and the responses could only be collected from those who received an invitation email. Voluntary participation was enacted by clicking on the survey link, and then electronically signing a consent form prior to accessing the survey content. No monetary incentives were provided for participation; however, we offered to share the survey results with the participants as a non-monetary incentive. None of the items on the survey required mandatory responses, and participants could choose to skip questions. Responses were saved automatically by Qualtrics into a repository of recorded responses, and the survey data was then downloaded as a Microsoft Excel file. Partially completed surveys were labelled as ‘response in progress’ on Qualtrics for 1 week. If the student did not return to finish the survey after 1 week, the recorded responses were closed as they were and transferred to the repository of recorded responses. Each student could only complete one survey; Qualtrics was set up to prevent multiple entries from the same person (‘ballot box stuffing’) by placing HTTP cookies on each respondent's browser on completion of a survey.

Data analysis

We used Microsoft Excel and IBM SPSS V.22.0 to organise, code and analyse the data. The students' answers on the knowledge questions were coded as 1 (correct) or 0 (incorrect). For negatively worded attitude statements, the scores were inversed (subtracted from 100) to indicate the level of agreement to the theme as if it were positively worded. Multivariate linear regression was performed to evaluate for statistical significance of the module, gender, year and location on the knowledge and attitude questions. Univariate analysis of variance was performed to provide descriptive data (average and SD) for the attitude questions.


Data protection

Students completed the module and survey anonymously. The researchers were not able to trace back the responses to individual respondents because Qualtrics removes all identifying information from each survey response. An anonymous survey link was used to prevent the collection of any personal information such as the respondent's name or email address. Qualtrics assigned participants with random computer generated codes to mask students' identities, and used IP addresses to link students to their unique survey responses in case the student completed the survey in more than one sitting.

Informed consent

Participation in the study was voluntary. The first page of the online module and the survey was an informed consent form that required an electronic signature before proceeding to the study content. The informed consent page provided an introduction to the study and outlined the procedure, the risks and benefits of participation, confidentiality, voluntary participation and the researchers' contact information.

IRB approval

Institutional Review Board exemption for this study was granted by the Yale University Human Subjects Committee on 25 September 2012 under 45 CFT 46.101(b)(1).



A total of 152 students (response rate 51%) completed the survey. Almost half the participants were women, which is representative of the overall Yale School of Medicine student body. For the hospice clinical experience, 79% (n=119) rotated in outpatient hospice facilities (sites 1 and 2) and 13% (n=19) on inpatient palliative care consult services (sites 3 and 4). Nine per cent (n=14) of the students did not indicate their hospice rotation locations; 56% (n=85) of students completed the online module prior to their hospice experience and 37% (n=56) did not; 7% students (n=11) did not indicate whether they had completed the module or not. Comparing the students who did or did not complete the module, no differences were found for gender, year cohort or hospice rotation location (table 1).

Table 1

Participant distribution


Students who completed the online module scored higher on the overall knowledge-assessing questions (p=0.006), and in five out of the eight individual questions (p≤0.002) compared with those who did not complete the online module (table 2 and figure 2). There were no significant differences of performance on the knowledge questions based on gender (p=0.730), hospice rotation location (p=0.381), or class cohort (p=0.377) except for one question regarding the death rattle (p=0.041).

Table 2

Knowledge questions results summary

Figure 2

Students who completed the online module had a high score (p<0.05, denoted by asterisk) in the overall quiz total, and in five out of eight knowledge-assessing multiple choice questions.


There were no statistical differences in the students' attitude ratings based on whether they completed the module, their gender, year cohort or hospice rotation location (table 3 and figure 3). Overall, the students expressed high agreement to statements pertaining to professional responsibility (average 94/100 agreement, SD=11) and the importance of end-of-life care in medical education (average 85/100 agreement, SD=22), but displayed only moderate levels of comfort with end-of-life care (average 54/100 agreement, SD=28).

Table 3

Summary of the attitude results p value

Figure 3

Students strongly agree that it is a physician's duty to care for dying patients though they felt somewhat uncomfortable while doing so, and that palliative care education is important in medical school. There were no statistically significant differences between those who had completed the online module and those who had not.


To our knowledge, this is the first reported blended curriculum on end-of-life care that combines online learning with a hospice experience for preclinical second-year medical students. Prior reports of end-of-life education for second-year medical students are mostly classroom-based, including lectures,31 small-group clinical case studies32 and reflective exercises.33 For third-year students, examples of blended curricula on end-of-life care include combinations of home or inpatient hospice visits, standardised patients and didactics embedded within ambulatory or family practice clerkships.34–37 More recently, online end-of-life educational programmes for third-year medical students have been piloted with success at the University of Alberta,19 Baylor College of Medicine20 and the Yale School of Medicine.21

Our initiative is unique in offering a blended curriculum on end-of-life care to second-year medical students, combining online learning with an experiential hospice rotation. This online module appears to be effective in improving the students' understanding of hospice care and its eligibility and services. Students who completed the module recognised that hospice enrolment is eligible for patients with a prognosis of 6 months or less as certified by two physicians, and that the approach of care is changed from curative/life-prolonging to palliative even though a Do Not Resuscitate status is not necessary. Moreover, the students became more familiar with the provisions outlined in the Medicare Hospice Act, including medical payments coverage for all medications and medical equipment related to the terminal illness, chaplaincy support for patients, and bereavement programmes for families. Learning about hospice care can serve as a preparatory step for preclinical students prior to their advancement to third-year clerkships where they may encounter and participate in the care of patients at the end of life.20 ,26

Our study identified some areas of terminal care that second-year medical students struggled with, particularly the stages of the natural dying process, and the pharmacological treatments for terminal symptoms. These findings are not entirely unexpected since preclinical students have had minimal exposure to patients and pharmacology. Typically, the curriculum in the first 2 years of medical school in the USA focuses on physiology and pathophysiology rather than clinical management. We believe that this supports the notion that end-of-life care education should be a continuum spanning the entire medical curriculum, such as introducing hospice care in the preclinical setting while addressing pharmacological treatments for terminal symptoms in the clinical years.

In terms of attitudes, we found a discrepancy between the degree of personal comfort and professional responsibility towards end-of-life care. Students expressed strong agreement to the statements pertaining to professional responsibility, such as ‘physicians have a duty to care for dying patients’, ‘doctors should talk to patients about death and dying’ and ‘doctors have a significant role in the care of patients at the end of life’. However, they were only moderately comfortable with being in the presence of, speaking with, or providing care for patients at the end of life. Perhaps it is because of this perceived discrepancy between knowledge and responsibility that the students strongly agreed that end-of-life/palliative care education is an important part of medical school, and that it is just as important as other curricular topics related to treating or curing diseases. We believe that competency in end-of-life care delivery requires both knowledge and personal comfort. As expected, a single, limited exposure to the online module did not seem to affect the students' comfort level. Rather, as previous studies have shown, more in-depth, experiential learning opportunities may improve students' levels of comfort and self-perceived efficacy.20 ,38–40

E-learning in palliative care

Students in the 21st century are sometimes deemed ‘digital natives’ who were born into a world where computers are prevalent and relevant to their work, school and play.41 This generation of students can absorb information quickly, in images and video as well as text, from multiple sources simultaneously. They are said to operate at ‘twitch speed’ and expect instant responses and feedback. Adapting to the changing environment and audience, teaching methodologies have evolved towards the trend of ‘learner-centred’ and ‘student-centred’ designs. Students are given more control over their own learning—the pace, the format and the mode of content delivery. Autonomy of the learner is emphasised alongside active learning.

E-learning can be seen as an innovation in medical education amidst a paradigm shift from instructor-centred teaching to a learner-centred model. In congruence with the adult learning theory, e-learning technologies offer the means for students to learn by relating new material to old experiences, linking learning to specific needs, and applying learning in a practical manner.42 E-learning can be individualised, collaborative and transformative,43 as demonstrated by online case-based modules, virtual discussion forums, image banks and self-assessment questions.16–18 Previous studies have found that e-learning has been successful even for sensitive topics such as end-of-life and palliative care in third-year medical students.19 ,20 ,26 Our study is unique in showing improvement of knowledge in preclinical students in the context of a blended learning experience.


A limitation to this study is that it was conducted with medical students at a single medical school which may limit the generalisability of the results. Moreover, our survey contained relatively few items to assess knowledge and attitudes, and could be expanded for a more comprehensive assessment.


Our newly developed Life, Death, and Medicine: the Dying Process, Terminal Care, and Hospice Care online module is a promising tool to enhance second-year medical students' domain knowledge. Combining this online module with experiential clinical exposure can form an effective blended terminal and hospice care educational experience for preclinical medical students.


The authors would like to thank Dr Margaret Bia and Dr Jaideep Talwalkar, Directors of Clinical Skills programme, for welcoming us to pilot the research project with their students in the Clinical Skills Course. We would like to thank the staff at the Teaching and Learning Center, particularly Dr Janet Hafler for her willingness to provide advice and direction on educational scholarship and Mr Gary Leydon for his technological expertise. The authors would also like to acknowledge the American Medical Students Association and VITAS Innovative Hospice Care for inviting Chung Sang Tse to participate in the End-of-Life Fellowship Program, which inspired her to pursue this project.



  • Contributors CST drafted the manuscript, designed the educational intervention, obtained IRB approval, implemented the intervention, evaluated it, and performed the statistical analyses. MSE edited the manuscript, edited the content of the educational intervention, assisted in the implementation and evaluation of the educational intervention. CST procured funding from the Yale School of Medicine Office of Student Research. MSE procured funding from the Alexandra K Munroe Fund.

  • Funding Yale School of Medicine Office of Student Research and Alexandra K Munroe Fund.

  • Competing interests None declared.

  • Ethics approval Yale University Human Subjects Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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