Fourth year medical students' reflective writing on "death of Ivan Ilych: a qualitative study.

INTRODUCTION: Medical students should be familiar with the end of life ethical issues and its considerations. For teaching end of life care to medical students, literature is a source of excellent narratives of patients with experiences of terminally ill condition in their journey through suffering and one of the most favourite bioethics literature readings has been the death of Ivan Ilych by Tolstoy. We used this novel to show medical students end of life events and suffering and asked them to write a reflective essay on it. We aimed to find what students think about terminally ill patients and their journey to death.
METHODS: In an inductive qualitative content analysis model, 350 essays, collected by homogenous sampling, were analyzed. The fourth year medical students were provided with the Death of Ivan Ilych novel to read. They were asked to write a reflection essay based on the reflective stages defined by Sandars. These essays served as the unit of analysis, each being read several times and a coding model was formed according to main topics. The related concepts in each unit were named as themes and each theme was abstracted to a code and the related codes were compared and developed as categories.
RESULTS: Qualitative content analysis of 350 essays of fourth year medical students revealed three major categories in students' reflection on reading Death of Ivan Ilych as an end of life human body. These included: 1) Emotional experience, 2) Empathy and effective communication, 3) Spirituality and dignity. Analysis of essays showed that this reflection activity may help medical students have a deeper idea of the end of life situation and feelings.
CONCLUSION: This project suggests that literature can be used as an example to introduce new ethical concepts to less experienced medical trainees. The students acquired the concept of the story and reflected the major aspects of the suffering of a human being in their essays. Having used and evaluated the effect of literature on facilitating ethical insight in the teaching end of life care, we strongly recommend this method and specially the novella, Death of Ivan Ilych.

Introduction

Nowadays, there are few people with no experience of a life-threatening condition in their families, friends or in the neighbourhood. Of the 58 million people dying each year (1), approximately 60% die with a chronic condition of which 6 million deaths are from cancer with the majority occurring in developing countries (2-4). With aging of the population, health care workers will confront terminally ill persons increasingly (2).

Chronic disease and cancer are growing in Iran as other developing countries (According to the statistics from Ministry of Health and Medical Education), cancer is the third cause of death in Iran and other developing counties (5,6) and this means, need for appropriate facilities and most importantly education for caring this population.

End of life care issues are among the pivotal cares for chronic disease and cancer patients. These patients need to have their remaining life meaningful. Medical students should be familiar with the end of life ethical issues and its considerations (7). For teaching end of life care to medical students, literature is a source of excellent narratives of patients with experiences of terminally ill condition in their journey through suffering.

One of the most favourite bioethics literature reading has been the Death of Ivan Ilych by Tolstoy. The Death of Ivan Ilyich (Russian :Смерть Ивана Ильича, Smert' IvanaIlyicha), initially published in 1886, is a novella by Leo Tolstoy , one of best writings of his late fiction, written shortly after his religious conversion in late 1870s.

The Death of Ivan Ilych is the story of an ordinary man coming to terms with his mortality (8). This text is commonly used in literature and medical courses to discuss death and end of life philosophy.

We provide our students a Persian translation of Death of Ivan Ilych to read and write their reflection on the concept of the book and their attitude and feeling toward the story. This was a part of professionalism and ethics curriculum at Shiraz Medical School and also included a two-hour workshop as an end of life ethics module. In this course, fourth year medical students are introduced to fundamentals of ethics of care in terminally ill patients.

Methods:

This study is a qualitative content analysis of medical students’ essays about the end of life ethics module at Shiraz Medical School. The sample size was 350 essays by fourth year medical students (180 female students and 170 male students). The sampling was performed with homogenous sampling method of fourth year medical students in Shiraz Medical School. All of the students had courses in pathophysiology of diseases and general psychology.

In the end of life ethics module, fourth year medical students at Shiraz Medical School have an opportunity to “develop an awareness of their own attitudes, feelings, and expectations regarding death and loss as an essential component of learning the end- of -life issues .

After reading the Death of Ivan Ilych novel, the students were asked to write a reflection essay based on the reflective stages defined by Sandars (9). The first general question was: “What do you think about end of life ethical issues?” In class discussion, each student was probing for explanation or justification about the end of life ethical aspects, and thereby providing a deeper understanding of the end of life issue. Following guidance and using Kolb four-stage experiential model (10), the students were asked to write a reflective essay addressing issues raised by reading the Death of Ivan Ilych and class discussion based on their feelings about death and caring for the dying.

This approach may be valuable because reflective writing exercises have been shown an effective way for learners to critically examine their own and other people’s experiences and this can result in greater empathic responses to both patients and themselves (11).

The obtained data were analyzed using inductive content analysis (12). The unit of analysis was written students’ essays. Each set of essays was read several times and a coding scheme was developed based on the predominant themes and topics discussed.

According to the units of analysis, which was the whole body of the essays, the written essays were divided into themes, codes and categories. At first, the sentences or paragraphs containing aspects related to each other were named as themes. Then, each theme was abstracted and labelled with a code. The various codes compared based on the relationship of the underlying meanings. The same meanings were gathered together and this formed categories. Finally, three categories were formed with the agreement of the researchers.

Trustworthiness:

To ensure validity and reliability in this qualitative research, examination of trustworthiness is necessary (13). In this study, full explanations were used to reduce the chance of losing significant information. Member check was done by sending a copy of the transcript with themes, codes and categories to some of the participating students and asking them to assess authors’ understanding of their thoughts and ideas. Peer check was done by checking themes, codes and categories by a researcher familiar with ethical issues and the qualitative method.

Ethical considerations:

All of the process took place anonymously; students took part in the study voluntarily and name of the students was not disclosed to the persons who were reading the reflective writing.

Results:

Analysis of the content of these essays revealed fifteen coded quotes and three major categories regarding students’ primary concerns and thoughts related to caring for the dying patient, Ivan Ilych. These codes are the key concepts of developing end of life care competencies.

Emotional experiences

The students found Ivan Ilych lonely and fragile, confronting his fate and some of them thought that this terminally ill condition made Ivan Ilych reflecting on his life to some kind of awakening.

Students thought that human illness was a source of isolation, loneliness and frailty. ‘The journey of Ivan through his illness showed us human frailty and loneliness.” Also the main reflection on Ivan’s emotions was his emotional transition from anger and frustration to final compassion.

“Ivan Ilych confronted death and experienced a transition from anger to frustration and then acceptance of death and this might be a common pathway in most patients that might ultimately come to comfort and compassion”. Students found that the journey of Ivan through suffering ended up in awakening. “This suffering made Ivan reflect on his spoiled life and some kind of awakening even very late”.

Empathy and effective communication

Empathic problems were pointed out frequently in students’ reflective narratives. They thought that disoriented communication of Ivan’s family and the impact of illness made him isolated and fragile. “Ivan isolated himself and adopted a formal contractual relationship toward his family thus during his suffering he was alone without empathy and care from his friends”.

Our students noticed the wrong way of caring physician for communication with Ivan and they described the mindset of Ivan in his journey to death. “Ivan was not conscious of the error he made and he had no compassion and empathetic human connection but his illness had curative influence and made him reflect on his life”.

“Ivan’s physician had not made a good communication with him and did not sympathize with him”. The students found a pure empathic relationship between Ivan Ilych and his servant Gerasim. “The only character that could make a reflective relationship with purity and dignity was Grasim, the poor peasant, and this means that social ambition and materialistic way of living are barriers to a real existence”. “Gerasim is at peace with himself, and the mutual, comforting relationship he has established not only add immeasurable joy to life, but also give him the courage and strength to confront death”.

According to our students caring the patients in terminally ill condition needs a pure soul to sympathize and focus on it and this may relieve some suffering.

Spirituality and dignity

Spiritual and religious thoughts have a great impact on the way people think about life and death and this issue is reflected clearly in the students’ essays. With Islamic thoughts, our students paid much attention to spiritual journey of Ivan and the role of his illness in his perception of true nature of life.

“Gerasim is a truly spiritual character. He exemplifies the right way to life, and his contact with Ivan helps the man along the road to spiritual health”. “Ivan's illness reveals the true nature of life to him”. “When Ivan passes into the light and realizes that compassion and love are the true life values, the great joy he experiences is proof of the quality of such a life”.

“Belief in God and His mercy may help relieve the suffering of death by focusing on the true meaning of life”. “Materialistic life without any belief in God and true meaning of life make confrontation with death a very horrible thing”. “Sometimes it may be logical to decide how and when to die and euthanasia may help people to experience less suffering”.

“In terminally ill patients, suffering may awaken the person and decision on doing euthanasia is not logical because this may disrupt the pathway to true relief and compassion”.

Discussion

Medical students should be exposed to the concept of death and end of life care so that they could prepare for their real encounters and also learn that fears, uncertainties and conflicts are natural (14). Literature is an excellent source of reflection on life and medical students could experience a virtual journey with characters in stories.

Death of Ivan Ilych is a powerful story by Leo Tolstoy about the final days of life. Despite the fact that this story was written about a century ago, it reminds us that in a hectic therapeutic environment of patient management we should focus on the person who is suffering. In this qualitative study, we provided medical students with a Persian translation of the novel, Death of IvanIlych, and they wrote a reflective essay on it.

According to content analysis of the essays there were three main categories- emotional experience, empathy and effective communication, and spirituality and dignity- that were reflected by the students.

The first category is the emotional experiences that Ivan Ilych passed through during his last days. Students found the transition of feeling from anger to acceptance of death and also the fragility and loneliness of Ivan during this time.

Bigley, et al. found that postgraduate nursing students also specifically focused on loneliness and the isolation experience of Ivan as “loneliness of death” (15). Nursing students in Bigley’s study also highlighted lack of honesty and poor communication of Ivan’s family and doctors.

The second category showed a focused concept on empathy and careless communication of Ivan’s family, friends and doctors. The students were also impressed by pure and honest relationship of Ivan and Gerasim.

The third category findings were about the students’ perception of dignity and impact of spirituality on the concept of suffering.

As Muslims, the students have special beliefs that affect their concept of suffering and death. According to the Islamic belief, death is a connection between this world and the other world. Afterlife is the most important and infinite part of life and this earthly life is just preparing the person for afterlife (15-18).

Looking at students reflective essays allowed us to find the main concerns that medical students have about dying Ivan Ilych as a human being. Reading and thinking about patients’ experiences in literature is a great opportunity with positive impact on students, encouraging them to think more deeply about their experiences, feelings and concerns than only focus purely on a didactic lecture-based curriculum.

Conclusion

Nurturing practical and moral insight is clearly essential in end of life and palliative care and students can accomplish excellence through example. This project suggests that literature can be used as an example to introduce new ethical concepts to less experienced medical trainees. Unfolding the story of Ivan Ilych as a dying person offered a unique opportunity to reflect on ethical issue arising in scenarios of terminally ill patients.

The students acquired the concept of the story and reflected the major aspects of the suffering of a human being in their essays. Having used and evaluated the effect of literature on facilitating ethical insight in the teaching end of life care, we strongly recommend this method and specially the novella, Death of Ivan Ilych. It could be assigned as a part of the reading source for medical students.

Table 1

The themes, codes and meaningful units

Theme	Code	Meaning unit
Feeling of loneliness, isolation, fear, deception, and collision	Isolation, loneliness and frailty in illness, anger, frustration, acceptance of death, awakening, comfort, compassion	Emotional experience
Gerasim’s empathy: despite being a peasant, he had a pure soul. Physicians need to develop empathy for care of terminally ill patients.	Gerasim’s pure soul for empathy, physician’s lack of empathy, reciprocal empathy	Empathy and effective communication
Suffering may clear the soul; euthanasia is in contrast to belief in God and His mercy	Belief in miracle, belief in God, suffering and compassion, true nature of life	Spirituality and dignity