Creat ive Educati on
2014. Vo l.5, No.2, 93-96
Published Online February 2014 in SciRes (http://www.scirp.org/journal/ce) http://dx.d oi.org/10.4236/ce.2014.520 15
Documentary Effects on Medical Student Attitudes & Skills
Regarding Nutrition at the End of Life
Scott De La Cruz1, Francesca Nicosia2, Eva Aagaard1
1Department of General Internal Medicin e, Univ er sit y of Colorado Denver, D enver, USA
2Department of Anth r opology, History and Social Medicin e, University of
California San Francisco, San Francisco, USA
Received January 1st, 2014; February 1st, 2014 ; acc ep ted Feb ruar y 8 th, 2014
Copyright © 2014 Scott De La Cruz et al . This is an open acc ess article distri b uted under t he Creati v e Common s
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2014 are guarded by law and by SCIRP as a guardian.
Medic al trai nees ra r ely have t he opp or tuni t y to pr ovi de co mpr ehe nsi ve end of l i fe c a re or see t he ph ysi cal
tra nsforma tion of the d ying p roces s. Studi es sug gest that the use of fi lm in medica l educ ation i s an ef fec-
tive means of exp osing s tudent s to a spec ts of medic ine the y might not other wis e recei ve. Dying Wish is a
visual inst rumental cas e study of a patient wit h end-stage ca ncer who chos e to stop eati ng and drink ing at
the end of hi s li fe. In t his ra ndomized, c ontr ol led s t udy, we as s essed t he imp ac t of Dy in g W is h on medical
students’ attitudes, knowledge, and confidence in patient/family discussions surrounding nutrition at the
end of life using student surveys and independently validated standardized patient assessments. By the
middle of the first clinical year, about 58% of students witnessed and 38.6% actively participated in a
disc ussion rega rding nut riti on at the end of life wi th a p atient a nd/or thei r famil y. Althoug h there wa s no
signi ficant differenc e in student s’ self -perceived k nowledge or s kills , a signif icantl y higher perc entage of
students who viewed “Dying Wish” prior to standardized patient visits clearly explained the biological
consequences of stopping eating and drinking compared to those who had not viewed the film. Students
agreed t hat “Dying Wis h” impro ved their knowl edge of the ph ysica l eff ects of stoppi ng eati ng and dr ink-
ing and effectively introduced the ethical and psychosocial issues associated with nutrition at the end of
life. Documentari es are considered by students to be effect ive teaching tool s and “Dying Wish” represents
a feas i ble wa y to d eli ver ins tr uc ti on rega rdi ng nut ri ti on a t t he end of l i fe. Vi s ual dep ict ions a nd doc umen-
tary films that portr a y the nat ura l cour ses of ill ness es may pr ove to b e help ful , ef fi cient teac hi ng tool s and
their role in the educational process for healthcare providers shoul d continue to be s tudied.
Key words: Medical Education; Docu ment ary Fil m; Visual Ins trumental Case Study; End of Li fe;
Understanding and identifying the signs and symptoms of
death is an essential skill needed by all physicians to provide
quality care and, as such, is an important component of medical
stud ents’ competenc y in end of life care (Field & Cassel, 1997;
Gibbins, McCoubrie, Alexander, Kinzel, & Forbes, 2009; Nel-
son, Angoff, & Bin der, 2000). Medi cal trainees rarel y have th e
opportunity to provide comprehensive end of life care or see the
physical transformation of the dying process (Gibbins, McCou-
brie, Alexander, Kinzel, & Forbes, 2009; Billings & Block,
1997). This lack of exposure may result in medical trainees
feeling underprepared and having difficulty educating patients
and their families about what to expect at the end of life (Buss,
Marx, & Sulmasy, 1998; Fraser, Kutner, & Pfeifer, 2001; Van
der Riet, Good, Higgins, & Sneesby, 2008; Gibbins, McCou-
brie, & Forbes , 2011).
Didactic sessions can be limited in their ability to convey
complex aspects of care. Experiential approaches including
stand ardized patients, role-play, and the humanities have been
shown to be effective means of learning affective and skills-
based objectives (Block, Bernier, & Crawley, 1998; Schmidt,
Norton, & Tolle, 1992; Serwint & Simpson, 2002; Kahn, Sher-
er, Alper, Lazarus, Ledoux, Anderson, & Szerlip, 2001). Early
studies suggest that the use of film in medical education is an
effective means of exposing students to aspects of medicine
they might not otherwise receive (Self, DeWitt, & Baldwin,
1990). Films can be used to educate, create self-reflection and
generate d iscu ssio n abou t the general emotio n al react ions of th e
viewer, diagnostic impressions, therapeutic and treatment con-
siderations, and associations with one’s own profession and
personal life (Alexan der & Lenahan , 2005).
Dying Wish is a visual instrumental case study of Dr. Mi-
chael Miller, a retired surgeon with end-stage cancer who vo-
luntarily chose to stop eating and drinking at the end of his life.
The film documents Dr. Miller’s decision-making process and
raises the topics of bioethics, spirituality, patient autonomy,
voluntary refusal of food and fluids (VRFF), as well as the
physical and emotional aspects of stopping eating and drinking.
The film allows the viewer to visualize the physical dying
OPEN ACCE SS 93
S. DE LA CRUZ ET AL.
process and the physiology of stopping eating and drinking at
the end of life.
In this study, we assessed the impact of Dying Wish on med-
ical students’ attitudes, knowledge, and confidence in patient/
family discussions surrounding nutrition at the end of life. In
addition, we assessed the effect of the film on the likelihood
that students would initiate a conversation about nutrition or
VRFF and the adequacy of their description of the biological
consequences of such a decision during a simulated patient
encou nt er .
This randomized, single-blinded, controlled trial took place
at University of Colorado School of Medicine during a required
one-week curriculum delivered near the mid-point of the third
year of medical school. The overarching goal of the curriculum
is to teach the fundamentals of end of life care and advanced
communication skills. One hundred twenty-seven medical stu-
dents answered questions about their knowledge, attitudes and
self-confidence in discussing the topic of nutrition/hydration at
the end of life via a computerized Likert scale survey at the
start of the one-week curriculum. Three yes or no questions
also assessed the students’ prior personal and curriculum-asso-
ciated experiences with nutrition at the end of life. Students
were then randomized into 2 groups (Figure 1).
The intervention cohort (n = 64) viewed Dying Wish and
then worked in pairs to lead a standardized patient (SP) en-
counter of a family meeting wherein the patient has late stage
Alzheimer ’s disease an d has been ad mitted for r ecurren t aspira-
tion pneumonia. The family is being asked to address the issue
of nutrition and hydration, among other end of life issues. The
control cohort (n = 64) completed the same SP encounter in
pairs without having viewed Dying Wish. Immediately follow-
ing the SP encounter, students from both groups were asked
again about their knowledge, attitudes and self-confidence re-
garding nutrition/hydration via a computerized survey.
SPs completed a computerized checklist that asked if the
medical students: 1) initiated a conversation about nutrition at
the end of life, 2) mentioned voluntary refusal of food and flu-
ids as an option at the end of life, and 3) clearly explained the
biological consequences of stopping eating and drinking at the
end of life. The SPs were blinded to intervention or control
group assignment status. The SPs’ responses to the checklists
were validated by a video review of 20 randomly selected en-
Finally, all students were asked about their level of agree-
ment regarding the usefulness of “Dying Wish” and documen-
tary films i n general for medical edu cation as p art of th e course
evaluation at the completion of the week of curriculum. A Li-
kert-type scale was used to measure responses: 1 = strongly
disagree, 2 =disagree, 3 = agree, 4 = strongl y a gree.
Chi-square analysis was used to compare the control and in-
tervention groups’ responses to the pre-SP encounter survey
and their performances on the SP checklist. McNemar’s test
was used to compare students’ responses to the pre- and post-
SP encounter surveys within groups. The Wilcoxon signed rank
test was used to compare the intervention and control groups’
responses to the post-SP encounter surve y. Descrip tive anal ysis
of the 4 point Likert-type scale survey administered at the end
of the weeklong curriculum documented the percei ved ef ficac y
of the documentary film as a teaching tool.
One hundred and twenty-eight of the 147 students that grad-
uated in the class of 2011 participated in the surveys. The dis-
crepancy in the number of students reflects those who were
absent or who joined the graduating class later from combined
degree programs or other causes for delay in training. There
were 48.3% female students, 10.2% ethnically diverse students
and the age range at the time of graduation was 26 years 9
months to 39 years 11 months.
Pre-Interventio n Survey
Of all the students surveyed, 58.2% (57.1% of the control
group and 59.4% of the intervention group) reported that they
had witnessed a discussion regarding nutrition at the end of life
with a patient and/or their family in their rol e as a medical stu-
dent, while 38.6% (31.7% of the control group and 45.3% of
the intervention group) had actively participated in such a dis-
cussion with a patient and/or their family in their role as a
medical student and 44.1% (44.7% of the control group and
43.8% of the intervention group) had personal experience with
decisions regarding nutrition at the end of life outside of their
role as a medical studen t. There were no si gnificant differences
found between the control and intervention groups with regard
to prior experiences with nutrition at the end of life.
A majority of students felt they had the knowledge (62.5%
control and 57.1% intervention) and skills (68.8% control and
68.3% intervention) necessary to discuss the biological effects
of stopping eating and drinking at the end of life. Fewer stu-
dents felt they had the knowledge (56.3% and 49.2%, respec-
tively) or skills (65.6% and 68.3%, respectively) to discuss the
various nutrition options at the end of life. Most students in
both groups felt that voluntary refusal of food and fluid at the
end of life is both ethical and legal. There were no significant
differences found between the control and intervention groups
in self-perceived knowledge or skills on the pre-intervention
Post -Inte rvention Sur vey
Both the control and intervention groups reported significant
improvements in the knowledge and skills needed to lead a
OPEN ACCE SS
S. DE LA CRUZ ET AL.
discussion with patients and their families regarding nutritional
options and the biological effects of stopping eating and drink-
ing at the end of life (Table 1).
In addition, both the control and intervention groups signifi-
cantly improved with regards to their comfort level with dis-
cussing nutrition at the end of life. Neither group significantly
changed its belief that voluntary refusal of food and fluids at
the end of life is both l egal and ethical.
SP Evaluation of Student’s Per formance
SPs did not note a significant difference between the control
and intervention groups in the percentage of students that in-
itiated conversations about nutrition nor those that mentioned
voluntary refusal of food and fluids as an option (Table 2).
However, a significantly higher percentage of students in the
intervention group clearly explained the biological conse-
quences of stopping eating and drinking at the end of life (76%
vs. 48%, p = 0.005).
End of Curric ulum Survey
Students agreed that documentary films can be ef f ective tools
for teaching medical topics (mean Likert-type response was
3.3/4.0, SD 0.6). In addition, students agreed that “Dying Wish”
improved their knowledge of the physical effects of stopping
eating and drinking (mean Likert response 3.1/4.0, SD 0.7) and
effectivel y introdu ced the ethical an d psychosocial i ssues asso-
ciated with nutrition at the end of life (mean Likert response 3.1
and 3.1/4.0, SD 0.7 and 0.6 respectively). Students were not
concerned that “Dying Wish” was shown to manipulate their
personal thinking regarding nutrition at the end of life (mean
Likert response was 2.1, SD 0.8).
This study describes mid-third year medical students’ expe-
riences, knowledge and attitudes regarding nutrition at the end
of life and VRFF at one institution. By the middle of third year,
just over 58% of students witnessed and 38.6% actively parti-
cipated in a discussion regarding nutrition at the end of life with
a patient and/or their family in their role as a medical student.
Although watching Dying Wish did not improve students’
self-percei ved knowledge or skills compared to those who did
not, a significantly higher percentage of students who viewed
“Dying Wish” prior to their SP visits clearly explained the bio-
logical consequences of stopping eating and drinking compared
to those who had not viewed the film. Students agreed that
“Dying Wish” i mproved th eir kno wledge of th e physical e ffects
of stopping eating and drinking and effectively introduced the
ethical and psychosocial issues associated with nutrition at the
end of life.
Medical trainees rarely have the opportunity to provide com-
prehen sive en d of life car e or see th e ph ysical tran sfor mati on o f
the dying process. This lack of exposure may result in medical
trainees having difficulty educating patients and their families
about what to expect (Van der Riet, Good, Higgins, & Sneesb y,
2008). In our study, although both the control and intervention
groups reported significant improvements in the knowledge and
skills needed to lead a discussion with patients and their fami-
lies regarding nutritional options, SPs reported that students
who had viewed Dying Wish were significantly more likely to
clearly explain the biological consequences of stopping eating
and drinking during the standardized patient encounter. This
suggests that Dying Wish helped the students to translate their
new knowledge and skills to actual behavior at least in the si-
Tabl e 1.
Responses to pre- and post-SP encounter surveys.
Control Group (n
Inter v ention Grou p (n
“yes” or “agree”
“yes” or “agree”
“yes” or “agree”
“yes” or “agree”
I have the knowledge I need to discuss the
biological effects of stopping eating and
drinking at the end of life.
I have th e sk ills I need to discuss t he biolo gical
effects of stopping eating and drinking
at the end of life.
I have the knowledge I need to discuss the
various options for nutrition at the
end of life .
I have the skills I need to discuss the various
for nutrition at th e end of life
Based on my personal beliefs, VRFF at
the end of life is ethical.
Legally, a patient ha s the right to volun tarily
refuse food and fluids at th e end of life.
I feel comfort able lead ing a discussi on
about options for nutr ition at the end of life.
OPEN ACCE SS 95
S. DE LA CRUZ ET AL.
SP evaluation of students’ performance.
% of SPs responding “Yes”
SP Checklist Item Contr ol Intervention p-value
conversation about nutrition
59% 62% 0.715
64% 63% 0.351
clearly explained the
biological consequ ences of starvation
48% 76% 0.005
The results of this study further supports the idea that films
can be u sed as an adjun ct in medi cal ed ucat io n to provid e expe-
riences that are hard to ensure consistently during clinical
training. The students surveyed as part of this study agreed that
documentary films can be effective tools for teaching and
agreed that “Dying Wish” improved knowledge of the physical
effects of stopping eating and drinking. The efficacy of “Dying
Wish” is consistent with prior studies of humanities modalities
as educational tools for end of life topics (Self, DeWitt, &
Baldwin, 1990; Lorenz, Steckart, & Rosenfeld, 2004; Weber &
Silk, 2007; Kumagai, 2008).
There are some limitations to this study and its assessment.
As the film was shown to students as part of a weeklong mul-
timodal end of life curriculum, it is difficult to isolate the ef-
fects of the film on the changes in self-reported attitudes and
knowledge. It is also unclear how evaluations and self-reported
efficacy at this early point in medical students’ careers will
translate to ability in actual practice. Traditionally self-report
has been an unreliable measure of clinical skill (Davis, Thom-
son, O’Brien, F reemantle, Wol f, Maz manian, & Ta yl o r-Vaisey,
Although the self-reported knowledge and skills around
counseling patients regarding nutrition and VRFF at the end of
life we re not significantly altered by viewing “Dying Wish”,
the film did affect students’ ability to clearly explain the bio-
logical effects of stopping eating and drinking to SPs. This is
likely due to the film’s visual depiction of the process of stop-
ping eating and drinking at the end of life. Documentaries and
other humanities modalities are considered by students to be
effective teach ing too ls and “Dyi ng Wish” represen ts a feasible
way to deliver instruction regarding VRFF and nutrition at the
end of life. Visual depictions and documentary films that por-
tray the natural courses of illnesses may prove to be helpful,
efficien t teachin g tool s and their role in the educat ional process
for healthcare providers should continue to be studied.
Alexander, M., Lenahan, P., & Pavlov, A. (2005). Cinemeducation: A
comprehensive guide to using film in medical educat ion. Singapore:
Billings, J. A., & Block, S. (1997). Palliative care in undergraduate
medical education: Status report and future directions. JAMA, 278,
733-738. http://dx.doi.or g/10.1001/jama.1997.03550090057033
Block, S. D., Bernier, G. M., & Crawley, L. M. (1998). Incorporating
palliative care into primary care education. National Consensus
Conference on Medical Education for Care Near the End-of-life.
Journal of General Internal Medicine, 13, 768-773.
http://dx.doi.org/10.1046/j.1525-1497.19 98.00230. x
Buss, M. K., Marx, E. S., & Sulmasy, D. P. (1998). The preparedness
of students to discuss end-of-life issues with patients. Academic
Medicine, 73, 418 -422.
Davis, D., Thomson O’B rien, M. A., Freeman t le, N., Wolf , F., Mazma-
nian, P., & Taylor-Vaisey, A. (1999). Impact of formal continuing
medical education—Do conferences, workshops, r ounds, and other
traditional cont inuing education acti vities change ph ysician behavior
or health care out co mes? JAMA, 2 82, 867-874.
Field, M. J., & Cassel, C K. (1997). Approaching death: Improving
care at the en d of lif e. Washington DC: National Academy Press.
Fraser, H. C., Kutner, J. S., & Pfeifer, M. P. (2001). Senior medical
stud ent s’ perceptions of the adequacy of edu cation on end-of-li fe is-
sues. Journal of Palliative Medicine , 4, 337-343.
Gibbins, J., McCoubrie, R., Alexander, N., Kinzel, C., & Forbes, K.
(2009). Diagnosing dying in the acute hospital setting—Are we too
late? Clin ical Medicine, 9, 16-19.
http://dx.doi.org/10.7861/c linmedicine.9 -2 -116
Gibbins, J., McCourbrie, R., & Forbes, K. (2011). Why are newly qual-
ified doctors unprepa red to care for pat ients at the end of life? Medi-
cal Education, 45, 38 9-399.
http://dx.doi.org/10.1111/j.1365-2923.20 10.03873. x
Kahn, M. J., Sherer, K., Alper , A. B. , Lazarus, C., Ledoux, E., Ander-
son, D., & Szerlip, H. (2001). Using standardized patients to teach
end-of-life skills to clin ical c lerks. Jour nal of Cancer Education, 16,
Kumagai, A. K. (2008). A conceptual framework for the use of illness
na rrati v es in medica l ed ucation. Academ ic Me di ci ne , 83, 6 53-658.
http://dx.doi.org/10.1097/ACM .0b013e31817 82e17
Lore nz, K. A., Steckart, M. J., & Rosenfeld, K. E. (2004). End-of-life
education using the dramatic arts: The Wit educational initiative.
Academ ic Me di ci ne , 79, 481-486.
Nelson, W., Angoff, N., & Binder, E. (2000). Goals and strategies for
teaching death and dying in medical schools. Journal of Palliative
Medicine, 3, 7-16 . http://d x.doi.org/ 10.1089/jpm.2000.3 .7
Schmidt, T. A., Nor ton, R. L., & Tol le, S. W. (1992). Sudden death in
th e ED: Educating residents to compassionately inform families. The
Journal of Emergency Medicine, 10, 643-647.
Self, D., DeWitt, C., & Bal dwin , J. (1990). Teaching medical humani-
ties through film discussions. Journal of Medical Humanities, 11, 23-
29. http://d x.doi.org/1 0.1007/BF01142236
Serwint, J. R., & Simpson, D. E. (2002). The use of standardized pa-
ti ents in pedia tric r esiden cy t rainin g in pa lliati ve car e: Anatomy of a
stan dar dized pat ient ca se sc ena rio. Journal of Palli ative Med icine, 5,
146-153. http://d x.doi.org/10.1089 /10966210252785123
Van d er Ri et , P., Good, P., Higgins , I., & Sneesb y, L. (2008). Palliative
care professionals’ perceptions of nutrition and hydration at the end
of life. International Journal of Palliative Nursing, 14, 145-151.
Weber, C. M., & Silk, H. (2007). Movies and medicine: An elective
using film to reflect on the patient, family, and illness. Fam ily Me di-
cine, 39, 317 -319.
OPEN ACCE SS