Approach to death and dying patients and its relation with death anxiety among medical interns: a multicenter cross-sectional study

Abstract

Background

Dealing with death and dying patients is one of the most challenging aspects of medical practice. The purpose of this study was to assess the attitude of medical interns toward death and dying patients as well as their level of death anxiety.

Methods

This cross-sectional study was conducted on medical interns across three countries—Egypt, Jordan, and Palestine—using an online survey created with Google Forms. The survey included sociodemographic information, the Approach to Death and Dying Patients Attitude Scale (ADDPAS), and Templer's Death Anxiety Scale (DAS). The sample size was calculated using OpenEpi, aiming for minimum 466 from Egypt, 273 from Jordan, and 348 from Palestine. Data were analyzed using SPSS version 27. Kruskal–Wallis and Mann–Whitney U tests were used to evaluate significant associations between demographic variables and the outcomes of the scales. Spearman’s correlation coefficients and simple linear regression analysis assessed the relationship between the scales. A p-value of ≤ 0.05 was considered statistically significant.

Results

This cross-sectional study analysis was done on 1156 participants. The median age was 24 years (interquartile range “IQR”: 24–25), with most living in urban areas (74.6%). Females comprised 53.6%. The median score on the DAS was 8.00 (IQR: 6–11). Hardness in communicating with the dying and their relatives and avoidance of death and dying patients subscales median scores were 2.22 (IQR: 1.89–2.44) and 2.54 (IQR: 2.18–2.81), respectively. Females had higher death anxiety and a less positive attitude toward communicating with dying patients and their relatives. Egypt scored lower on the ADDPAS subscales but higher than Palestine and Jordan on the DAS. DAS had a significant indirect relationship with hardness in communicating with the dying patients and their relatives (r = -.384; p < 0.001) and avoiding death and dying patients (r = -.123; p < 0.001). Simple linear regression showed that the DAS significantly predicts both subscales.

Conclusions

Medical interns showed moderate death anxiety and a positive attitude toward communication and avoidance of death and dying patients. Those with a higher level of death anxiety demonstrated a greater tendency to avoid dealing with dying patients and had more difficulties with communication. End-of-life training is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-024-02321-4.

Background

Death is a permanent irreversible cessation of all human biological functions that maintain human life; it is a natural process that certainly occurs at some point in human life [1]. It is normal to feel anxious about one’s death, others’ death, how death happens, and what happens after that, as long as these thoughts do not affect one’s daily activities. Improvements in medical care, coupled with the rising number of patients with chronic illnesses, have led physicians to encounter dying patients in their work regularly. They frequently find it challenging to manage terminally ill patients, which is a crucial but often neglected part of medical practice [2].

Caring for dying patients is widely regarded as one of the most challenging aspects of medical practice [3]. Physicians may sometimes avoid such patients, as it serves as a reminder of their own mortality and acts as a psychological defense mechanism [4]. Evidence shows that doctors who accept their mortality are generally more at ease when caring for terminal patients and provide higher-quality care [5]. In contrast, those with a greater fear of death often experience increased guilt when their patients pass away [6]. This fear can also influence clinical decisions; for example, neonatologists who fear the dying process and premature death are more likely to expedite an infant's death when further treatments seem futile [7]. Additionally, physicians often choose aggressive treatments over a watchful waiting approach to avoid confronting difficult outcomes [8].

Medical interns are at a transitional stage in their medical careers, where they first begin to encounter death and dying patients in medical practice. This stage is often associated with intense emotional responses and underdeveloped coping mechanisms compared to more experienced physicians [9]. As a result, their attitude toward death and levels of death anxiety may differ significantly, making them an important group to study. Additionally we did not target more experienced physicians because their attitudes and anxieties may be influenced by years of clinical experience, exposure to death, and the coping strategies they have developed over time, which could mask the challenges faced at the early stages of medical practice [10, 11].

While several studies focused on how nurses level of death anxiety affects their dealing with death and dying patients [12–14], there is a notable lack of research focusing on how medical interns navigate this, despite their frequent exposure to terminal cases. He et al. conducted a study in early 2020, during the COVID-19 pandemic, to explore how the crisis influenced medical interns' death attitudes and death anxiety [9]. The research identified two key factors affecting their attitudes: whether the interns were involved in COVID-19 treatment and whether a close friend or relative had been diagnosed with the virus [9]. However, currently, there is a knowledge gap regarding the attitude of medical interns toward death and dying patients in the Middle East and North Africa (MENA) region. Therefore, the primary aim of this study is to assess the attitude of medical interns toward death and dying patients in the MENA region as well as their death anxiety. The study also aims to assess the relationship between medical interns’ death anxiety and their attitude toward death and dying patients. In addition, we aim to explore the relationship between demographic characteristics and the attitude toward dying patients and death anxiety.

Methods

Study design, population, and recruitment procedure

We conducted a multicenter, cross-sectional study among medical interns across three countries: Egypt, Jordan, and Palestine. Data were collected using an online survey and followed the Strengthening The Reporting of Observational Studies in Epidemiology (STROBE) Checklist [15]. The survey was distributed between July 2024 and August 2024. The sample size was determined using the OpenEpi online statistical calculator, Version 3.01, [16, 17]. OpenEpi is a well-known and widely used online statistical calculator [18, 19]. Because of its accessibility, OpenEpi was a perfect fit for our study and is especially helpful for epidemiological research [17]. We set parameters at a 95% confidence interval, an expected frequency of 50%, and a 5% margin of error. Consequently, we aimed for 373 participants from Egypt, 218 from Jordan, and 278 from Palestine. However, after conducting our pilot study, we increased the sample size by 25%. The new-targeted sample sizes were 466 from Egypt, 273 from Jordan, and 348 from Palestine.

Eligibility criteria

The study involved intern physicians, defined as medical school graduates undergoing supervised training in hospitals for one or two years to obtain their medical licenses. We excluded non-intern physicians, individuals who participated in the pilot study, and those who had already completed the survey.

Data collection

An online questionnaire created through Google Forms was used. The questionnaire comprised three sections: sociodemographic data, the Approach to Death and Dying Patients Attitude Scale (ADDPAS), and Templer's Death Anxiety Scale (DAS). Our Independent Variables included mainly sociodemographic data such as age, sex, place of internship, place of residency, number of experiences of dealing with the death of a close relative and number of attending death situations at hospitals. Dependent variables were ADDPAS scale score and Templer's Death anxiety scale score.

The Approach to Death and Dying Patients Attitude Scale (ADDPAS) consists of 20 items, divided into two subscales: hardness in communicating with dying patients and their families (9 items) with Cronbach's alpha of 0.7 suggesting adequate internal consistency. The other subscale is avoidance of death and dying patients (11 items) with Cronbach's alpha of 0.7 suggesting also adequate internal consistency [20]. Each item is rated on a four-point Likert scale from one to four (strongly agree, agree, disagree, strongly disagree), with higher scores indicating a more positive attitude. This scale was initially tested on medical students who are in their clinical practice [17]. This scale then was used on postgraduate nurses and showed good internal consistency in their study (Cronbach’s alpha = 0.75 for hardness in communicating with dying patients and their families and 0.76 for is avoidance of death and dying patient). As medical interns are considerably fresh postgraduates in their clinical practice, this scale could apply to them. Moreover, this scale was primarily derived from various existing English and Turkish scales, though its validation was conducted in Turkish. In our study, we used the English version as presented in the original research.

The second scale, Templer's Death Anxiety Scale(DAS), measures death anxiety [21]. It includes 15 items, each rated on a binary Likert-type scale as either true (1) or false (0) with a Kuder-Richardson coefficient of 0.76 suggesting reasonable internal consistency. Total scores range from zero to 15, with higher scores indicating greater level of death anxiety.

To assess whether participants were answering consciously, a question was repeated within the death anxiety scale. This test question was: "I am not particularly afraid of getting cancer or AIDS." If the participant provided a different answer to the repeated question, their response was considered biased, suggesting they were not fully attentive while completing the survey. In addition, a medical question was included in this section to ensure that all participants were indeed doctors and not members of the general population. The medical question asked interns to identify the cause when a patient presents saying, "This is the most severe headache of my life." If any participant answered the repeated question differently or answered the medical question wrong, their response was excluded from the analysis.

An online link to the Google form was shared with intern doctors via social media platforms, mainly on Facebook, WhatsApp, and Telegram groups for medical interns. The data collection period was for one month to ensure sufficient time for data collection. During this period, we monitored the response rate to ensure it met the predetermined target that was calculated before starting the data collection process. We employed convenience and snowball sampling techniques to recruit eligible participants and boost response. The link was distributed through social platforms and where medical interns are encouraged to forward the survey to their colleagues.

The link recorded data anonymously without collecting any contact or personal information. At the beginning of the questionnaire, participants were given the option to consent or decline participation in the study. If they chose to participate, they had to confirm that they were current interns. To avoid duplicate responses, we set the questionnaire to be opened only one time per each signed-in email without collecting email addresses. Additionally, all questions were made mandatory to answer to ensure that no responses were left unanswered. This will help us to avoid any missing data.

This cross-sectional study initially included 1629 responses with a total response rate of 40%. Six respondents refused to participate in the study and 72 were not medical interns, so their responses were automatically ended. About 573 from Egypt, 525 from Jordan, and 453 from Palestine completed the survey. From the 1,629 responses, we excluded 473 for the following reasons: six individuals refused to participate, 72 were not medical interns, 170 provided incorrect answers to the medical question, and 225 demonstrated inconsistency in their responses to the test question. After excluding the responses with the prespecified exclusion criteria, the final total number was 1156 responses.

Validation and pilot study

Initially, we designed the online survey using demographic data and the two scales. Then we did face validity by distributing the initial survey to about seven medical interns. Our primary goal was to assess how long it would take to complete the survey, identify any unclear demographic questions, and address potential issues. Some respondents mentioned that the ADDPAS scale was lengthy and required significant focus. As a result, we reorganized the survey, placing ADDPAS before the Death Anxiety Scale. Additionally, we considered repeating questions within the Death Anxiety Scale to enhance the validity of responses. To lower sample contamination, we also included a medical-related question. Subsequently, we did a pilot study to ensure the clearness, appropriateness, and relevance of the questions and to gain preliminary insights into the analysis and results. This pilot study was conducted on 40 participants from each of the three countries. In the analysis, we excluded approximately 10 responses due to inconsistent answers to the repeated test question in the death anxiety scale. The results of the scales in the pilot study are shown on Table S2 (see Additional file 2). To account for future exclusion of responses, we added 25% to the sample size as described previously.

Ethical considerations

The study adhered to the principles of the Declaration of Helsinki (1964, last revised in 2013) [22]. Participation in the survey was voluntary, with participants providing informed consent by checking a box to indicate their willingness to join the study (this was a required item). Anonymity and confidentiality were maintained throughout the data collection and analysis processes. The Research Ethics Committee (REC) at Al--Quds University granted ethical approval (IRB number: 407/REC/2024).

Data analysis

The data were organized in a Microsoft Excel sheet and then imported into Statistical Package for the Social Sciences (SPSS) version 27 for analysis. Frequencies and percentages were used to describe the categorical variables for baseline demographic characteristics. The Shapiro–Wilk test was used to assess the normality of the continuous data. The results of the two scales were presented as the median and interquartile range (IQR). The Kruskal–Wallis and Mann–Whitney U tests were used to assess the significant association between demographic characteristics and the two scales' results. Spearman’s correlation coefficients determined the relationship scores of the scales. Simple linear regression analysis was used to determine to what extent death anxiety explained the change in their approach to death and dying patients. A p-value of ≤ 0.05 was considered significant. In addition, Cronbach’s alpha of the used scales was calculated to assess their internal consistency.

Results

Sociodemographic characteristics

Data analysis was done on 1156 responses: Egypt (N = 398, 34.4%), Jordan (N = 420, 36.3%), and Palestine (N = 338, 29.2%). The median age was 24 years (IQR: 24–25), with most living in urban areas (74.6%). Females made up 53.6% of the total sample of 1156 participants. Regarding exposure to death situations in hospitals, 15.1% had never exposed to any deaths situations, 15.7% had exposed once, 18.4% twice, 14.7% three times, and 15.7% more than six times. For the experience of the death of a close relative, 19.0% had never experienced such an experience, 25.4% experienced it once, and 24.5% twice. The details about the sociodemographic characteristics of participants are shown in Table 1..

Table 1.

Sociodemographic characteristics of medical interns in the study (N = 1156)

Variables	Category	N = 1156
Age (median, IQR)		24 (24–25)
Gender	Male	(46.4%) 536
	Female	(53.6%) 620
Place of living	Urban	(74.6%)862
	Rural	(25.4%)294
Place of internship	Egypt	(34.4%)398
	Jordan	(36.3%)420
	Palestine	(29.2%)338
Number of death situations encountered in hospital settings	Never	(15.1%)175
	Once	(15.7%)182
	Twice	(18.4%)213
	Three times	(14.7%)170
	Four times	(9.8%)113
	Five times	(6.6%)76
	Six times	(3.9%)45
	Seven times	(1.9%)22
	Eight times	(0.4%)5
	More than that	(13.4%)155
Number of close relative deaths encountered in their lives	Never	(19%)220
	Once	(25.4%)294
	Twice	(24.5%)283
	Three times	(15.4%)178
	Four times	(7.6%)88
	Five times	(1.9%)22
	More than that	(6.1%)71

Levels of death anxiety and approach to death and dying patients attitude

The DAS scale items showed acceptable internal consistency with a Cronbach’s alpha of 0.71.

The median score for the DAS was 8.00 (IQR: 6–11), indicating a moderate level of death anxiety among respondents. Notably, 60.7% of participants exhibited a DAS of more than seven.

As for the ADDPAS scale, it revealed that the items on the communication hardness subscale had a somewhat lower internal consistency (Cronbach's alpha of 0.67), whereas the items on the avoidance subscale had an acceptable internal consistency (Cronbach's alpha of 0.77).

The median score for hardness in communicating with the dying and their families and avoiding death and dying patients was 2.22 (IQR: 1.89–2.44) and 2.54 (IQR: 2.18–2.81), respectively. These results suggest that most participants generally tend to have a positive approach to dealing with dying patients and their relatives (Table 2). Participants' responses on items of the ADDPAS subscales are shown in (see Additional file 1).

Table 2.

Scores of medical interns' death anxiety scale and approach to death and dying patients attitude subscales

Scale and Subscales	Score(median(IQR))
Death anxiety scale	8 (6–11)
Hardness in communicating with the dying and her/his relatives subscale	2.22 (1.89–2.44)
Avoiding death and the dying subscale	2.54 (2.18–2.81)

Associations of sociodemographic characteristics with death anxiety and approach to death and dying patient’s attitude

Regarding gender differences, females demonstrated a significantly lower positive attitude on the communication difficulty subscale and a higher score on the DAS (p < 0.001). In addition, Egypt differed significantly from Jordan and Palestine; participants in Egypt had lower scores on both the communication difficulty subscale and the avoidance of death and dying patients subscale, along with slightly higher DAS levels (p < 0.001). Additionally, participants residing in urban areas displayed a significantly more positive attitude toward avoiding death and dying patients (p = 0.002) (Table 3).

Table 3.

Comparison of sociodemographic characteristics and death anxiety scale and approach to death and dying patient’s attitude subscales among medical interns

Sociodemographic Characteristics	Hardness in Communicating with the Dying Patients and Their Relatives		Avoiding Death and Dying Patients		Death anxiety scale
	Median(IQR)	P value	Median(IQR)	P value	Median(IQR)	P value
Gender
Male	2.33(2.11–2.56)	< 0.001*	2.55(2.18–2.82)	.958	7 (6–9)	< 0.001*
Female	2.11(1.78–2.33)		2.55(2.18–2.82)		9 (7–11)
Internship **
Jordan	2.22(2.00–2.44)	< 0.001* (Egypt vs Palestine: < 0.001* Egypt vs Jordan: < 0.001* Palestine vs Jordan: 0.435)	2.55(2.27–2.82)	< 0.001* (Egypt vs Palestine: < 0.001* Egypt vs Jordan: < 0.001* Palestine vs Jordan: 0.753)	8(6–11)	< 0.001* (Egypt vs Palestine: < 0.001* Egypt vs Jordan: < 0.001* Palestine vs Jordan: 0.109)
Egypt	2.11(1.78–2.33)		2.36(2.09–2.73)		9(7–11)
Palestine	2.22(2.00–2.44)		2.55(2.27–2.82)		8(6–10)
Residency
Urban	2.22(1.89–2.44)	.667	2.55(2.27–2.82)	.002*	9(6–11)	.239
Rural	2.22(1.97–2.44)		2.45(2.18–2.73)		8(6–11)
Number of deaths situation at hospitals
Never	2.11(1.89–2.44)	.571	2.55(2.18–2.73)	.957	9 (7–11)	.521
Once	2.22(1.89–2.44)		2.45(2.18–2.82)		8(6–11)
Twice	2.22(1.89–2.44)		2.55(2.27–2.73)		8(6–10)
Three times	2.11(1.97–2.36)		2.55(2.18–2.82)		9(6–11)
Four times	2.22(2.00–2.39)		2.55(2.18–2.82)		9(6–11)
Five times	2.11(1.89–2.33)		2.54(2.27–2.82)		9(7–11)
Six times	2.33(2.00–2.50)		2.55(2.18–2.81)		8(5–11)
Seven times	2(1.88–2.3)		2.5(2.27–2.77)		8(5.75–9.25)
Eight times	2.1(1.94–2.3)		2.54(2.36–2.77)		9(6.5–10.5)
More than that	2.22(2.00–2.44)		2.45(2.18–2.73)		8(6–11)
Number of close relative death
Never	2.11(2.00–2.42)	.846	2.45(2.18–2.73)	.054	9(6–11)	.386
Once	2.22(1.89–2.44)		2.55(2.18–2.82)		9(6.75–11)
Twice	2.22(2.00–2.44)		2.54(2.18–2.82)		8(6–11)
Three times	2.22(1.89–2.44)		2.54(2.25–2.82)		8(7–11)
Four times	2.22(2.00–2.44)		2.63(2.45–2.91)		8(6–10)
Five times	2.05(1.8–2.36)		2.27(2–2.63)		8(6–11)
More than that	2.11(1.89–2.44)		2.54(2.27–2.82)		9(7–12)

Mean and SD were used for normally distributed data. Median and IQR were used to distribute data that was not normally distributed

^* Indicates significant results

^** Significant results even after Bonferroni correction (P value less than 0.0167)

Correlations between death anxiety scale and approach to death and dying patients subscales

There was a significant inverse relationship between the death anxiety scale and hardness in communicating with the dying patients and their relatives (r = −0.384; p < 0.001), as well as avoiding death and dying patients(r = −0.123; p < 0.001). Hence, patients with a higher death anxiety scale had a less positive attitude toward communicating with dying patients and their relatives and tended to avoid death and dying patients more.

Linear regression analysis for death anxiety scale and approach to death and dying patients attitude subscales

Simple linear regression analysis showed that the DAS significantly predicts both communicating with the dying patients and their relatives (β = −0.4, p < 0.001) and avoiding death and dying patients scales (β = −0.115, p < 0.001). Scatterplots of the linear regression model are shown in Fig. 1.

Fig. 1.

Scatterplots for how the death anxiety scale predicts A: Hardness in communicating with dying patients and their relative's subscale B: Avoiding death and dying patients subscale

Discussion

Caring for terminally ill patients is one of the most difficult aspects of medical practice for physicians [3]. Medical schools and healthcare institutions often do not provide sufficient training to prepare physicians for handling these situations, creating significant challenges in management [6]. The experience of working with dying patients can be deeply distressing, leading to prolonged grief and heightened death anxiety [23, 24]. This study examines the extent of death anxiety among medical interns and its impact on their attitudes and approaches to death and caring for dying patients.

In our study, medical interns tend to have positive attitudes to both hardness in communicating with dying patients and relatives and avoiding death and dying patients. This could be explained by the direct contact of medical interns with dying patients through their internship and also by religious beliefs of the eschatology of Arabic people [25]. It was found that religious people tend to have a more accepting approach toward dealing with dying patients, and this is a result of their belief in the afterlife [26]. Moreover, people with a liberal attitude toward religion tend to have more death anxiety [26].

Our results align with Asadpour et al. and Zdziarski et al. who found that medical students tend to have positive attitude indicating lower anxiety levels upon dealing with death and dying patients. [27, 28]. However, a study by Yildirim et al. found that physicians displayed moderate avoidant attitudes toward the approach to death and terminally ill patients [29]. Moreover, physicians had a higher avoidant approach toward communication with terminally ill patients and their relatives than nurses [29]. This was explained that the end of life education was not considered enough by the medical curriculum [29].

In our study, medical interns had a median DAS of eight, with about 61% scoring above seven. This is consistent with the findings of Tarhan et al., where postgraduate nurses had an average score of 8, with 70% scoring above seven. However, our results showed a higher score than the medical interns in the study by He et al. [9]. This discrepancy may be due to the greater exposure of the medical interns in their study to Coronavirus disease 2019 (COVID-19) cases. It is believed that those working during the pandemic developed a more positive outlook on death and were less inclined to avoid thinking about it [9]. Nevertheless, there was no significant difference in DAS between those who worked with COVID-19 patients and those who did not [9].

We found that higher death anxiety leads to a more negative attitude toward communication with death and dying patients and avoidance of death and dying patients. Physicians' fear of their mortality could explain this leading them to avoid communication with dying patients [30]. Physicians who accept their mortality can make them more comfortable when discussing death with their patients [5]. This relationship was tested more on nurses than physicians. Tarhan et al. found that higher death anxiety among postgraduate nurses tends to predict poor communication with terminally ill patients [12]. However, another study found that higher death anxiety among nurses led to a less avoidant approach toward dying patients [31]. Further research is recommended to study how physicians' death anxiety affects their communication with dying patients and how this relationship could affect their medical decisions.

In this study, females showed higher DAS and less positive attitudes toward communication with dying patients and their families. These findings align with previous evidence that female healthcare professionals score higher than males in terms of death anxiety [9, 32]. Further evidence reported that females might have a higher score in death anxiety due to cultural traits, as women are more likely to express their feelings than males, who are more likely to hide their feelings [33]. However, both males and females showed an equal response to avoiding death and dying patients with a score of 2.55, which suggests a less avoiding behavior toward death, and dying patients. Being not affected by gender makes avoidance behavior a promising target for development through professional training.

Due to participants belonging to Arabic culture, it is vital to acknowledge that, despite the wide range of perspectives about death, it is accepted, understood, and regarded as an integral aspect of faith in God [25]. In our study, Palestinian and Jordanian participants' scores were almost identical on the hardness in communication, avoiding death and dying patients, and DAS. They both scored lower than the Egyptian participants on the DAS and higher on the ADDPAS subscales. However, participants from these three countries tend to have a positive attitude toward the ADDPAS subscales. Zahran et al. reported that nursing students in Jordan had a good attitude about caring for dying patients and families [34]. Another study by Alhusamiah et al. showed that Jordanian oncology nurses and doctors reported moderate levels of death anxiety and fear of death, which is somewhat consistent with the moderate scores in our study [32]. However, medical students at Arabian Gulf University experienced more complicated grief compared to those at the University of Toronto, which may be attributed to cultural and religious differences [35]. Thus, it is crucial to examine physicians' attitudes towards patient deaths across various cultures and regions.

We found no significant difference in either attitude or death anxiety based on the number of encountered close relatives’ deaths or patients' deaths. These findings are consistent with another study by Asadpour et.al which found no significant correlation between fear of death and clinical experience in medical students [28]. Alhusamiah et.al supported these findings and revealed no significant differences in death anxiety levels among nurses and physicians based on their experiences with the loss of a close person [32]. It is important to acknowledge that while medical interns interact with dying patients, their experience remains relatively limited. Greater exposure to dying patients has been linked to attitudes that are more positive and increased knowledge regarding end-of-life care [10]. Dickinson et al. found physicians with 20 years of experience were more open to communicating with terminally ill patients and their families [11].

Similarly, a study by Ibrahim et al. revealed that as internal medicine residents progress through their training, they seek support, improve their communication skills, and learn to manage their emotions when faced with patient deaths [36]. Additionally, medical students often develop coping mechanisms, such as avoidance and emotional detachment, when dealing with dying patients [37, 38]. Therefore, teaching students how to handle death, dying patients, and their emotions during medical training is fundamental.

Our study has many strengths. First, we used various strategies throughout the questionnaire to ensure accuracy and avoid contamination of the sample. Second, many papers have been published concerning the attitudes and anxiety of nurses, contrary to that of medical students and doctors. This study would cement itself as one of the handful of studies shedding light on this urgent matter. Additionally, our study achieved a response rate of 40%, which is nearly comparable to the 44.1% reported in a meta-analysis of online surveys from published articles [39].

However, there are limitations of this study that need to be acknowledged. Firstly, the use of convenience and snowball sampling methods, rather than random sampling, was due to time and resource constraints. This may affect the generalizability of our findings. Second, the ADDPAS subscales were both measured using a 4-point Likert scale. However, a significant limitation of using a 4-point Likert scale involves the absence of a neutral option, as respondents were forced to either agree or disagree to some extent. A score of two on either of these subscales could be misleading. It may represent respondents who would have chosen a neutral stance if that option were available but instead had to choose a response that could skew the results toward a more positive or negative outlook. Moreover, in the avoidance of the Death and Dying Patients subscale, the narrow IQR indicates that responses were similar and lacked variability. This could be due to the scale's forced-choice format, which might not have allowed participants to express more nuanced or neutral views on death.

Another limitation that we should address is that The MENA region encompasses a large number of countries. Since the authors are from these three countries, it was more feasible for us to collect data from them. There was no specific reason for selecting these particular countries, but we aimed to provide a broader perspective on the MENA region by including multiple countries rather than focusing on just one. It is worth noting that this type of study on medical interns is lacking across the entire MENA region, including the countries we examined. We hope future research will include additional countries to provide a more comprehensive understanding.

Of note, Cronbach's alpha of the hardness in the communication subscale shows a lower value than the widely acceptable threshold of 0.7 which might suggest that the subscale items do not reliably measure the underlying construct therefore raising some concerns upon drawing any conclusion from this subscale. As known, the best approach is to depend on a validated and reliable translated version of the scale which was not available in our case. This led us to consider the translation given by the original author for the exploratory purpose of our study which may act as a cause for the lower consistency within the communication subscale. However, we tried to enhance our methodology and assessed the items' clearness, appropriateness, and consistency by doing face validity, a pilot study, and assessing Cronbach's alpha per each subscale. This formulates another gap for developing a valid and reliable English version of this scale.

Recommendations

Future research may benefit from using a Likert scale that includes a neutral option. A 5- or 7-point scale would provide respondents with a midpoint, allowing for a more balanced expression of their attitudes. Additionally, expanding the sample size across different countries and different cultures may yield insights that are more comprehensive. These adjustments could help clarify the true attitudes and anxieties medical interns experience when dealing with death and dying patients. Moreover, we recommend implementing end of life care training in the medical curriculum to improve care for dying patients.

Conclusions

In this cross-sectional study, medical interns tend to have a more positive attitude toward death and dying patients. Notably, higher death anxiety can lead to communication challenges and a greater tendency to avoid dealing with dying patients. Death anxiety was more prevalent in female interns. However, caution should be taken when interpreting the attitude results because the used scale lacks a neutral option. Due to the significant impact, caregiver staff have on the treatment process, we recommend implementing professional end-of-life care training.

Abbreviations

ADDPAS

Approach to Death and Dying Patients Attitude Scale

DAS

Death Anxiety Scale

IQR

Interquartile range

COVID-19

Coronavirus disease 2019

Authors’ contributions

IS and MM conceived the idea, and developed the study design. IS, MM, HAJ, MA, AE, AK, MA, NR, SS, RA, ORA, MB, JR, TH, RA, and FAM authors contributed to the acquisition of the data. HAJ, MA, AE, IS, and MM performed the statistical analyses. MA, HAJ, AE, MH, ORA, AK, and JR drafted the manuscript under the supervision of IS and MM. IS, MM, MA, MH, MB, RA, AE and RA contributed to the revision of the manuscript. IS, MM, HAJ, MA, AE, AK, MA, NR, SS, RA, ORA, MB, JR, TH, RA, and FAM read and approved the final manuscript.

Funding

All the authors received no financial support for the research, authorship, or publication of this article.

Data availability

The data presented in this study are available upon request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study adhered to the principles of the Declaration of Helsinki (1964, last revised in 2013) (22). Before answering the survey, participants were informed about the purpose of the study. Participation in the survey was voluntary, with participants providing informed consent by checking a box to indicate their willingness to join the study (this was a required item). Since no personal identification information was collected through the survey, anonymity and the protection of personal data were ensured. The study received approval from the Research Ethics Committee (REC) et al.-Quds University in Palestine (IRB number: 407/REC/2024).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.