Survey on attitudes toward end-of-life care among third-year students in the faculty of physical therapy: a study across the first and second semesters

Abstract

[Purpose] This study aimed to clarify third-year students’ awareness of end-of-life care, using questionnaire items. [Participants and Methods] The participants were 81 third-year students enrolled in 2024 (post-clinical training group; post-G), and 84 third-year students enrolled in 2025 (pre-clinical training group; pre-G). This study was a cross-sectional observational study using questionnaire surveys for end-of-life care throughout the 2025 first (pre-G) and 2024 second (post-G) semesters. To examine whether completion of the 4-week clinical training was associated with awareness of end-of-life care, analyses were performed between two groups using the chi-square test. [Results] Regarding preferred place to spend final days, 79% selected home. In the final 3 months of life, 85% of students preferred to be allowed to die naturally to some extent, whereas 9% favored life-prolonging treatment only. A significant difference was found between pre-G and post-G in this item. [Conclusion] Commonly expressed wishes were for a natural death, dying at home, and being told of the status of their illness. It was suggested that, through clinical training, students may be able to develop perspectives more attuned to the experiences of patients and families.

INTRODUCTION

The structure of disease has shifted. The number of patients with cancer is increasing, and it remains the leading cause of death. However, advances in diagnostic and treatment methods are significant, and the perception of cancer as an incurable disease is evolving. Supporting those who continue to undergo cancer treatment is vital to maintain and enhance quality of life.

According to a survey in Japan, 83% of facilities offer rehabilitation services for patients with cancer. Even in facilities that do not provide these services, recognition of the need for rehabilitation is growing¹⁾. Additionally, opportunities to engage in cancer care and home-based end-of-life care are steadily increasing^{2, 3)}. Matsushita et al. conducted a survey on older adult outpatients’ attitudes toward end-of-life care, clarifying whether individuals aged ≥65 years wished to be informed of their condition and detailing their perceptions regarding end-of-life care⁴⁾.

The spread of coronavirus has profoundly affected undergraduate physical therapy education, including training in end-of-life care. Infection control measures were imposed on students during graduation research and practical classes^5,6,7). Clinical training was sometimes canceled, requiring students to switch to simulated training on campus. Physical therapy, as an allied health profession, is generally taught at universities through face-to-face instruction to deliver essential knowledge and practical skills. Currently, clinical training proceeds while carefully observing infection prevention measures.

This study aimed to clarify third-year students’ awareness of end-of-life care, using questionnaire items developed by Matsushita et al.⁴⁾ Furthermore, these students completed four weeks of clinical training during the summer between the first and second semesters, allowing for comparison of survey results before and after training. It is presumed that many students have a family member or relative affected by cancer. This research was conducted to understand students’ awareness of end-of-life care and to accumulate and disseminate knowledge based on their perspectives.

PARTICIPANTS AND METHODS

The participants were 81 third-year students (42 males and 39 females) enrolled in the Department of Physical Therapy, Faculty of Health and Medical Sciences at Odawara, University of Health and Welfare in 2024 (post-clinical training group; post-G), and 84 third-year students (47 males and 37 females) enrolled in 2025 (pre-clinical training group; pre-G).

This cross-sectional observational study was conducted at the International University of Health and Welfare using questionnaire surveys administered during the first (pre-G) and second (post-G) semesters. The study protocol was approved by the Ethics Committee of the International University of Health and Welfare (Approval No. 25-TA-192).

Because survey questions and wording can influence responses, the exact phrasing is presented in Table 1.

Table 1. Questions and wording of the survey⁴⁾.

A. Where would you prefer to spend your final days?
	1. My Home		2. Nursing Home	3. Older adult care facilities	4. Hospital	5. Others
B. If you are diagnosed with a serious, incurable illness (such as cancer) and have approximately 3 months left to live, how would you wish your treatment to proceed?
	1. I want to extend my life by any means possible
	2. I would like to receive nutritional support and symptom management, then allow death to occur naturally.
	3. Others
C. In that case, would you want to be informed of the name of the illness? (Choose only one)
	1. I want to know the exact name of the illness.
	2. I want the explanation to be vague so I can infer the name.
	3. I do not want to know the name, but I want to be told if it is a serious illness.
	4. I want it explained as a different illness.
	5. I do not want to know, but I want my family to be informed.
	6. I do not want anyone to know the name of my illness.
	7. I cannot choose.
D. If you would like any information about your illness, would you want to be told your estimated survival time? (Choose only one)
	1. I want to know the estimated survival time.
	2. I do not want to know, but I want my family to be informed.
	3. I do not want anyone to know the estimated survival time.
	4. I cannot choose.
	5. Others
E. If your spouse (assuming you have one) were diagnosed with an incurable illness and had approximately 3 months left to live, how would you inform them? (Choose only one)
	1. I would clearly explain the name of the illness.
	2. I want the explanation to be vague so it can be inferred.
	3. I would explain that you are seriously ill.
	4. I would explain it as a different illness.
	5. I would not disclose the name of the illness
	6. I cannot choose.
F. If early-stage cancer (small and curable) were found in your body and you underwent treatment including surgery, how would you want to be informed?
	1. I want to know the name of the illness.
	2. I want the explanation to be vague so I can infer the name.
	3. I do not want to know the name, but I want to be told if it would be fatal if untreated.
	4. I want it explained as a different illness.
	5. I do not want to know, but I want my family to be informed.
	6. I cannot choose.
G. If you developed severe dementia or experienced a severe stroke, with difficulty swallowing, becoming bedridden, and unable to communicate clearly, what care and treatment would you prefer?
	Please circle all that apply.
		1. Create a gastrostomy tube (tube placed through the abdominal wall into the stomach for direct nutrition)
		2. Tube feeding through the nose into the stomach
		3. Intravenous fluids
		4. I do not want any intervention.
	Pain management
		1. I want pain fully controlled with narcotics.
		2. I prefer medication but can tolerate some pain.
		3. I do not want narcotics.
		4. I do not want any intervention.
	Breathing Difficulty
		1. Even if death is hastened and consciousness decreases, I would prefer relief with narcotics and sedatives.
		2. I do not want narcotics.
		3. I do not want any intervention.
	Treatment (circle if you agree to each question)
		1. If pneumonia or cholecystitis occurs, I should be treated with antibiotics.
		2. If I have difficulty breathing, supplemental oxygen should be provided.
		3. If I have difficulty breathing, a tracheotomy should be performed and mechanical ventilator should be initiated.
		4. If I develop a stomach ulcer and bleed a lot, blood transfusion should be administered.
		5.If I have an intestinal blockage, surgery should be performed.
		6.I do not want any intervention.

Reference⁴⁾ A questionnaire by Matsushita et al. was translated from Japanese to English and used.

The questionnaires were distributed face-to-face in November of the second semester for third-year students in the 2024 academic year (post-G) and in May of the first semester for third-year students in 2025 (pre-G). Third-year students completed a 4-week clinical training period between the first and second semesters. Sixty clinical training facilities were available. Of these, 51 (85%) were medical facilities with inpatients, 9 (15%) were clinics without beds, and there were no long-term care insurance facilities. Therefore, the survey was administered to post-G after completing clinical training and to pre-G before training. In both years, the survey was conducted prior to the start of the elective course “Cancer Rehabilitation”.

To examine whether completion of the 4-week clinical training was associated with awareness of end-of-life care, analyses were performed using the χ² test. A p-value <0.05 was considered statistically significant.

RESULTS

The number of valid responses was 67 (79.8%) in post-G (37 males and 30 females) and 77 (95.1%) in pre-G (43 males and 34 females).

Overall, 88% of students wished to be informed of the name of their illness, and 98% preferred disclosure when some explanation of the condition was included (Table 2). Similarly, 88% wanted to know how much time they had left to live. Assuming early-stage cancer was curable, 95% wished to be informed of the diagnosis. When asked whether they would inform a spouse of a terminal illness, 51% responded affirmatively.

Table 2. Notification of illness.

Periods		End stage			End stage			End stage			Early stage cancer
Target of notification		Yourself			Yourself			Spouse			Yourself
Contents		Name of illness			Days left to live			Name of illness			Name of illness
Semesters		post-G	pre-G	Total	post-G	pre-G	Total	post-G	pre-G	Total	post-G	pre-G	Total
1. Exact name		89.6	87.0	88.2	86.6	88.3	87.5	52.2	50.6	51.4	95.5	94.8	95.1
2. Be vague enough		9.0	9.1	9.0				13.4	16.9	15.3	3.0	5.2	4.2
3. Serious illness			1.3	0.7				14.9	14.3	14.6	1.5		0.7
4. Another disease								1.5	2.6	2.1
	Subtotal	98.6	97.4	97.9	86.6	88.3	87.5	82.0	84.4	83.4	100.0	100.0	100.0
5. I want my family to know			1.3	0.7	6.0	9.1	7.6
6. I don’t want anyone to know		1.5		0.7	6.0	1.3	3.5	10.4	1.3	5.6
7. I can’t choose			1.3	0.7	1.5	1.3	1.4	7.5	14.3	11.1

The numbers are %.

Regarding preferred place to spend final days, 79% selected home, followed by 17% choosing a hospital (Table 3). In the final 3 months of life, 85% of students preferred to be allowed to die naturally to some extent, whereas 9% favored life-prolonging treatment only (Table 3). A significant difference was found between pre-G and post-G in this item (p<0.01).

Table 3. Results of end-of-life care.

Semesters			post-G	pre-G	Total
Choosing a place for end of life
	1. My Home		80.6	77.9	79.2
	2. Nursing Home		0.0	1.3	0.7
	3. Elderly care facilities		0.0	1.3	0.7
	4. Hospital		17.9	16.9	17.4
	5. Others		1.5	2.6	2.1
End-of-life medical care*
	1. By any means possible		3.0	14.3	9.0
	2. Die out naturally		95.5	76.6	85.4
	3. Others		1.5	9.1	5.6
Regarding treatment options in a near vegetative state
	Nutrition
		1. Gastrostomy	19.4	10.4	14.6
		2. M-tube	11.9	6.5	9.0
		3. IV drip	46.3	58.4	52.8
		4. No intervention	22.4	27.3	25.0
	Pain
		1. With narcotics	37.3	40.3	38.9
		2. tolerance	58.2	46.8	52.1
		3. Without narcotics	1.5	1.3	1.4
		4. No intervention	1.5	9.1	5.6
	Difficulty breathing
		1. With narcotics and sedatives	71.6	67.5	69.4
		2. Without narcotics	20.9	13.0	16.7
		3. No intervention	6.0	14.3	10.4
	Treatment
		1. With antibiotics	26.9	39.0	33.3
		2. Oxygen	58.2	58.4	58.3
		3. Artificial ventilator	19.4	15.6	17.4
		4. Blood transfusion	17.9	27.3	22.9
		5. Surgery	20.9	31.2	26.4
		6. No intervention	11.9	16.9	14.6

The numbers are %. *significant <0.05.

When considering responses to symptoms in patients unable to make decisions, 15% preferred gastrostomy, 9% nasogastric tube feeding, 53% intravenous drip, and 25% no intervention for fluids and nutrition (Table 3). For pain management, 39% favored narcotics, 52% preferred to endure the pain, 1.4% disliked narcotics, and 5.6% preferred no intervention. When experiencing difficulty breathing, 69% would use narcotics, 17% disliked narcotics, and 10% would choose no intervention. Regarding treatment options, 33% preferred antibiotics for pneumonia, 23% wanted blood transfusions for bleeding, 26% selected surgery for intestinal obstruction, and 17% chose tracheotomy and artificial ventilation for breathing difficulties.

DISCUSSION

This study was an observational cross-sectional survey in which third-year students in the Department of Physical Therapy reported their awareness of end-of-life care during the first and second semesters. The first novelty of this study is that the survey was conducted on third-year students over two academic years, in 2024 and 2025. The second novelty was that the timing of the survey was changed each year to compare the results before and after clinical training, and to examine the influence of experience during training. In the third year, specialized subjects in physical therapy are mainly offered. While students acquire specialized knowledge and skills, they are not yet faced with real-life situations prior to their clinical training experience. In Japan, where the baby boomers have reached the late elderly stage of 75 years of age or older, it can be assumed that opportunities for them to receive end-of-life care will certainly increase. This study was unable to examine differences in the types of facilities where students practice. However, it can be positioned as a study that suggests that the experience of a month-long clinical training program affects students’ attitudes.

Approximately 90% of students wished to be informed of the name of their illness and the estimated duration of survival in the terminal stage, a proportion higher than that reported by Matsushita et al.⁴⁾ When assuming early-stage cancer was curable, all students wanted disclosure of the diagnosis along with some explanation of their condition. In contrast, when asked whether they would inform their spouse, only 50% responded affirmatively. While many wish to be informed themselves, they tend to exercise caution regarding disclosure to their spouses. These findings suggest that it is important to clarify the priority of recipients of such information.

Regarding preferred place of death, Hayashi et al. reported that medical professionals more often preferred home compared to bereaved families⁸⁾. In the present study, 79% of students preferred to spend their final days at home, followed by 17% selecting a hospital. Matsushita et al. reported that 64% of older adult outpatients preferred dying at home, while 24% preferred hospital death⁴⁾. In choosing life-prolonging treatments during the final 3 months, significant differences were observed depending on the timing of the survey. Students surveyed in the second semester selected less aggressive treatments than those surveyed in the first semester. Matsushita et al. reported that 80% of older adult outpatients preferred palliative care, while 9.3% wished for intensive life-sustaining treatment⁴⁾. Through four weeks of clinical training, students may develop perspectives more attuned to the experiences of patients and families. This notable difference may reflect exposure to the realities of care during training.

In a near vegetative state, 9–15% preferred tube feeding, while 53% chose intravenous drip infusion. For pain and dyspnea management, narcotics were preferred by 39% and 69%, respectively. Oxygen or tracheostomy with artificial ventilation were selected by 58% and 17%. Antibiotics for infections were desired by 33%, surgery for intestinal obstruction by 26%, transfusion for bleeding by 23%, and no treatment under any circumstances by 15%. Kanematsu et al. reported similar preferences among nursing students, with gastrostomy selected in 9.5%, nasogastric tube feeding in 12.1%, intravenous drip in 54.5%, antibiotics in 39.2%, and artificial ventilation in 16.9%⁹⁾. These comparable results suggest common patterns of awareness regarding end-of-life care among students in health-related fields.

Certain limitations should be noted. This two-year survey was conducted during the second semester in 2024 and the first semester in 2025, but involved different participants. Cohort studies following the same individuals would be more appropriate to analyze changes in perceptions of end-of-life care. The majority of clinical placements (85%) were inpatient medical facilities. Therefore, it was not possible to analyze whether the differences in the choice of life-sustaining treatment observed in this study were due to differences in the type of facility where the internship took place or the internship experience itself. This is a future challenge and further research is needed. For the 2025 academic year, the elective course “Cancer Rehabilitation” was scheduled to begin in June because the start of lectures was adjusted. If the survey had been conducted in the second semester of 2025, it would have been necessary to consider not only clinical training experience but also the impact of this course. Furthermore, because the participants were drawn from a single campus, generalization of the findings requires caution.

Conflict of interest

The authors declare no conflict of interest in this work.