TABLE 4.

Themes from qualitative analysis.

Theme 1. Life and Death
Sub-theme	Explanation	Illustrative quotes
1.1. The meaning of life	The value of existence can only be fully grasped when considering mortality. Many students associated life with positive emotions (“joy,” “happiness,” “hope”) or actions. For others (e.g., Romania), the defining characteristics of life are those that capture its uncertainty, unpredictability, and volatility.	“The meaning of life depends on the value associated with death” (IT 3). “If one does not learn about death s/he cannot live to the fullest” (IT 12). “Life is the ability to experience things, to feel everything, to create” (PL2). “Shifting sands, which can disappear at any time, but I think it’s very important to enjoy the moment, and to do everything you can in the here and now.” (RO1).
1.2. Death is not an end	Life and death were often interpreted in terms of their religious faith and personal values. Their own beliefs about life and death gave them meaning and a possible antidote to existential anxiety. The underlying idea was that death is not an end, is a passage (bridge, gateway) to a different form of existence.	“There is something after death, the energy transforms” (AU3). “I don’t see it as the end. it’s a gateway to another dimension” (RO3). “I believe this world is full of suffering, but. it is a bridge to the next world” (IL2).
1.3. Denial of death	For other participants, death did not appear to exist at all. Life was defined as a lesson, where the end brings enlightenment or “the afterlife” where individuals experience good or bad depending on their conduct in life. The idea that they might die was often somehow suppressed but the discourse changed when it came to the death of loved ones: here death was considered to signify tragic moment and an irreversible loss.	“I have faith that the human soul is eternal. Life is lessons that the soul chooses to experience on its way to enlightenment” (IL3). “I treat death as a beginning. And I am more afraid of what is after death than death itself” (PL1). “I’m not afraid of death. maybe it’s the fault of youth.” (RO1). “[death is] an extremely tragic moment, no matter how you look at it” (RO2).
1.4. Death is the end of life	Only a few students saw death as the ultimate end. Very few of them saw life as something natural and were aware that one’s attitude toward death can be educated.	“for me death is the end of the creation process, simply, the end of creation” (PL 5). “Death is simply the end of life” (PL2). “I’m not afraid of death. I think it is a part of life, it’s important to know how to leave and move on, to say goodbye in the right and safe way” (IL4). “Everything we encounter is life, because we do not know anything else” (PL2).
Theme 2. Learning About Death
Sub-theme	Explanation	Illustrative quotes
2.1. Interest in the study of death	The results highlighted a general interest in studying about death, which is regarded as taboo in the family, society, and universities.	“because it is a topic that is very rarely discussed and avoided even in the family, we do not talk about it. Not just in my family, it is not discussed very openly anywhere” (RO1). “We should talk about it a little more and be a little more open, even to children, for example, discussing all our experiences, in my opinion” (IT6). “How do you really deal with dying people? I really think it’s important to learn” (AU3).
2.2. Lack of information	All the students considered that there is a considerable lack of information about death, mourning, and palliative care. Lack of knowledge and skills generated feelings of incompetence, helplessness, fear and frustration in most students.	“It’s just that it was always brought up so casually, and really never brought up so much” (AU2). “In the psychology curriculum, it is absurd that there are not - except for the end-of-life course - other courses, especially in the BA program” (IT25). “It is embarrassing that there is no course so we should make plans” (AU3).
2.3. Perception of death and palliative care course	In this context, the vast majority considered that this type of course would be “necessary” and “useful.” In general, students reacted ambivalently to the opportunity to study this topic: interest and enthusiasm are accompanied at the same time by fear, anxiety and doubt.	“a necessity and as a void to be filled in our training and development” (RO4). “The subject is interesting…. but I don’t know if I can handle it” (IL1). “I think it would be useful to me, because I know that if I needed to interact with this type of person, I would be very emotional about it, and not professional” (PL2). “It is an opportunity and it’s needed because the elderly in old age homes or hospices need someone who can make the last moments of their lives more beautiful, someone to be there for them” (RO5).
Theme 3. Psychological Burden
Sub-theme	Explanation	Illustrative quotes
3.1. Fear of death & loss	The students were aware of the psychological impact it could have on them because it could force them to face some of their greatest fears, such as the fear of death, the fear of losing a loved one, the suffering caused by loss. The students seemed to be aware of their avoidance strategies, which were bolstered by their families, society, customs and by the curriculum; they commented that this type of course would also entail abandoning avoidant behaviors and confronting the concept of death.	“because they do not know how to deal with their own grief the grief of others and especially with the dying themselves” (AU3). “…whoever takes such a course is doing continuous therapy, because you do not escape, it takes place every week, and what is more, you also have to take an exam” (RO1). “Anguish will come out because [we will be] in contact with the absence of meaning and our inability to find value when exposed to the concept and experience of death” (IT14).
3.2. Fear of reliving painful feelings	The students who had experienced loss were particularly afraid of reliving painful feelings. For a few others, exposure to the inevitability of death, and possibly their own defense mechanisms, make it difficult to understand the value of palliative services, to the extent of considering them ridiculous.	“…those thoughts, emotions. I’m afraid they’ll come back” (RO3). “I feel somewhat uneasy because I do not know what I would have to do, and a little anxiety because I have lived through similar situations, and I go straight back to the thought of what happened then” (RO4). “I could [learn and apply it], but I don’t know if I would like to, because there is a lot of sadness in this job… any job involving helping people is an enormous responsibility, but I would feel overwhelmed here” (PL1). “I think it [palliative care] only tends to delay a process that is already ongoing; even more so when the patient knows what is happening; then it becomes excruciating” (IT5).
3.3. Fear of being inept & powerless in the work	When imagining themselves working with a patient, their fear was twofold. On the one hand, they experienced the same fear, but amplified, that they would not be able to cope emotionally with the therapy. On the other hand, they felt they lack the necessary knowledge and skills, and this fear of being incompetent and powerless was overwhelming for most of them.	“…and unfortunately, we are not prepared for it, neither emotionally nor cognitively… this type of situation scares me very much.” (RO5). “I would certainly feel guilty even at the idea of not being able to provide patients with all the help they need” (IT1). “I would be pervaded by the fear of saying something that could hurt the person and would not help them” (IT3). “A great sense of helplessness and therefore frustration within myself” (IT20).
Theme 4. Personal Experience and Robust Training
Sub-theme	Explanation	Illustrative quotes
4.1. Personal experience with death	The first-hand experience of caring for someone on their deathbed contributed to a more in-depth understanding of the importance of palliative care. All the students acknowledged that it is crucial to know how to address mourning. In the case of mourning some believed that the lack of a theoretical background about death could be compensated for through personal experience (Israeli and Romanian students), but it’s definitely not enough. The desire to learn and work, and especially the self-confidence needed for studying and working with death, are built on this personal foundation. Accordingly, for some students, the motivation to take a course on death is personal: the course would provide the opportunity to clarify and process their own experience of loss.	“Despite the difficulty of dealing with patients who are suffering from terminal illnesses, this is a population that I am very interested in working with” (IL3). “As someone who has lost a father, I feel I have the ability to understand mourning and the situation. Because I have processed this experience in my own therapy, I feel that I can contribute to the field, you can contain it and just be sad” (IL 4). “I have experienced bereavement (I am a military orphan) and lost a good friend who passed away from cancer. I do not know if this is a specialization that I would like to deal with exclusively, but if patients bring up this content, I would have no hesitation in coping with them” (IL3). “I would not want another person to go through what I went through. although this would be more than useful” (RO3).
4.2. Personal beliefs and values	The beliefs about life and death (most often religious) and personal values are an important role in generating the motivation and self-confidence to study and work with death.	“I think that looking at death as an integral part of the life process can help deal with the fear of death” (IL2). “the main thing that gives me power and strength is my belief and trust in God and knowing that the soul comes down to the material world for a purpose” (IL1).
4.3. The desire to be good professionals	The students’ interest in the course and motivation to enroll were amplified by their acknowledgment of the need to learn about death. For most students, a high level of trust in their ability to handle these patients was directly linked to their academic training.	“How do you really deal with dying people? I really think it’s important that you learn about that” (AU3). “I believe that if I have the proper training, I can do it” (RO4).
Theme 5. Four Key Training Needs
	Explanation	Illustrative quotes
	(a) a structured framework and theoretical background to understand mourning and the dying process. (b) acquire the appropriate intervention methods, techniques, and settings which was viewed as the first step toward understanding how to address such issues. (c) have a sufficient practical education, ranging from clinical case analyses in class to practical hands-on training that would help them determine how to do the actual work. (d) undergo a personal process of self-growth to deal with the psychological burden of this type of course. Some students stated that they would need to process their own painful experiences, fear of death and loss, and their beliefs associated with them for their education and training in this area to come full circle.	“theoretical background before we begin our internships” (RO1). “We are not familiar with the stages of mourning. Some of us have first-hand experience. But others do not, and they have no background to rely on” (RO5). “to know how we work… [we need] some benchmarks for interventions in mourning. We do not know anything about the stages of mourning if we have not gone through them ourselves” (RO2). “the practice… would be a waste of time if it is not face to face. I think 80% (practical experience)” (PL2). “I am interested in learning the therapeutic approaches for this type of treatment, but even if I had the tools, I am not sure I would be able to overcome the emotional hurdle of treating terminally ill patients” (IL4). “If I work with people who have gone through similar experiences, I will automatically sympathize with them, at least at this point in my life. I need to work hard on myself not to do this” (RO5). “I am very interested in being part of a palliative team that supports and helps with the last stages of life. Of course, concerns arise as to how I would personally take the separation, and questions such as whether I did my best with the patient and family, whether I was there for them when they needed it” (IL5).