title: Fourth year medical students' reflective writing on "death of Ivan Ilych: a qualitative study.
abstract: BACKGROUND
  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 theDeath of Ivan Ilychnovel 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 readingDeath of Ivan Ilychas 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Faculty of medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mahshid
authors.initials: M
authors.lastname: Zohouri
authors.affiliation: Quality Improvement in Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mitra
authors.initials: M
authors.lastname: Amini
authors.affiliation: Quality Improvement in Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran ; Internal Medicine Department, Nephrology Division, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mohammad Mehdi
authors.initials: MM
authors.lastname: Sagheb
keywords:  Death ;  Medical students ;  Qualitative study; Education 