We searched six electronic databases, namely Web of Science, PubMed, Embase, OVID, China National Knowledge Infrastructure, and Wanfang databases. Retrieval time was from January 2012 to September 2023. Boolean operators were used, with two librarians helping to develop the search strategy. The Boolean search combined subject and free words, including “medical student,” “nursing student,” “death attitude,” and “attitude toward death.”

The following inclusion criteria for studies was applied: (1) research subjects were medical students, including clinical medicine students and nursing students; (2) study of factors influencing death attitudes of medical students; (3) full text available; and (4) articles published in Chinese or English. Exclusion criteria included: (1) intervention research on death attitudes of medical students and (2) books, editorials, letters, or conference abstracts. Searched studies were imported into NoteExpress to remove duplicate studies. Two reviewers independently selected the remaining studies by screening the title and abstract. If studies met inclusion criteria, the full text was screened, and studies that continued to meet inclusion criteria were explored further. Selection results were cross-checked, and a third reviewer was invited to discuss and make a final decision when there were differences.

Two reviewers independently screened the full text of each included article. Extracted data included authors, country, publication year, sex ratio, samples, and questionnaire used to investigate death attitudes. To ensure validity, two reviewers cross-checked the extracted data.

The extracted data were discussed by the team. We summarized the factors influencing death attitudes of medical students and divided the influencing factors into three categories comprising personal factors, social factors, and psychological factors.

As shown in Figure 1, a total of 2,257 articles were initially retrieved, and 1,732 duplicates were removed. After screening the titles and abstracts, 452 records were removed because study type did not meet inclusion criteria (e.g., conference abstracts, letters, protocols, and intervention research). After screening 73 full texts, 38 studies were further excluded, of which 16 were intervention studies, 18 were not published in Chinese or English, and 18 did not have full text available. After all screening, a total of 35 studies were included in the current scoping review (9–44). As shown in Table 1, most of the included studies came from China, while seven studies came from Iran, Spain, Korea, Bolivia, Poland, and Palestine. Student majors included medicine, nursing, physiotherapy, pharmacy, rehabilitation, midwifery, medical laboratory technology, and preventive medicine. Additionally, most of the included studies used the Death Attitude Profile-Revised questionnaire to measure the death attitudes of medical students.

As shown in Table 4, psychological well-being (20), sense of meaning in life (29, 40), suicidal thoughts (9), powerful emotional reaction to death (42), professional recognition (26, 32), and Internet addiction (33, 41) were factors that influenced death attitudes of medical students. Students who possessed a heightened feeling of spiritual well-being and a deep understanding of the meaning of life tended to exhibit a more distinct purpose in life and a greater appreciation for the worth of their own existence (20, 29, 40). Xie et al. (32) discovered a correlation between medical students’ level of professional recognition and their anxiety about death, which was similar to the results of another study (26). Additionally, two studies (33, 41) found that the degree of Internet addiction could influence medical students’ death attitudes.

Research examining the impact of gender on death attitudes revealed that females exhibit more fear of death than males, which is similar to the results of a previous review (43). This is likely due to the female tendency to engage in more emotional thinking and experience higher levels of anxiety, which consequently intensifies their fear of death (12, 39). Moreover, the contrasting attitudes toward death in clinical and nursing professions can be attributed to the higher number of females in the nursing field. This finding is similar to a previous study, which suggested that the nursing interns had statistically significantly higher scores in death attitudes compared to the norms (19). In addition, the nursing profession directly engages in patient care, which suggests that its curriculum and clinical experiences may influence its perspectives on death. However, additional comparative research is needed to confirm these findings.

Diverse researchers have reached varying conclusions regarding the disparities in death attitudes among medical students of different ages. This discrepancy can be attributed to the fact that the medical student population consists of individuals who are relatively similar in age, thereby limiting the ability to accurately assess the distinct impact of age on death attitudes. Study findings indicated that those with a longer duration of medical education, namely, those who were in higher grades, tend to exhibit more positive death attitudes compared to individuals in lower grades (18, 20). The hypothesis suggests that the primary factor behind this phenomenon is the progressive development of more positive attitudes toward death as individuals advance in grade level, which can be attributed to their exposure to clinical training in hospice care or education connected to death (20).

The perspectives of family members toward death, as well as familial backgrounds, exert a certain degree of influence on the perceptions of medical students regarding death. This finding is similar to the results of a previous review (43). The presence of a familial environment that encourages open acknowledgment and discourse about death, along with a strong sense of kinship, has the potential to assist medical students in mitigating their fear of death to a certain degree and fostering a more optimistic outlook on the subject of death (11, 21, 29, 39). If there are older adults within the family, the younger generation will inevitably encounter disease and death at a younger age, thus gradually forming a more accurate perception of death (26).

Various religions hold distinct notions regarding life and death, and it may be argued that religious convictions will influence individuals’ perspectives on death to some degree (21, 34). These results are similar to the previous study (43). Based on the analyzed studies, it is evident that the presence or absence of religious beliefs does not significantly influence medical students’ attitudes toward death. It is worth noting that some of these studies had limited sample sizes and lacked precise screening regarding the definition of, and loyalty toward, religious beliefs, which may have impacted the results. Further research is needed to thoroughly investigate this factor (34, 44).

Various countries exhibit distinct societies and cultures. However, this study lacks sufficient literature pertaining to race or country of origin, necessitating further investigation. Chinese scholars have conducted studies examining disparities in death attitudes between medical students from urban and rural backgrounds. The research suggests that an urban upbringing and higher levels of parental education may contribute to greater emphasis on the psychological development of children, resulting in a relatively positive outlook on death (10, 34).

In summary, while implementing death education, colleges and universities should tailor their approach based on several factors, including gender, location of origin, and family background. For instance, when targeting women, the emphasis should be on alleviating their apprehension toward death. Medical students hailing from rural areas should receive intentional guidance to approach death with a positive mindset. Death education should be conducted promptly and efficiently. Furthermore, it has been discovered that both family and society exert significant effects on the attitudes of medical students regarding death. Consequently, death education for medical students should extend beyond the confines of the school classroom. Schools should actively collaborate with families and communities of medical students to implement death education, aimed at assisting medical students in developing a positive attitude toward death through subtle impacts.

The results of this study found that receiving death education can also improve medical students’ attitudes toward death. This is similar to results of previous studies (45, 46). It is evident that current universities are actively broadening their methods of death education and constructing effective death education classrooms, which can assist medical students in developing a more optimistic perspective on death. However, there are currently a limited number of universities that have truly integrated death education into their academic programs (20).

Based on the current findings, the impact of funeral experiences on medical students’ perspectives regarding death remains uncertain. It is necessary to conduct additional research to determine whether funerals, as a temporary situation involving direct confrontation with death, can aid medical students in developing favorable attitudes toward death. Experiencing the death of family members in life can result in medical students having negative attitudes toward death for a certain period of time.

In summary, death education can extend beyond conventional lecture formats, and confronting death can prove effective in enhancing medical students’ disposition toward death. Universities should actively engage in the exploration and discovery of comprehensive and varied approaches to death education. Simultaneous attention should be paid to the social experiences of medical students. This includes providing immediate support to students who have recently lost a family member to assist them to quickly adjust their physical and mental condition during critical moments. Further, universities should offer guidance to help students develop a constructive mindset and approach toward death through real-life encounters.

Psychological well-being among medical students is a significant indicator of attitudes toward death. Students with relatively sound mental states tended to have more positive attitudes toward death. Psychological well-being is essential for medical students to effectively cope with the demanding circumstances they encounter, including the emotional toll of witnessing deaths in their professional setting and clinical training (20). Therefore, when implementing death education, universities should promptly consider the mental well-being of medical students and conduct customized death education based on their mental health. Additionally, there is a need to enhance the management system of universities to prevent medical students from developing Internet addiction, which consequently impacts their physical and mental well-being, as well as their attitudes toward death.

Furthermore, considering the distinctive characteristics of medical students, it is imperative to include professionalism education in conjunction with death instruction. By doing so, these two components can mutually reinforce each other, fostering the development of medical professionals who possess a scientific and professional approach toward death and who are also inclined to volunteer.