Simulation scenarios can approximate many aspects of the real-world environment,1 an attribute that accounts for their success in teaching management of rare critical events and life-threatening situations. Simulation has also been used successfully to teach about death during one of these infrequent events.2–6
Although death and dying are natural events, students receive limited exposure to these aspects of health care practice during their formal education.4 In fact, students and practicing nurses report insufficient educational preparation in this area7 and have expressed a desire for more exposure, especially in the context of end-of-life care.8
Despite this demand for expanded training, considerable controversy persists regarding whether facilitators should let a simulator die unexpectedly during a “nondeath” scenario. Some educators never allow the simulator to die unless death is the objective of the scenario; some believe that death is only appropriate for the more advanced learner, and still, others allow the simulator to die unexpectedly during any scenario with learners at any level of experience. There are few studies, however, to guide our practice.
The objective of this review was to survey the literature that examines this topic, present arguments for and against permitting learners to experience simulator death, and provide some recommendations for using death scenarios in health care simulation.
For this review, we conducted literature searches in the MEDLINE and Education Resources Information Center (ERIC) (education) databases. Search terms included patient simulation, simulated clinical experience, high-fidelity simulation, death, simulated death, and end-of-life care and were applied both singly and in combination. Inclusion criteria were articles published in the last 10 years, in English, about humans, and in MEDLINE and nursing journals. Specifically, medical subject headings (MeSH) terms used were death and patient simulation.
Despite traditional teachings about the negative impact of death on learners, it is a common practice in many simulation laboratories to allow the simulator to die. Nickerson and Pollard9 recently surveyed 94 people who work with simulation in medical scenarios. Eighty-four percent of respondents reported that their laboratory allowed simulated patients to die, and only 32% of respondents reported that their laboratory had a policy regarding simulator survival. In planned versus unplanned death, 58.5% of simulator laboratories had scenarios with planned fatal outcomes, and 54% allowed simulated patient death “on the fly.” The most common death scenarios were (1) end-of-life situations intended to prompt discussion about talking to a family after the death of their loved one and (2) cardiac arrest scenarios performed as part of advanced cardiac lifesaving. Differences between adult and pediatric simulated death were also noted, with 80% of those surveyed responding that they would not allow infant or pediatric death.
Leighton10 outlined concerns about simulator death expressed by nurse educators and the benefits of using patient simulation for learning “end-of-life care.” The author describes 3 types of death—expected death, unexpected death, and death resulting from action or inaction. Expected death is planned, and learners are prepared for it. They receive the case information before the session, so they know that the simulator will die. Unexpected death is purposefully incorporated into the scenario by the instructor but comes as a surprise to the learners. Finally, death that results from a learner’s action or inaction during the session is unexpected by learners and the instructor. An example of a simulated death that results from student action is death after a medication overdose.
Leighton10 also discusses advantages and disadvantages of simulated death. Advantages include (1) providing experiences that would not be available in traditional clinical environments, (2) the ability to learn in a safe environment, and (3) the ability to reflect on personal feelings about mortality. Leighton10 also cited positive affective impact such as decreasing fear, anxiety, and feelings of inadequacy. Finally, simulation allows students to witness and learn from the results of their actions without the potential for harm to live patients. Leighton10 also enumerates disadvantages, which include (1) distraction from planned learning objectives, (2) potential psychologic harm to the learner, and (3) potential harm to overall long-term interest in simulation as an educational modality. According to Leighton,10 death may cause students to feel guilt and may obliterate the desired learning outcomes.
Phrampus et al11 surveyed students about their perceptions of death in simulation-based training programs. Of 207 subjects (including physicians, nurses, and paramedics), nearly half had experienced a simulated death during training (61% of physicians, 42% of nurses, and 41% of paramedics). Participants disagreed that simulated death distracted them from the learning objectives, strongly disagreed that students in their respective fields should be exempted from simulated death, and strongly disagreed that experiencing simulated death would create reluctance to participate in further simulation training. These findings appear as an abstract and were thus not peer-reviewed. Furthermore, the type of simulated death used for this survey was not defined. However, this study, albeit limited, is among only a few reported in the literature.
The study of Phrampus et al11 suggests that educators may be overly cautious about simulated death; however, there are dissenting opinions. Nickerson and Pollard9 note that death can elicit strong emotions from trainees and that instructors must be prepared to manage these reactions. Some instructors strongly assert that simulated patients should always survive and that discussion about patient death should take place only in the debriefing session. Other instructors believe that experiencing a patient death in a controlled environment, with allotted time for processing, provides benefits for students.
Nehring and Lashley,12 in their nurse education textbook, make specific recommendations regarding simulated death to ensure a favorable learning outcome. In particular, they state that it is essential to consider (1) the educational level of the learners, (2) their comfort with the current situation, and (3) the scenario’s learning objectives. They recommend a phased approach to simulator death, slowly easing the student into acceptance.
Simulation allows students to practice managing the death of a patient in a safe learning environment. A number of arguments support the notion that high-fidelity simulation is an opportunity to teach about death.
Medical Students and Nurses Receive Limited Instruction About Death
Death creates an uncomfortable situation for care providers because of the event itself and because they typically are not taught how to communicate difficult news. Although the circumstances surrounding death are delicate, death is inevitable and one of the truly universal human experiences. For this reason, health care providers should be better prepared for this eventuality.4,7,8,13
Students Want to Learn More About Death
Some students believe that they have received insufficient instruction and have indicated that they would like more workshops to learn about dying and death.4
Simulated Death Can Be a Powerful Learning Tool
Simulated death has been described by some authors as a beneficial learning experience.12 Leighton10 states that death of a simulator can be a useful pedagogic tool because it gives learners the opportunity to experience care for a dying patient, see the consequences of their actions without putting a real patient at risk, learn how to communicate difficult news to family members, and discuss their feelings and similar personal experiences during the debriefing.
Simulation Provides a Safe Controlled Yet Realistic Environment
We believe that we can take advantage of these features and use this tool to practice managing patient death away from the bedside. In the simulation suite, the facilitator can manipulate the environment and control the scenario so that learners can practice responses to significant events.14 In the case of simulated death, such control is essential to maximize benefits for the learner. Death in the real world may occur unexpectedly, adding to the pain and distress felt by the health care provider. Simulation allows us to control the degree of stress felt by the learner by designing specific training objectives and considering the student’s personality and level of preparation.
Gaba15 defines simulation as “a technique to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.” One salient feature of such replicated experiences is the ability to practice death scenarios in a nonthreatening environment. However, the success of such scenarios is dependent on the degree of mimesis.
Full Environment Simulation, Learning, and Emotion Are Related
According to Bryson and Levine,16 full environment simulation provides the unique opportunity to stage realistic scenarios that allow students to make mistakes and experience bad outcomes without patient harm. Adding emotional content to simulated crises can be used to effect emotional changes in participants and thus enhance learning. In their experience, emotional events tend to leave lasting impressions.
Simulated Death Is Accepted Among Learners
In the survey of Phrampus et al11 from 2006, participants reported that simulated death did not distract them from the learning objectives, and they felt that other students should be allowed to experience simulated death. Although there are few data to characterize levels of acceptance for simulated death among learners, it is worth noting that reports from such studies as the survey of Phrampus et al11 are drawn from actual simulation practice. Furthermore, student evaluation of the death scenario that Gaba et al6 developed as part of a simulation-based curriculum for anesthesiologists was extremely positive, with 91% agreeing that it was appropriate to simulate the death of the patient.
There Is a Large and Potentially Relevant Body of Literature That Relates to the Use of Simulation in Other Domains
Aviation, for example, has a long and successful history of using simulation to expose learners to critical and hazardous situations.17 Commercial airlines and the military have used flight simulators for decades.18 As in medicine, the cost of a mistake in aviation is potentially very high.
The literature does not provide much evidence regarding whether crashing the simulator is allowed in training military or commercial pilots, and pilot opinions on the use of such scenarios vary. Anecdotally, from a limited number of aviation training sources that we and others (D. Gaba, MD, personal communication) could identify, it seems that at least some aviation simulation applications do allow for a crash of the simulated aircraft during a training session if relevant conditions are met.
Arguments against simulated death, regardless of the type of death, revolve around the psychologic safety of students and their learning outcomes.
One concern regarding learning outcomes is the potential impact of stress. Stress affects learning and memory, and this effect can be positive or negative depending on whether the stress is temporally associated and placed within the context of the information to be learned.19
Another argument frequently made against allowing death in simulation is that it may instill negative feelings about learning with simulation. The study of Phrampus et al11 (albeit reported in abstract form only) contradicts this concern. In fact, most of the physicians, nurses, and paramedics surveyed strongly disagreed that simulated death would cause future reluctance to participate in simulation training. However, it should be noted that most of the participants sampled had previous experience with simulation, suggesting that they were more advanced learners.
More specific concerns arise in discussions about unexpected death. When the simulator is allowed to die unexpectedly, the whole dynamic of the session could be affected. For example, a death scenario requires additional time for a skilled instructor to discuss the experience with the.This may detract from the original learning objectives and may extend the learning session beyond the time allotted.
Concerns about negative psychologic effects on learners have also been expressed and are often central to arguments against unexpected simulated death. In the survey of Nickerson and Pollard,9 28% of respondents reported encountering emotional distress at some point during an unexpected simulator death, and 50% of simulation laboratories reported having a plan for addressing participant emotional distress. Although data that define distress, the methods used to diagnose distress, or the types of cases associated with distress were not collected, the findings of Nickerson and Pollard9 underscore the possibility of significant psychologic effects. Another concern of unexpected death is that death resulting from a learner’s action or inaction causes psychologic damage to the student.10 However, this concern has no supporting evidence in the literature.
Simulation training provides an opportunity for students to practice their knowledge in a safe environment without risking harm to a real person20 and also allows learners to develop and improve their skills through sustained deliberate practice.21 Such environments have long been used to teach students how to cope with significant events such as death. Death is an unavoidable component of health care. Given the lack of definitive research studies that address the controversy of incorporating death into simulation scenarios, best practices in this area are difficult to determine. However, in our opinion and based on the evidence presented previously, the educational benefits of simulated death outweigh the risks. For example, simulation can be a powerful learning tool for students who want to learn more about death. Learners may reflect and learn from their feelings while internalizing the role they played in the negative outcome. We believe that guided reflection by a skilled facilitator may prevent a negative outcome in the learner’s real practice.
As we mentioned previously, when deciding to perform death scenarios, concerns revolve around the psychologic safety of students and the learning process. However, evidence that validates these concerns is still lacking. From our perspective and secondary to this paucity of evidence, it is essential to consider carefully when deciding whether to implement an expected or an unexpected death scenario.
Leighton10 describes 3 types of death scenarios. The first 2 types are expected and unexpected from the perspective of the learner. The third type is a direct result of the student’s actions or inactions and is unexpected by learners and apparently unexpected by the facilitator as well. We believe simulated death should be considered from the perspective of both the learner and the facilitator.
1. Death is expected by the facilitator and the learner: In this scenario, managing a death crisis is a planned objective of the exercise. Learners receive the case stem and learning objectives before the session and are aware that the simulator will die. Death may result from a terminal condition such as end-stage cancer or end-of-life care or may occur in the case of a rare but possible risk of an intervention.
2. Death is expected by the facilitator and unexpected by the learner: Death is one of the objectives of the exercise and is generally planned by the facilitator, but the learners do not know that the simulator will die. An example is death due to a respiratory complication in a traumatized patient.
3. Death is unexpected by the facilitator and the learner: In this case, the unexpected simulator death is a result of action or inaction on the part of the learners. An example is death secondary to a failure to recognize a malignant hyperthermia crisis.
Therefore, a simulated death that is expected by the learner may have a different effect on the learning experience than simulator death that the student does not expect or that comes about from actions or inactions of the learners. Indeed, the outcomes of these 3 scenarios are expected to be significantly different. There is almost no serious discussion about the impact of a death expected by the facilitator on the other planned learning objectives because in those cases, death is a clear objective of the session and has been previously considered. The impact of a death unexpected by the facilitator on previously planned learning objectives has not been reported.
Finally, in addition to the type of death, several other factors should be considered when deciding to perform simulated death scenarios. For example, early learners are focused on the development of basic cognitive scaffolding and psychomotor skills and should not experience death. Learning about death, instead of the intended objectives, would rob these learners of basic knowledge and would be emotionally trying. More advanced learners, who have mastered the basics, typically use simulation to focus on nuances of care. Advanced learners would benefit most from learning about unexpected death—especially as a direct result of their actions. We have included recommendations in the next section that characterize factors to be considered when using simulated death scenarios.
We believe that, if simulated death is to be incorporated into the learning environment, it is of utmost importance that it be done with care, forethought, and proper facilitation resources. We do not yet have best practice guidelines for using simulated death in health care training. However, based on the findings presented in this review, we have framed some preliminary recommendations for optimizing the use of this technique in all 3 types of simulated death described previously. In addition, we have included additional recommendations that are specific to death scenarios that are unexpected by the facilitator and the learner because these have the potential for unique challenges.
General Recommendations for Simulated Death
Assess the Disposition of the Instructor
How the facilitator copes with death during the development of the scenario is an important concern. Individual facilitators have different comfort levels about these matters or indeed may have different religious or ethical stances. Facilitators must be trained in handling learners who are confronted with simulated death. This topic should be included in facilitator training courses around the world. Faculty who are hesitant or unable or unwilling to approach this topic should not include simulated death in their teaching.
Prepare an Adequate Prebriefing Session
A prebriefing session should be held before training sessions. Prebriefing should include a discussion of the students’ expectations, a review of simulator features, and (for every simulation) the possibility of death. This is vital for minimizing psychologic distress and managing expectations.
Do Not Allow Death With Early Learners
Early learners, such as medical students and baccalaureate nursing students, likely have not experienced death in clinical practice and are not prepared to face death in the simulator. In this situation, simulation objectives must be clear at the outset and must be adhered to during the training. For example, if medical students are being trained to manage anaphylaxis, that objective should be the focus of the training. The simulator should not die during the session if the learners perform poorly because that was not the previously established target. On the other hand, if the objectives include teaching about death from anaphylaxis, the simulator can be allowed to die, and the outcome can be discussed during debriefing. The important point for early learners is to keep the goals in mind and fulfill the learning objectives.
Allow Simulator Death for More Advanced Learners
More advanced learners, such as residents, staff, and advanced practice nurses, have likely experienced death clinically and must learn to cope with the death of patients in their own practice. Simulator death will ensure that the students have the appropriate tools and background knowledge to succeed.
Do Not Use Simulated Death Punitively
Facilitators should not use simulated death as punishment (eg, repeatedly making the same noncritical drug dosing error). If unplanned, the simulator should be allowed to die only when the learner’s actions or inactions would lead to a life-threatening consequence in real life.
Previously, we noted that emotions can facilitate learning. However, emotional reactions to simulated death can have a serious psychologic impact, particularly when the death results from actions or inactions of the learner. In these cases, it is important to focus on the incident as a learning experience and not on placing blame. Furthermore, students should never be made to feel that they are being punished for poor performance. At the same time, however, students should not be shielded from seeing the result of their actions or inactions. In short, potential effects of emotional distress should always be considered when using simulation to teach about death, to ensure a safe session that does not cause psychologic harm to students.
Perform a Detailed and Careful Debriefing
A thorough debriefing after a simulator death is crucial both as part of the learning process and to mitigate excessive distress. Rudolph et al22 suggest establishing a psychologically safe environment by allowing students to share their concerns, thoughts, and feelings and allowing trainers to provide support as needed.
Assure Psychologic Safety
As we mentioned earlier, psychologic safety must be a priority throughout the process—while planning the session, when choosing the type of death, and during the prebriefing and debriefing sessions. The debriefing should touch on all aspects of patient care that led to the simulated death, including environmental factors, team dynamics, and individual decisions. These will be hard discussions and must be led by thoughtful experienced facilitators. When death occurs as a result of a learner’s action or inaction, the potential for psychologic harm is clearly present; instructors should be specially trained to recognize and address psychologic distress. For extreme cases, counseling services could be made available to students after the session, or sessions could be cofacilitated with psychosocial faculty.
Additional Recommendations for Simulated Death That Is Unexpected by the Facilitator and the Learner
In this case, each simulation center must develop its own policies regarding death unexpected by the facilitator, taking into account its overall philosophy and objectives, as well as the curriculum, instructor, and learner population.
Follow the Meta-Objectives
Every simulation center should maintain a set of “meta-objectives” for unexpected death that can be invoked at any time. These “death objectives” should be used at the discretion of the facilitator and would trump the objectives of the zoriginal scenario.
Consider Extra Laboratory Time
Extra laboratory time should be considered to ensure that students have enough time to thoroughly discuss their experience with unexpected death—giving adequate time to thoroughly reflect on their actions (or inactions), the impact of those actions, and their feelings about the outcome.
Although simulated death presents an important opportunity to enhance the limited education that health care providers currently receive regarding death, facilitators must always take into account the limitations of this tool and the potential for psychologic harm to learners.
Several questions remain unanswered in this review. For example, the real impact of simulated death on the learning process and on the psychologic well-being of students awaits further characterization and should be the focus of future investigations. Such studies could inform not only the development of formal guidelines or policies but also the integration of simulated death into the curriculum for health care providers.
The authors thank David Gaba for his valuable comments and suggestions to improve the quality of the article and Kathy Gage for her editorial contributions.