Dawn Mangine

    Medical errors – including errors made by doctors, nurses, EMS personnel, and pharmacists – are the third largest cause of death in the United States.1 Healthcare professionals, regardless of how long they go to school and how much they care for their patients, sooner or later are going to make a mistake that may result in the death of a patient.

    A current issue in the field of simulation education is how to best prepare students for a patient’s death – and if it’s even appropriate to do so within a scenario. Many medical simulation scenarios provide hands-on education for performing diagnostic tests, treating injuries, placing IVs or catheters, filling prescriptions, and giving shots (among many other types of simulation!), but should death be part of simulation scenarios?

    Using Patient Death in Simulation

    As healthcare educators know from the book and documentary To Err Is Human, preventable patient death is an unfortunately common result of treatment. Since this is true, addressing it in simulation scenarios cognitively makes sense to many instructors. Making a mistake that “kills” a manikin can provide a safe space for learners to examine not just the technical nature of what went wrong, but the aftermath of any resulting trauma.

    One hypothesis is that learners who are allowed to manage a scenario and allowed to fail, causing simulated morbidity, consequently perform better when re-exposed to the same scenario.

    Unfortunately, increasing the awareness of issues surrounding death doesn’t necessarily promote learning. According to research by Bruppacher et al,

    “Using patient death… potentially introduces fear-based motivation for improving one’s clinical practice and, hence, represents a backward step in efforts to promote a non-punitive culture around medical error and critical incidents in the health care setting.”2

     According to Suzie Kardong-Edgren, RN, ANEF, CHSE, in the early days of simulation the “death” of a manikin was treated very cavalierly.3 “Oh well,” an instructor would say. “You just killed the patient. Let’s run through the scenario again and see if he survives this time.” Now, through debriefing and research studies, instructors are starting to understand how to better react in the face of possible “death” and in turn, give their learners options and opportunities for good outcomes.

    Introducing Patient Death in Simulation Scenarios

    • Some undergraduate programs do not create scenarios that include patient death. With the awareness that learners may be grieving an event outside of the classroom, re-traumatizing them through simulated death is unconscionable.
    • Other simulation instructors stop the simulation as soon as it is clear that the student actions are going to result in patient death. This way, the learner isn’t caught off guard by causing “death,” and the instructor can lead the learner to the correct treatment.
    • Dr. Kardong-Edgren says, “There seems to be an emerging consensus of opinion that the manikin should not be killed or allowed to die unless that is the objective of the scenario and all learners are aware that this might/could occur.” For example, a scenario at Franciscan University runs through an end-of-life scenario in order to teach students empathy, compassion, and end-of-life care.

    Dr. Dorian Williams, Medical director of the Shaw Center for STEPS (Simulation Training and Education for Patient Safety) at West Virginia University recently presented on "Difficult Simulation Situations: To Die or Not to Die."4 He looked at the outcome from several randomized trials where death was introduced in a simulation scenario. His summary is as follows:

    • Evidence exists to support the hypothesis that “learner exposure to patient death from errors during learning result in better long-term performance for the majority.” (Emphasis added.)
    • The emotional impact of patient death may result in difficulty in processing information and reduced learning; in some cases, the negative impacts have long-term consequences.
    • The impact on learners differs significantly if the death is planned as opposed to if the death is unexpected and the result of student action or inaction.
    • Debriefing is essential when the death is unexpected.

    Although the overall consensus is still inconclusive from the studies Dr. Williams examined, instructors can agree that the emotional state and level of preparedness of learners need to be considered when attempting to introduce death into simulation scenarios. Dr. Kardong-Edgren suggests the field of healthcare simulation education continue to develop policies regarding psychological safety of learners and present alternative assignments for students with recent traumatic events.


    To Err Is Human: Building a Safer Health System, U.S. Institute of Medicine, Nov. 1999

    Bruppacher HR, Chen RP, Lachapelle K. “First, do no harm: using simulated patient death to enhance learning?” Medical Education, NCBI, 2011.

    Kardong-Edgren, “Thoughts on the Evolution of Unexpected Death in Simulation,” Clinical Simulation in Nursing (2015) 11, 317. Elsevier, Inc.

    Williams, Dorian, “Difficult simulation situations: To die or not to die!”, SimPOW (Simulation Alliance of Pennsylvania, Ohio, and West Virginia) Presentation, April 27, 2019.

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