To Die or Not to Die?That is the Question!

Eric Bauman, PhD, RN, ParamedicKim Leighton, PhD, RN, CNE

“. . . nurses are privileged tohave the unique and specialopportunity to be present at themost remembered eventsduring one’s life—both birth anddeath.

How you handle thesesituations will always beremembered.”

(Walsh & Hogan, 2003, p. 890)

Disclosure

Eric is an education consultant forthe Town of Madison FireDepartment, Vernon MemorialHealthcare, and a Pfizer stockholder

Kim is adjunct faculty for METI,receiving honorarium for trainingand consultation

Objectives

Examine perceptions of simulateddeath experiences

Explore faculty concerns related toteaching students about death anddying

Identify the benefits of integratingsimulated patient death experiencesinto clinical curricula

What is the Problem?

Should the simulator die? Very controversial Beneficial or harmful? What should be considered when

deciding whether to allow thesimulator to die?

What Are YOUR Thoughts?

What Others Have Said. . .

Won’t see correct outcome of SCE Takes too long to restart simulator Don’t have enough time to re-run

SCE Might affect students’ feelings about

learning with simulation Won’t like coming to simulation lab

Additional Concerns

Feel like they killed the simulator Might think they didn’t provide

correct care Educator not comfortable talking

about death Might hurt students psychologically,

bring out buried feelings

Simulated DeathExperiences

Expected End-of-Life

Unexpected Acute Respiratory Distress Syndrome

(ARDS), Herniation Syndrome

Result of Action or Inaction Blood Transfusion, ACS, Medication

Error, Failure to act - provide treatment

We Need TWO Volunteers!

What Does the Research Say About StudentNurses and Patient Death?

Anxiety stems from feelings of personalinadequacy and limited clinical experiencecaring for dying patients (Beck, 1997; Van Rooyen, Laing, &Kotzk, 2005)

Preconceived ideas/not prepared for reality, self-doubt leading to fear and anxiety, feel couldhave done more/did something wrong leadingto guilt (Van Rooyen, Laing, & Kotzk, 2005)

Anxiety R/T shock over physical deterioration,feeling inadequate, not knowing how tocommunicate, making mistakes; Sudden deathmore distressing than expected (Cooper & Barnett, 2005)

What Do Practicing Nurses SayAbout Their EOL Education?

75% of Australian nurses receivedneither adequate nor appropriate trainingto enable them to deal with death anddying (Mooney, 2002)

Survey 352 nurses, 66% ratedknowledge of EOL care fair or poor (Meraviglia,McGuire, & Chesley, 2003)

Survey 2300 oncology and generalistnurses, 62% rated EOL education asinadequate (Ferrell, Virani, Grant, Coyne, & Uman, 2000)

Medical Education LiteratureIn a study of Internal Medicine Residents(8)

49.3% felt inadequately trained to lead acardiac arrest

50.3% felt that standard ACLS training did notprovide necessary team leadership skills relatedto resuscitation

40% indicated they received no additionaltraining related to resuscitation beyond astandard ACLS course

52.15 felt prepared to lead a cardiacresuscitation - 55.3 worried they made errors

Residents felt unsupervised - No backup Post event debriefing/feedback was lacking

(Hayes, Rhee, Detsky, LeBlanc, & Wax, 2007)

How Do We Prepare Them? 2% of nursing textbook content related to EOL

care (Ferrell, Virani, & Grant, 1999)

Review of 50 top medical, surgical, psychiatrytexts for 13 EOL content areas found helpfulEOL info in < 25%, minimal coverage in 20%,and no content in over 50% (Rabow, McPhee, Fair, & Hardie,1999)

In the UK, average 12.2 hours of EOL educationin degree programs and 7.8 in diplomaprograms (Lloyd-Williams & Field, 2002)

Clinical experiences Medical Students lack educational experience

related to delivering death notification and legalaspects of death investigation

How Do YOU ThinkSimulation Can Help?

How Can Simulation Help? Experience death in a safe environment Pattern recognition for expected or

adverse outcomes See consequences of actions or inactions Improve communication skills Increase comfort in caring for patient at

EOL Do everything right; sometimes patients

still die “Bad Pathology is Bad Pathology” Opportunity to talk about current or

suppressed feelings(Squire, 2006; Gee 2003)

Psychological Safety

Debriefing is vital: support, reassurance,guidance, knowledge (Allchin, 2006; Walsh & Hogan, 2003;Thiagarajan, 1992)

Qualitative study found personalreflections of loss, death, dying, and griefhelped students deal with patient deathand helped them deal with their ownlosses (Allchin, 2006)

Chaplain/Religious practitioner Psychiatric nurse practitioner Backup for the instructor Counseling opportunities

Have a psychological safetyplan in place prior to

death and dying training

Psychological Safety:Take Home Message

More Volunteers Please!!

NOW What Do You Think?

Should the simulator die? What are the benefits? How do we prevent potential harm? What will YOU do?

Responses to End-of-LifeSimulated Clinical Experience

“I learned valuable ways of caring for dying patients.”

“Students need more exposure to these situations.”

“Made me realize I need more time to practice providingcares to the dying and their families.”

“More realistic than just talking about it (and role playing).”

“Demonstrated a real life-like event and the emotions andfeelings that one might experience.”

“We need to know if we can handle patients dying before ourfirst day taking call”

“Gaining experience with death and dying earlier in medicalschool might have influenced my choices related to residencytraining”

Questions?

Dr. Eric Bauman, Faculty AssociateDepartment of AnesthesiologyUniversity of Wisconsin School of Medicine and Public HealthMadison, WIebauman@wisc.edu608-263-5911

Dr. Kim Leighton, Dean of Educational TechnologyBryanLGH College of Health SciencesLincoln, NEkim.leighton@bryanlgh.org402-481-8713

Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal ofHospice and Palliative Nursing, 8(2), 112-117.

Beck, C. T. (1997). Nursing students’ experiences caring for dying patients. Journalof Nursing Education, 36(9), 408-415.

Cooper, J., & Barnett, M. (2005). Aspects of caring for dying patients which causeanxiety to first year student nurses. International Journal of PalliativeNursing, 11(8), 423-430.

Ferrell, B., Virani, R., & Grant, M. (1999). Analysis of end-of-life content in nursingtextbooks. Oncology Nursing Forum, 26(5), 869-876.

Ferrell, B., Virani, R., Grant, M., Coyne, P., & Uman, G. (2000). Beyond thesupreme court decision: Nursing perspectives on end-of-life care. OncologyNursing Forum, 27(3), 445-455.

Gee, J. P. (2003). What video games have to teach us about learning literacy. NewYork: Palgrave MacMillian.

Hayes, H.W., Rhee, A., Detsky, E., LeBlanc, V.R., and Wax, R.S. (2007). Residentsfeel unprepared and unsupervised as leaders of cardiac arrest teams inteaching hospitals: A survey of internal medicine residents. Critical CareMedicine 35(7), 1668-1672.

Lloyd-Williams, M., & Field, D. (2002). Are undergraduate nurses taught palliativecare during their training? Nursing Education Today, 22(7), 589-592.

REFERENCES

REFERENCES (cont)

Meraviglia, M. G., McGuire, C., & Chesley, D. A. (2003). Nurses’ needs foreducation on cancer and end-of-life care. Journal of Continuing Education inNursing, 34(3), 122-127.

Mooney, D. C. (2002). Nurses and post-mortem care: A study of stress and theways of coping [doctoral dissertation]. Griffith University, Southport,Queensland, AU.

Rabow, M. W., McPhee, S. J., Fair, J. M., & Hardie, G. E. (1999). A failing grade forend-of-life content in textbooks: What is to be done. Journal of PalliativeMedicine, 2(2), 153-156.

Squire, K. (2006). From content to context: Videogames as designed experience.Educational Researcher. 35(8), 19-29.

Thiagarajan, S. (1992). Using games for debriefing. Simulation and Gaming, 23(2),161-173.

Van Rooyen, D., Laing, R., & Kotzk, W. J. (2005). Accompaniment needs of nursingstudents related to the dying patient. Curationis, 28(4), 31-39.

Walsh, S., & Hogan, N. (2003). Oncology nursing education: Nursing students’commitment of ‘presence’ with the dying patient and the family. NursingEducation Perspectives, 2A, 866-890.