Introduction

The World Health Organization recognizes palliative care as a method of improving quality of life by preventing and treating pain and other physical, psychosocial, and spiritual issues.[1] In 2006, the American Board of Medical Specialties approved the creation of a Hospice and Palliative Medicine (HPM) subspecialty. As technology has improved over the last 20 years, it has played a vital role in medical education, especially in simulation. Simulation-Based Medical Education (SBME) has been shown to improve clinical competence, patient safety, and is cost-effective if used appropriately.[2][3][4] Many educational principles must be considered when developing an effective SBME curriculum, including curriculum integration, feedback, deliberate practice, and mastery learning.[3][5] Simulation has also been used in palliative care education, especially early on in medical trainees’ careers. Ann Faulker was a medical educator in the UK who was one of the first to advocate for simulation in palliative care in 1994.[6] Palliative care simulation is different than procedural based simulation, and this must be taken into consideration when developing a successful simulation technique. There should be more emphasis on communication tools, interpersonal skills, self-reflection, and end of life care.

Function

The publication of “To Err is Human: Building a Safer Health System” in 1999 revealed concerning statistics about patient safety, including that an estimated 98,000 people die in hospitals due to medical errors.[7] Since then, the medical field has had a greater emphasis on patient safety. Medical simulation has been implemented in medical curriculums in recent years as it offers a solution to improving patient safety. While simulation is not a new concept, it has been revised and improved in the last 20 years with the addition of recent technology. Palliative care can use simulation to help improve communication skills, patient safety, and end of life care.

Curriculum Development

While most palliative care simulation experiences are with standardized patients, there are other methods of simulation for palliative medicine that have been identified. Two that have been discussed are the sociodramatic method and the virtual patient.[8] The sociodramatic method is a role-play simulation that emphasizes reading body language and interactions. It allows learners to switch roles in a scenario better to understand the concealed motivations of family members and patients. The other method, the virtual patient, was incorporated into a three year Family Medicine Clerkship rotation. Over the eight week clerkship, students followed a cancer patient with bony metastasis over six virtual months, as they progressed to hospice and death.[9] Self-assessment of comfort level with all aspects of end of life care increased, as did group knowledge score.

Some consider that high fidelity simulation, including mannequins and virtual reality, should be used more frequently as live actors can be costly.[10] Kozhevnikov et al. report that only 15% of studies evaluated used robotic simulation. Mannequins and robotic simulators have benefits that include replicating physiologic processes to help with symptom management, allowing for standardization without variance, and replicating standardized child patients, which can be expensive.[8] Tachycardia and tachypnea are physiologic findings that can be seen in end of life cases. Seeing a physiologic response after administering comfort medications is one of many essential teaching points in end of life care, as this hands-on experience might be limited in the real world.

Additional findings from Kozhevnikov et al.’s review of palliative care simulation found that primary skills addressed over the 78 studies were eliciting treatment preferences (50%), providing bad news (41%), and empathy skills (40%). Only 13% of studies reviewed symptom management, although the studies they evaluated included learners in medicine and nursing.[8] This discrepancy might be due to the greater emphasis of end of life in medicine curriculums rather than in nursing curriculums. Still, more emphasis could be placed in the future on end of life symptom management while utilizing robotic simulation.

Clinical Clerkships

Developing a curriculum for SBME is a complex task that has been studied for over 20 years. Per Motola et al., establishing such a curriculum requires consideration of the following educational principles: feedback, curriculum integration, deliberate practice, mastery learning, range of difficulty, capturing clinical variation, individualized learning, and approaches to team training.[3] These educational principles must be kept in mind when implementing a simulation into a medical school curriculum. 

A successful medical simulation is most effective when it is integrated into the curriculum of the learner.[3] Integrating simulation into the medical curriculum has improved much over the last 20 years. Such integration divides into four steps: Plan, Implement, Evaluate, Revise.[3] The planning process includes developing a curriculum, logistics, type of simulation, and how feedback will be delivered. Implementing encompasses the execution of the simulation and troubleshooting issues that arise. Evaluating and Revising involves recognizing the quality of the simulation, determining how to improve it, and then putting forth the improvements. A successful palliative care simulation should follow this same framework of plan, implement, evaluate, and revisions to be successfully integrated into the medical curriculum.

Palliative care is a specialty that requires effective communication.[11] Different types of simulations exist, including mannequins, live role-playing, the virtual patient, the sociodramatic method, and virtual reality. A review of the literature on 78 studies on simulation experiences in palliative care by Kozhevnikov et al. found that 68% of encounters involved standardized patients, which was attributed to the significance of communication skills.[8] Hence, communication skills are the major pillar of designing palliative care simulations.

Debriefing is another crucial part of SBME. An effective debriefing allows learners to reflect on their experiences and learn from them adequately. A studied method of debriefing sessions for medical simulations includes the 3 Ps: Planning, Pre-brief, and Providing feedback.[3]

First, it is important to plan for how the debriefing will take place. Palliative care debriefing sessions should have a debriefer who can help cope with emotionally stressful situations. It has been shown that an effective debriefer can help students cope with their feelings about palliative care. Additionally, students should be able to freely talk about their feelings in debriefing sessions as it can normalize their own emotions.[12] Having a safe environment allows participants to suspend their disbelief and fully engage in the simulation, as well as be able to reflect and learn from the simulation adequately.

Next, Pre-briefing is the explanation of expectations to participants before beginning the simulation.[3] Pre-briefing helps set the stage for the simulation, to make trainees feel comfortable and understand the steps after the simulation is complete. Finally, feedback/debrief is important during and after the scenario. Feedback allows for reflection on actions during the simulation and debriefing to reflect on events after the simulation. For example, in an end of life simulation, trainees might be able to have feedback of physiologic responses in real-time when giving comfort medications. Post-event debriefing should have an opportunity for learners to reflect on one’s thinking and why actions occurred. Many types of debriefing methods exist, but one frequently used is the positives and deltas.[3] A positive column allows reflection on strengths in the scenario. The delta column highlights what things learners could improve on or what weaknesses they noticed. If debriefing sessions are developed with the 3 P’s in mind, palliative care simulations can be more successful.

Clinical Significance

Palliative care is a vital part of the medical curriculum. Palliative care has found an important role in the modern age as early utilization of palliative care correlates with improved quality of life, mood, and survival.[13] Another benefit of using palliative care is cost savings for inpatient hospitals.[14][15] End of life discussions between cancer patients and caregivers lead to earlier hospice referrals, less regret with caregivers, and improved preparedness for death.[16] Despite the importance of palliative care, the requirements for their education in medical school are minimal. The Association of American Medical Colleges' only requirement for palliative medicine education is to have end-of-life care included at some point in the medical school curriculum. A survey of U.S. medical schools showed that their end-of-life training varied widely and is not standardized. This end-of-life exposure has been provided at different levels and settings, either as didactic lectures during the first two years and/or as palliative/hospice care training during the clinical rotation years.[17] 

Palliative care simulation plays an important role in the eyes of medical trainees. An internal survey among Internal Medicine Program Directors found that 87.5% of respondents felt that having training in palliative care was "very important." [18] A small panel of medical students felt that simulations helped them better prepare to take care of dying patients.[19] A palliative care simulation was made part of an Emergency Medicine residency training program at an urban academic emergency department. By providing the simulation, researchers found significant improvement in perceiving the importance of palliative care as well as improved confidence in implementing its skills.[20] Emphasis should be placed on developing high quality and standardized palliative care curriculum for medical trainees, as it benefits patients, trainees, and health care systems.

Enhancing Healthcare Team Outcomes

Palliative care is best delivered when all members of the health care team work together. Nurses are important as they are coordinating care for patients and families while tailoring their care for each patient differently.[21] Additionally, in palliative care, many other specialties play significant roles, including pharmacists, social workers, chaplains, physical therapy, occupational therapy, and music therapists. An Interprofessional Healthcare (IPE) simulation-based training for geriatric palliative care was created, including 110 health profession students from these specialties. The health profession students worked together as a team to prepare for and have a goal of care discussion for an 80-year-old female with multiple comorbidities. Post simulation survey of the students found that 97.3% had greater self-efficacy in team communication skills, felt satisfied with the training, and also felt more positive toward health care teams.[22] Utilizing IPE simulation-based training is an opportunity for medical trainees to expand and strengthen their interprofessional communication skills. Medical trainees need to understand the unique role that each specialty plays and learn how to communicate as a team effectively.