End of Life Symptom Management: Emergencies in Palliative Medicine—A Novel Simulation-Based Education Program

Key Message: Most simulation training in Hospice and Palliative Medicine has focused on communication skills. We present a unique simulation curriculum designed for our interdisciplinary Hospice and Palliative Medicine Fellowship, focusing on the management of refractory symptoms at the end of life, which represent our equivalent of palliative emergencies.

Abstract: Hospice and Palliative Medicine (HPM) simulation training has primarily focused on communication skills, rather than symptom management (1,2). Simulation has been shown in acute care specialties to be an effective educational tool in high stakes clinical settings and provides a safe environment to improve skills in crisis management (3). HPM providers are often called to manage refractory symptoms in emotionally charged situations, especially at end-of-life care. These scenarios may present infrequently during their one-year fellowship training.
We describe a novel two-part simulation series “End of Life Symptom Management: Emergencies in Palliative Medicine” that we have developed for our interdisciplinary HPM Fellowship. Aiming to illustrate an experiential narrative outlining the process of designing and implementing a unique educational initiative, simulation is utilized to instruct HPM fellows in the management of end-of-life symptom crises. Throughout the five year existence of this course, challenges have been faced and lessons learned, providing a framework or ‘road map’ for programs interested in incorporating simulation learning into their HPM curriculum.
Our simulation series is conducted at our institution’s Simulation Center with trained simulated patients (SPs)/actors and includes scenarios of (1) refractory pain, (2) palliative sedation, (3) initiation of buprenorphine-naloxone for cancer associated pain in a patient with opioid use disorder (OUD), (4) acute pain crisis in a hospice patient with OUD on buprenorphine-naloxone, (5) terminal delirium, (6) compassionate extubation/respiratory distress (7) status epilepticus and (8) terminal hemorrhage.
We will also share pre and post session data collected from our HPM Fellows as well as feedback from the SPs and Simulation Center Staff, gaining additional insight from key stakeholders for ongoing program development. This simulation curriculum has allowed our fellows the opportunity to encounter and navigate these scenarios in a safe and controlled learning environment before encountering them in practice.

References: 1. D. Kozhevnikov, L. J. Morrison, M. S. Ellman. Simulation training in palliative care: state of the art and future directions. Adv Med Educ Pract 2018 Vol. 9 Pages 915-924
2. M. B. Smith, T. G. R. Macieira, M. D. Bumbach et al. The Use of Simulation to Teach Nursing Students and Clinicians Palliative Care and End-of-Life Communication: A Systematic Review. Am J Hosp Palliat Care 2018 Vol. 35 Issue 8 Pages 1140-1154
3. L. Fung, S. Boet, M. D. Bould et al. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. J Interprof Care 2015 Vol. 29 Issue 5 Pages 433-44