1
Enhancing Registered Nurse Job Readiness and Patient Safety Outcomes Through
Clinical Simulation
Simulation Scenario End of life: Breaking bad news
Adaptation of California Simulation Alliance (CSA)
APRIL 2014
University of Ottawa
Algonquin College- Woodrofe and Pembroke
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
ALL DATA IN THIS SCENARIO IS FICTICIOUS
2
SECTION I SCENARIO OVERVIEW
A. Title
B. Summary
C. Evidence Base
SECTION II CURRICULUM INTEGRATION
A. Learning objectives
1. Primary
2. Secondary
3. Critical Elements
B. Pre-Scenario Learner Activities
SECTION III SCENARIO SCRIPT
A. Case Summary
B. Key Contextual Details
C. Scenario Cast
D. Patient/Client Profile
E. Baseline Patient/Client Simulator State
F. Environment/Equipment/Essential Props
G. Case Flow/Triggers/Scenario Development
SECTION IV APPENDICES
A.
B.
C.
D.
E.
F.
G.
Health Care Provider Orders
Digital Images of Manikin/Milieu
Debriefing Guide
Instructions for Standardized patients and Participants
Dot Not Resuscitate Confirmation Form
Medication Administration Records and Nursing Notes
Frommelt Attitude Toward Care of the Dying Scale (See RNAO
BPG EOL Care)
H. Palliative Performance Scale (Version 2)
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
ALL DATA IN THIS SCENARIO IS FICTICIOUS
3
SECTION I: SCENARIO OVERVIEW
End of Life Care and Breaking Bad News
Original Scenario Developer(s): University of Ottawa
Diane Alain, Susan Brajtman, Frances Boubonnais-Forthergill, Valérie Fiset,
Jeanne Falabi-Bakinde, Monique Maisonneuve.
Date - original scenario
March 2012
Validation:
October 2012 and October 2013
Revision Dates:
February 2014
Pilot testing:
October 2012
QSEN revision:
March 2014
Scenario Title:
Estimated Scenario Time:
20 minutes
Debriefing time:
20 to 30 minutes
Target group: 4th Year BScN
Core case: Hospice Palliative Care: End of Life for client dying at home
PRACTICE STANDARDS
QSEN Competencies
 Patient Safety
 Patient Centered Care
CNA

Position Statement: Providing Nursing Care at the End of Life (2008)
CNO

Practice Guideline: Guiding decisions in End of Life care (2009)
RNAO: Best Practice Guidelines
 End of Life Care During the Last Days and Hours (2011)
CHPCA

A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice
CASN
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
ALL DATA IN THIS SCENARIO IS FICTICIOUS
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
Entry-to-Practice Competencies and Indicators for Registered Nurses
Standardized Tools



Palliative Performance Scale (Community care Ontario CASN p.18)
SPIKES: 6 step strategy for delivering bad news (Baile et al. 2000, p.305-307)
Frommelt Attitude Toward Care of the Dying Scale (RNAO: Folmet, K. (1991) American Journal
Hospice Palliative Care (Vol. 8, Issue 5)p. 37-43
Brief Summary of Case
This is the part B of a two part unfolding scenario that can be used as a single, stand-alone scenario.
Case A: Palliative patient – admitted to the oncology unit from the ER with end stage lung cancer.
Case B: 55 year old male client is imminently dying of lung cancer with a Palliative Performance Scale (PPS).
of 10%. DNR assigned. Client chose to die at home. He is married and spouse is at the bedside. Client has 2
adult children and 3 grand-children who live out of town. One of which arrives at the home just after her/his
father passes away. Nurses must provide comfort measures to the dying client and support the spouse
during final breaths of life, in addition to breaking bad news to the child who arrives too late to say
goodbye.
EVIDENCE BASE / REFERENCES (APA Format)
Canadian Nurses Association (2013). Position Statement. Providing nursing care at the end of life. Retrieved
April 15, 2014, from
https://www.cna-aiic.ca/en/search-results?q=2013%20position%20statement
College of Nurses of Ontario (2009). Practice guideline. Guiding decisions about end-of-life care. (Nothing
more recent as of April 15, 2014)
Canadian Association of Schools of Nursing (2011). Palliative and End-of-Life Care Entry-to-Practice
Competencies and Indicators for Registered Nurses, Retrieved Feb 3, 20014 from:
http://www.casn.ca/en/Palliative_Care_122/items/4.html
Registered Nurses Association of Ontario: Best Practice Guidelines (2011) Retrieved Feb 14, 2014, from
http://rnao.ca/bpg/guidelines/endoflife-care-during-last-days-and-hours
Canadian Hospice Palliative Care Association retrieved Feb. 15, 2014 from
http://www.chpca.net/media/7422/a-model-to-guide-hospice-palliative-care-2002-urlupdateaugust2005.pdf
Charlton R, Dolman E. (1995) Bereavement: a protocol for primary care. Br J Gen Pract. 45(397):427-30
Casarett D, Kutner JS, Abrahm J. (2001). End-of-Life Care Consensus Panel. Life after death: a practical
approach to grief and bereavement. Ann Intern Med. 134(3): 208-15
Rando TA. (1998). Anticipatory grief: the term is a misnomer but the phenomenon exists. J Palliet Care. 4(12):70-3
Coyle N, Schachter S, Carver AC. (2001). Terminal care and bereavement, Neurol Clin. 19(4):1005-25
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
ALL DATA IN THIS SCENARIO IS FICTICIOUS
5
SECTION II: CURRICULUM INTEGRATION
A. SCENARIO LEARNING OBJECTIVES
Action verb
Content
Result
The student will use
relational and
communication skills
to support decisions of palliative and end-of-life
care on an ongoing basis.
The student will
integrate
knowledge of grief
and bereavement
to support others from a cross-cultural perspective
through an adaptive grieving process.
The student will
demonstrate
accurate assessment
with the focus on
pain.
personal attitudes
to provide adequate comfort measures to the
dying client.
The student will reflect
on
Competency
that may impact care of a dying patient and family
members.
Demonstrated Attributes
Uses relational
and therapeutic
communication
skills to support
end-of-life care
on an ongoing
basis.

Provides information and assurance to the patient and
family members regarding comfort measures during the
last minutes of living.

Communicates respectfully, empathetically and
compassionately with the PEOL patient and family
members by using appropriate and varied therapeutic
communication techniques.
Integrate
knowledge of
grief and
bereavement to
support others
from a crosscultural
perspective
through an
adaptive
grieving
process.

Accurately assesses and documents the patient’s and
family members’ needs related to loss, grief and
bereavement.

Identifies individuals experiencing, or at high risk of
experiencing, a complicated and/or disenfranchised grief
reaction, and discusses, documents and makes
appropriate referrals.

Uses insights gained from personal experiences of loss,
bereavement and grief to provide supportive care to
others.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
Needs
Improvement
Uses limited therapeutic
communication
techniques.
Choice of words is
inappropriate.
No assessment of family
members’ needs
No knowledge of the
grieving process
6

Identifies situations when personal beliefs, attitudes and
values result in limitations in the ability to be present for
the patient and family members experiencing loss, grief
and /or bereavement.

Demonstrates understanding of grief theories and their
application to PEOLC.

Demonstrates understanding of the common, normal
manifestations of grief (emotional, physical, cognitive,
behavioral, spiritual).

Demonstrates understanding in individual, social, cultural,
and spiritual variables that affect grief.

Provides guidance, support, and referrals to bereaved
family members and documents actions.

Listens, affirms, and responds empathetically and
compassionately to the patient and family members
working through the tasks of grief and bereavement.

Develops the capacity to be in the presence of patient and
family member’s suffering.
Demonstrate
accurate
assessment
with the focus
on pain to



provide
adequate
comfort
measures to the
dying client.
Identifies
personal
attitudes that
may impact
care of the
dying patient
and family
members.


Chooses appropriate medications/doses for comfort
Manages secretions appropriately
Provides proper interventions for changes in client’s
conditions
Limits unnecessary interventions
Continues to be caring and loving presence

Participates in the post simulation self-assessment activity

Contributes to the post simulation debriefing discussion
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
Assessment is
incomplete or
inaccurate and
implementation of
comfort measures is
absent.
Refuses to participate.
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C. PRE-SCENARIO LEARNER ACTIVITIES
Prerequisite Competencies
Skills/ Attitudes
Knowledge

Therapeutic communication skills

Respect and compassion

Stages of grieving: Anticipatory grieving
SPIKES 6 step process for delivering bad news
Dimensions of family centered care
Resources in the community about grieving
Signs and symptoms of imminent death

Assessment of dying patient

Palliative Performance Scale (PPS)

Interpret the scale




2. Review of Systems
Palliative Performance Scale (PPS) 10%
CNS
Cardiovascular
irregular heart rate; unstable BP
Pulmonary
crackles all lobes
Renal/Hepatic
decreased urine output, incontinence
Gastrointestinal
Constipation
Endocrine
N/A
Heme/Coag
N/A
Musculoskeletal
Bed-bound; weakness
Integument
Cool extremities; mottling on the arms and legs
Developmental Hx N/A
Psychiatric Hx
N/A
Social Hx
No drug use; retired construction worker; smoke 1 pack/day for 30 years but
stopped 5 years ago; married 30 years
Alternative/ Complementary Medicine Hx
N/A
3. Current
medications
Medication allergies:
Food/other allergies:
Drug
Hydromorphone
using CADD pump
Ondansetron
Haloperidol
Glycopyrrolate
NKDA
None
Reaction:
Reaction:
X
X
Dose
1 mg per hour
Route
SC
Frequency
Continuous
8 mg
2 mg
0.2 mg
IV or SC
IM
SC
PRN q12h if nausea
PRN q12h for agitation
PRN q4h SC if secretions
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
8
4. Laboratory, Diagnostic Study Results - N/A
Na:
Ca:
Hgb:
PT
ABG-pH:
VDRL:
K:
Mg:
Hct:
PTT
paO2:
GBS:
Cl:
Phos:
Plt:
INR
paCO2:
Herpes:
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
HCO3:
Glucose:
WBC:
Troponin:
HCO3/BE:
HIV:
BUN:
Cr:
HgA1C:
ABO Blood Type:
BNP:
SaO2:
Cxr:
EKG
9
SECTION III: SCENARIO SCRIPT
A.
Case summary
55 year old married man and father, has decided to die at home.
Spouse has power of attorney and is substitute decision maker.
Spouse at bedside and aware of imminent death; has called the children
The patient has lost weight and is experiencing general weakness, dyspnea, chronic cough, hemoptysis and
decreased urinary output.
Patient dies.
The child arrives too late to say good bye to father.
Student(s) must offer support to spouse and provide news of father’s death to the child as he/she arrives.
B. Key contextual details
Home environment. Pt is in a bedroom of the family house, dying. Room is dim and soft gospel music is playing.
Patient was in palliative care for 2 weeks on the Oncology Unit and has been home for 2 days now.
C. Scenario Cast
Patient/ Client
Family Members
M. Fisher
Mrs. Fisher
Child
High fidelity simulator
 Mid-level simulator
 Task trainer
 Hybrid (Blended simulator)
X Standardized patients (confederate/actor)
Brief Descriptor
Confederate/Actor (C/A) or Learner (L)
(Optional)
Dying client
High Fidelity Simulator
Spouse at the bedside
Actor
Arrive too late to say goodbye
Actor
Primary Nurse
Secondary Nurse
Clinical Instructor
Leads client care
Assists primary nurse
Resource person
Role
X
D.
Student Nurse
Student Nurse
Sim Facilitator
Patient/Client Profile
Last name:
Fisher
First name:
Mark
Gender: male
Age: 55
Ht: 6ft
Wt: 150 lbs
Code Status: DNR
Spiritual Practice:
Ethnicity:
Primary Language spoken:
Catholic
Caucasian
English and French
1. Past history
 He was diagnosed 15 months ago and received chemotherapy (Cisplatin and Etoposide) and some
thoracic radiation therapy.
 Was admitted to the oncology unit for cancer recurrence. The prognosis is poor.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
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

He stays at the hospital for 2 weeks during which, the client and his family have decided to honor his
wish to die at home.
The doctor has transferred the patient into palliative service with home care
Primary Medical Diagnosis
SCLC (small cell lung cancer)
2. Review of Systems
CNS
Cardiovascular
Pulmonary
Renal/Hepatic
Gastrointestinal
Endocrine
Heme/Coag
Musculoskeletal
Integument
Developmental Hx
Psychiatric Hx
Social Hx
GCS 7; terminal delirium: extreme restlessness and agitation
irregular heart rate; unstable BP (drops as death approaches)
crackles all lobes; cheyne-stokes respirations, increase secretions
decreased urine output, incontinence
Constipation
N/A
N/A
Confined to bed; weakness
Cool extremities and discoloured skin, mottling on the legs and arms
N/A
N/A
No drug use; retired factory worker; smoke 1 pack/day for 30 years but stopped 5 years
ago; married 30 years
Alternative/ Complementary Medicine Hx
N/A
3. Current
medications
Medication allergies:
Food/other allergies:
NKDA
None
Drug
Hydromorphone
using CADD pump
Ondansetron
Haloperidol
Glycopyrrolate
Reaction:
Reaction:
Dose
1 mg/ hour
8 mg
2 mg
0.2 mg
Route
SC
infusion
IV or SC
IM
SC
N/A
N/A
Frequency
Continuous
PRN q12h if nausea
PRN q12h for agitation
PRN q4h SC if secretions
4. Laboratory, Diagnostic Study Results: N/A
Na:
Ca:
Hgb:
PT
ABG-pH:
VDRL:
K:
Mg:
Hct:
PTT
paO2:
GBS:
Cl:
Phos:
Plt:
INR
paCO2:
Herpes:
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
HCO3:
Glucose:
WBC:
Troponin:
HCO3/BE:
HIV:
BUN:
Cr:
HgA1C:
ABO Blood Type:
BNP:
SaO2:
Cxr:
EKG
11
E. Baseline Simulator/Standardized Patient State
(This may vary from the baseline data provided to learners)
1. Initial physical appearance
Gender: Male
Attire: pajama or regular clothes
Alterations in appearance (moulage): client looks pale and has mottling on the arms and legs; no peripheral
IV, only Sub-Q sets are left in place for medication administration.
ID band present, accurate
ID band present, inaccurate
ID band absent or not applicable
Allergy band present, accurate
Allergy band inaccurate
Allergy band absent or N/A
2. Initial Vital Signs Monitor display in simulation action room:
X No monitor display
Monitor on, but no data displayed
Program High Fidelity Simulator to reflect the following:
BP: systolic 60,
HR: 130, irregular; RR: 8 with
T:
period of apnea;
then 40 after 3
palpable
CVP: N/A
AIRWAY: none
Lungs:
Sounds/mechanics
Heart:
min and absent 5
min later when
patient dies
after 3 min and
absent 5
minutes later
when patient
dies
PAS: N/A
ETC0²: N/A
Left: rales
PAD: N/A
FHR: N/A
Right: rales
Monitor on, standard display
SpO²: None detected
PCWP: N/A
Sounds:
ECG rhythm: irregular
Other:
Bowel sounds: Diminished
CO: N/A
Other: patient’s eyes are closed; he
moans from time to time; becomes
silent few minutes before death
3. Initial Intravenous line set up
Saline lock
#1
IV #1
Main
Piggyback
IV #2
Main
Piggyback
Site:
N/A
IV patent (Y/N)
Site:
N/A
Fluid type: N/A
Initial
rate:
N/A
IV patent (Y/N)
Site:
N/A
Fluid type: N/A
Initial
rate:
N/A
IV patent (Y/N)
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
12
X
Sub-Q –Set:
for infusion
100mg Hydromorphone
in 100ml 0.9 NaCl via
CADD pump
For PRN medications
Site:
abdomen
Initial
rate:
1mg/hour
continuous
Patent: Yes
Sub-Q set for Abdomen,
PRN meds.
arm or leg
4. Initial Non-invasive monitors set up
X
NIBP: N/A
ECG First lead:N/A
Pulse oximeter: N/A
Temp monitor/type: N/A
5. Initial Hemodynamic monitors set up
A-line Site:
Catheter/tubing Patency (Y/N)
6. Other monitors/devices
Foley catheter-N/A
Amount: N/A
ECG Second lead: N/A
Other:
CVP Site:
PAC Site:
Appearance of urine:
Epidural catheter:
Infusion pump: CADD pump
N/A
Fetal Heart rate monitor/tocometer: N/A
Pump settings:
1mg/hr
Internal
External
Environment, Equipment, Essential props
Recommend standardized set ups for each commonly simulated environment
1. Scenario setting: (example: patient room, home, ED, lobby)
Room of a house; bed, pillows, chairs, soft spiritual (gospel) music.
Wife at bedside.
Sim man in bed in semi-fowlers position.
2. Equipment, supplies, monitors
(In simulation action room or available in adjacent core storage rooms)
X CADD administration X SUB-Q-SET:
X CADD Pump
set
Bedpan/ Urinal
IV Infusion pump
Nasogastric tube
Defibrillator
PCA infusion pump
X
IV fluid
Type:
100 ml 0.9%
NaCl (normal
saline)
Foley catheter kit
Feeding pump
ETT suction catheters
Code Cart
Epidural infusion
pump
IV fluid additives:
subcutaneous infusion
set
Straight cath. Kit
Pressure bag
Oral suction catheters
12-lead ECG
Central line Insertion
Kit
100 mg
Hydromorphone
(Hydromorphone 100mg
X
X Sub-Q-Set for PRN
meds
X
Incentive spirometer
Portable suction
Chest tube kit
Chest tube equip
Dressing ∆
equipment
Blood product
ABO Type:
# of units:
mixed in 100ml 0.9%
NaCl)
3. Respiratory therapy equipment/devices
X Nasal cannula
Face tent:
BVM/Ambu bag
Nebulizer tx kit
Simple Face Mask:
Non re-breather mask
Flowmeters (extra supply)
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
13
4. Documentation and Order Forms
X Health Care
X Med Admin
Provider orders
Record
X Progress Notes
Graphic record
X
Medication
Transfer orders
reconciliation
Nurses’ Notes
Dx test reports
Actual medical record binder, constructed
per institutional guidelines
5. Medications (to be available in sim action room)
# Medication
Dosage
Route
Hydromorphone:
1
mg/hr
SC
1
2
3
100mg in 100ml
0.9% NaCl
Ondansetron
4mg/2ml vials
Glycopyrrolate
200mcg (0.2
mg/ml vials
continuous
1mg q 12 hr
SC PRN
0.2 mg
SC PRN
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
H&P
Lab Results
Anesthesia/PACU
record
Standing (protocol)
orders
Code Record
Other
Describe:
ED Record
#
Medication
4
Haloperidol
5mg/ml vials
ICU flow sheet
Prenatal record
Dosage
2 mg
Route
IM PRN
14
CASE FLOW / TRIGGERS/ SCENARIO DEVELOPMENT STATES
Initiation of Scenario :
Client (Clt) is in bed and has Cheyne-stokes breathing with periods of apnea. Clt. has limited response and spouse is at the bedside
with nurse(s). Nurse has been involved in family centered care since client arrived home and therefore a rapport has been
established previously.
STATE / PATIENT STATUS
1. Baseline
DESIRED LEARNER ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
Operator:
Learner Actions
Client is in low Fowler’s position,
has Cheyne-stokes breathing with
periods of apnea. Clt. has limited
response (only occasional light
moans if attempting to respond to
voices. Spouse is at bedside.
Facilitator will gradually decrease
rate of breathing from 8-0/min
over a period of 8 minutes.
HR: 130, irregular; then 40 after 3
min and absent 8 min later when
patient dies.
Triggers:
Spouse needs reassurance that
client still feels no pain.
Spouse is unsure about the
irregular breathing that is
occurring.
RR: 8, with periods of apnea and
absent after 8 minutes when
patient dies.
Assesses signs of no pain and checks
CADD pump.
Debriefing Points:
Signs and symptoms of imminent death
as per RNAO guidelines.
Communicates to spouse that patient is
comfortable.
Explain to the spouse that Cheynestokes breathing is normal at this stage
and indicates the end is near.
Support the patient in letting go.
Ask the spouse if there are any rituals,
prayers or customs to participate in.
CADD Pump at bedside and
Hydromorphone 1mg/hr is infusing
STATE / PATIENT STATUS
2. Death
DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
Triggers:
Learner Actions:
Nurse pronounces the client dead.
Spouse demonstrates some
apprehension about patient’s last
breath and looks to the nurse for
reassurance.
Nurse remains present with
spouse at bedside.
Confirms that client has passed.
Notes the time of pronouncing death to
later document.
Expresses words of compassion to
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
Debriefing Points:
How does being present feel for the
nurse?
15
Spouse is crying
STATE / PATIENT STATUS
3. Breaking bad news
Child arrives to the house and is
met at the entrance by the nurse
in order for her to notify the child
that the parent has already
passed away a few minutes ago.
Child remains with unresolved
disappointment.
Spouse is concerned about
children not being present but
asks the nurse to greet them at
the door to warn them before
entering the room.
spouse.
Closes patient’s eyes and asks spouse
for permission to place arms in crossed
position over chest.
DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
Triggers:
Learner Actions:
SPIKES:
Child is still hopeful that he/she
Sets the stage to communicate bad
has arrived on time.
news to the child.
Asks what was communicated when
Asks “how is he? Will he know
his/her mother called to notify of
that I’m here?”
imminent death.
Give news that father has passed away
Child expresses need for saying
peacefully.
good bye before his passing.
Observe emotions and make a
connecting statement such as : “ I am
sorry about not arriving on time. I know
this is not what you wanted.”
Child asks to be alone with
mother and father. Stays for a
couple of minutes and then
comes to the nurse and
expresses disappointment with
timing, that he/she did not have
a chance to say goodbye.
Scenario End Point: Spouse and child are left alone at the bedside to pray.
Suggestions to decrease complexity:
Suggestions to increase complexity:
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
UNIVERSITY OF OTTAWA: End of Life Care-Breaking Bad News
Leaves the room to allow time for the
family with the deceased.
Nurse remains nearby.
Debriefing Points:
Application of SPIKES framework for
communicating bad news.
16
APPENDIX A: HEALTH CARE PROVIDER ORDERS
Patient Name: Fisher, Mark
DOB: 1958-10-01
Age: 55
MRN: 24516789
 No Known Allergies
 Allergies & Sensitivities
Date
Time
2 days
ago
10:00
Diagnosis: Small Cell Lung Cancer (SCLC)
HEALTH CARE PROVIDER ORDERS AND SIGNATURE
Initiate Hydromorphone (Dilaudid) SC infusion using CADD pump: 1 mg/hr SC
continuous infusion
Hydromorphone 1mg SC PRN q 1hr for breakthrough pains (bolus via CADD
pump)
Odansetron 8mg q 12hr IV/SC PRN if nausea
Glycopyrrolate 0.2 mg q 4hr SC PRN if secretions
Haloperidol 2mg q 12hr IM PRN if agitated
Call Physician if prescribed pain medication dosage does not relieve client’s
pain
Signature
France Quirran, MD
Tel: 613-562-5800
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APPENDIX B: Digital images of manikin and/or scenario milieu
Insert digital photo here
Insertdigital
digitalphoto
photohere
of initial
Insert
scenario set up here
Insert digital photo here
Insert digital photo here
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APPENDIX C: DEBRIEFING GUIDE
CASN
Competencies
Debriefing Materials
Objectives
Debriefing
Questions
Frommelt Attitude
Toward Care of the Dying
Scale
Sample Questions for Debriefing
Identifies personal attitudes that may impact care of the dying patient and family members.
In developing a greater awareness of our attitude toward caring for dying patients, take a few moments to
complete the “Frommelt Attitude Toward Care of the Dying Scale” as a self-assessment.
1. What did you learn about yourself by participating in or observing this simulation and in completing
the self-assessment?
2. Are there any personal attitudes, beliefs, or values that may result in limitations in providing care and
in your ability to be present for the patient and family?
Competency: Integrates knowledge of grief and bereavement to support others from a cross-cultural
perspective through an adaptive grieving process.
1. Did you feel you had adequate knowledge of grief and bereavement in order to support the family
members in this scenario?
2. What cultural considerations came into play as support was provided to the patient or family
members?
Competency: Uses requisite relational and therapeutic communication skills to support decisions of
palliative and end-of-life care on an ongoing basis.
1. Which relational skills were you able to apply effectively and how would you have otherwise
improved in this area?
2. How did effective or ineffective communication skills support or deter from using relational
skills?
3. In light of the home-care environment, how confident where you in identifying services
needed for the patient after death and for the child who arrived too late to say good-bye.
Competency: Demonstrate accurate assessment with the focus on pain to provide adequate comfort
measures to the dying client.
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1. Did you feel you had adequate knowledge and skill to accurately assess the patient’s pain
control?
2. Why is this important to a dying patient?
Interprofessional Competencies to consider for debriefing scenarios
Role Clarification
Interprofessional Teamwork Functioning
X Patient/Family /Client? Community
Collaborative Leadership
centered care
Interprofessional Communication
Sample Questions for Debriefing
University of Ottawa: End of Life Care-Breaking Bad News- February 2014
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APPENDIX D: INSTRUCTIONS TO STANDARDIZED PATIENTS AND PARTICIPANTS
I. Instructions to Participants:
Mrs. Fischer is at the bedside of her husband who is dying of lung cancer. He was hospitalized
for 5 days and returned home once the doctor changed his status to palliative. He has now
been home for 2 days. She is very close to her husband and this is and has been very difficult
for her. She is his power of attorney and substitute decision maker (make the decisions about
care) for her husband. She is 55 years old and they have been married for 30 years and like to
travel to see their children and grandchildren who live out of town. She is concerned about
what is happening with her husband and is often tearful. She has questions about his care and
why things are happening so fast.
University of Ottawa: End of Life Care-Breaking Bad News- February 2014
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APPENDIX D: Instructions to Standardized Patients and Participants (Continued)
II. Instructions to Mrs. Fisher
You are Mr. Fisher’s wife. Your husband is dying of lung cancer. He was hospitalized for 5 days
and returned home once the doctor changed his status to palliative. He has now been home for
2 days. You are very close to your husband and this is very difficult for you. You are the power
of attorney and substitute decision maker (make the decisions about care) for your husband.
You are 55 years old and have been married for 30 years and travel to see your children and
grandchildren. You are concerned about what is happening with your husband and are tearful.
You have questions about his care and why things are happening certain ways. You are scared
to touch him and you do not know if you have to call your children because you are wandering
how long he will be like this.
The Current Situation:
It is currently 10 am at home. You are at your husband’s bedside. Your husband is
deteriorating but you are not sure what is happening. You ask questions about the sounds
and behaviors of your husband. You want the nurse to support you and communicate
effectively that support to you.
PROMPT 1 (immediately):
Touching mannequins arm gently saying “I am here for you Mark” Ask students “is he in pain.”
Ask mannequin “Honey, are you in pain?”
PROMPT 2 (by 3-4 minutes):
Your husband’s breathing will be more difficult ask the nurse “What is happening?” “Why is he
breathing like that and he sounds congested… do we need to sit him up more?” Be concerned
but not loud. State “He is so pale.” “Why is he not answering me?”
PROMPT 3 (by 5-6 minutes):
“I noticed he is picking at the sheets. He is so restless... Is that normal? Is he okay?” Is this it”
Tearful but not loud or over the top.
PROMPT 4 (by 6-10 minutes):
“Is he going to die now?” “What should I do?” ”Should I call my children?” ”My daughter is on
her way here”
PROMPT 5
Client dies. “Is he gone now?” “What do I do next?” “Why did this have to happen to him?”
Crying softly.
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PROMPT 5 (end)
Your daughter arrives at the house 10 min after you called her.
You said to her, crying softly: “he is gone; he is gone now and I don’t know what to do; I feel so
lost”
You hug your daughter and you both sit down and cry quietly.
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APPENDIX D: Instructions to Standardized Patients and Participants (Cont)
III. Instructions to the Daughter
You arrive at your parents’ house, just 10 minutes after your mother called you. You were met
at the door by the nurse.
PROMPT 1 (immediately)
You ask the nurse:
“What is going on?” “Where is my mom?” “How is he? Will he know that I’m here?”
If the nurse does not say anything, ask:
“Is my dad……gone?”
You rushed to your father’s bedside and your mother is sitting crying and another studentnurse is at the bedside comforting her.
PROMPT 2: (at your father’s bedside)
“Oh Mom, he is gone!” “I did not even have a chance to say a final goodbye!” “I tried to get
here as fast as I could and as soon as you called me Mom!”
You cry and hug your mom, you feel horrible because your father died and you were not there
during the last minutes of his life.
PROMPT 3:
“I didn’t know it was going to happen so quickly?” “I was already on my way here when Mom
called” “I feel so bad because I was not able to be here when my Dad took his last breath” “I
wanted be with him and to tell him how much I love him one more time”
“I feel horrible” “What do we do now?”
You both cry softly, looking at the student-nurses for answers.
PROMPT 4 (end of scenario):
“What do we do now?” “When do we call Kelly’s Funeral Home?”
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APPENDIX E: DO NOT RESCUSCITATE ORDER FORM
APPENDIX F: MEDICATION ADMINISTRATION RECORD
APPENDIX G: FROMMELT ATTITUDE TOWARD CARE OF THE DYING SCALE (SEE RNAO BPG EOL
CARE)
APPENDIX H: PALLIATIVE PERFORMANCE SCALE (Version 2)
University of Ottawa: End of Life Care-Breaking Bad News- February 2014