335CHAPTER 28
End-of-Life Scenario With Limited-English-Proficiency Patients
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
The introduction and discussion of end-of-life concepts are easily incorporated into lectures and clinical conferences. The actual experience of caring for a dying patient, or one who has died, may not actually occur during the students’ academic tenure. Providing a simulation scenario that enables each student to experience a patient death and then be able to discuss their thoughts and feelings is essential to providing the best nursing education has to offer.
Considering the use of International Nursing Association for Clinical Simulation and Learning (INACSL) “Standards of Best Practice: SimulationSM” (INACSL, 2013/2016), a needs assessment should be done. The needs assessment identifies gaps in the curricula that may exist related to the content of dying and death. A deeper delve into the gap guides the design of the simulation-based education (SBE) activity. This also guides the level of fidelity within the simulation as well.
This simulation scenario is based on the fact that in every health care setting and in every patient population, death can occur. Even happy environments, such as labor and delivery and the newborn nursery, have the occasional death of a mother, baby, or both. Each nurse must accept that at some point in their career the nurse will be faced with the loss of a patient through death. Creating a caring and empathetic environment via simulation can assist students to identify areas they personally need to develop (Díaz, Maruca, Kuhnly, Jeffries, & Grabon, 2015). It is essential that at some point during a nurse’s education, end-of-life concepts are introduced, discussed, and, we hope, experienced.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
In a hospital or acute care setting that is dedicated to an end-of-life patient, there is an importance for it to resemble a home environment. Moulage or props should be included in the environment that make it appear more comfortable and home-like. It is relatively easy to add homemade blankets and pillows to accent the environment for a realistic feel. A radio or television is useful to promote a soothing environment.
336C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Program objectives include the following:
1. Comparing and contrasting advanced directives and do not resuscitate orders (DNR)
2. Identifying important report information
3. Therapeutic communication with distraught family members
4. Postmortem care
In addition, critical thinking when entering an acute care end-of-life/hospice room is essential. Students must use all senses to assess the atmosphere, which may be charged with emotions such as anxiety, anger, or fear on the part of the patient and/or family members. Many learners are unfamiliar with the process of caring for a patient who is actively dying.
This simulation has been used with prelicensure baccalaureate students in traditional and accelerated nursing programs in an attempt to raise awareness of patient and family needs during the transition period at the end of life. Group discussion and vicarious learning are key to engaging learners.
This scenario helps to address many National Council Licensure Exam (NCLEX®) identified areas of learning, including, but not limited to error prevention, end-of-life care, collaboration with interdisciplinary team, advanced directive, loss, and grief.
D. INTRODUCTION OF SCENARIO
Ms. Garcia, 54, was admitted into the acute care setting to the hospice room again yesterday with uncontrolled pain and the inability to care for herself. She has a history of stage IV cervical cancer, diagnosed 10 months ago, and has recently experienced progression of her disease while on chemotherapy. She seems to be giving up, she’s tired and in pain. Her children, although not happy, understand she is suffering and does not want to go on. Her cousin, on the other hand, believes Ms. Garcia needs to fight to stay alive.
This simulation takes place in a typical hospice room in an acute care setting. The simulation lasts approximately 15 minutes. It may be a little longer or shorter. Remember, the facilitator/instructor and the observer are not allowed to talk to the group during the simulation unless specified on the role play instructions.
The human patient simulator (HPS) or confederate is lying in the bed and is nonverbal. This may also be a student role. The radio is playing spiritual music quietly. The patient’s head is turned to face the music. There is a Welcome to Hospice packet near the bedside. The room includes an intravenous (IV) pole and pump, chair for a visitor, and a bedside table. Added realism includes a robotic stuffed animal as a pet on the bed with the patient.
E. RUNNING OF THE SCENARIO
The scenario is meant to be a hybrid, with use of role play and the simulator. The objectives for the learners are the same if used as a regular scenario. The goal is for the learners to understand the complexities of caring for an end-of-life patient within a family dynamic. It is important to keep in mind the facilitator role within each type of application of this scenario. The facilitator should be cognizant of the type of scenario and the potential emotions that may be elicited with an end of life patient. Criterion II: Simulation Best Practice Facilitation (Franklin et al., 2013) encourages the use of cues and discussion before the 337simulation. For a realistic and meaningful experience, it is imperative that the participants understand the role they are assigned and their level of active engagement. A participant who overly engages in the role assigned hinders the learning environment for other participants.
Simulation role assignment includes the possibility of eight student participants. This facilitates an entire clinical group. The scenario has roles for eight students but can fit for more or less as necessary. A simple way to assign roles is to cut the simulation role page into individual slips and have each student randomly pick one slip that will be his or her scenario role. Students may share only their role title: float nurse, aide, and so on. No other information about the specific role should be shared. The facilitator should allow participants to practice as they would in a live situation.
During the simulation, the facilitator/instructor ideally does not speak to the students. Best practice related to running the scenario (Standards of Best Practice: Facilitator IV) encourages the simulation to continue and be minimally interrupted (Franklin et al., 2013). If necessary, a yes or no answer may be enough to keep the scenario moving forward. When the facilitator/instructor thinks the scenario objectives have been met, usually after 15 minutes, the facilitator will call out, “The simulation has ended” so that all participants know to stop their role-playing. If participants have not met the scenario objectives after 15 minutes or so, the simulation needs to come to a stop. If participants take the simulation off course, the facilitator/instructor may need to stop the scenario and let the participants regroup. This can then be used as part of the debriefing/discussion.
Debrief/discussion as a group should always begin with a positive comment to the participants: “You did fine.” “You picked up on some missing elements.” “Exhale, I know that can be a tough scenario.”
F. PRESENTATION OF COMPLETED TEMPLATE
Title
End-of-Life: The Acute Care Setting
Scenario Level
Nursing: Prelicensure, accelerated degree, degree completion
Focus Area
Medical–Surgical/Hospice
Scenario Description
Ms. Garcia, 54, was admitted again yesterday with uncontrolled pain and inability to care for herself. History of stage IV cervical cancer, diagnosed 10 months ago, recently experienced progression of her disease while on chemotherapy. She states she is giving up; she’s tired and in pain. Her kids are on board, not happy but understand she is suffering. Her cousin, on the other hand, believes Ms. Garcia needs to fight to stay alive.
Ms. Garcia had a total abdominal hysterectomy (TAH), bilateral salpingo-ophorectomy (BSO), and lymph node dissection (LND) followed by four cycles of chemotherapy with progression of her disease. Chemotherapy drugs were changed; she had two cycles with progression of her disease.
Ms. Garcia has been an administrative assistant for the last 20 years. She has never married. She does have three adult children living in the state. She lives alone and had been very social at the local center. She has smoked one pack of cigarettes per day for 25 years and drinks three to four glasses of wine per week.
338Scenario Objectives
In accordance with Criterion 3 of Standards of Best Practice: Participant Objective III (Lioce et al., 2013), it is important to keep the simulation within the overall program objectives. A more global view of program objectives includes the national exam. One area of specific objectives for this simulation is taken from the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan categories (National Council of State Boards of Nursing, 2015).
This end-of-life simulation includes the following NCLEX-RN test categories:
Safe and effective care environment: (advance directives, ethical practice, legal rights and responsibilities, collaboration with interdisciplinary team, continuity of care), Safety and infection control: (error prevention), Psychosocial integrity: (end-of-life care, grief and loss, support systems, therapeutic communications), Physiologic integrity: (palliative/comfort care), Pharmacological and parenteral therapies: (parenteral/intravenous therapies, pharmacological pain management, expected effects/outcomes).
Setting the Scene
Equipment Needed
Throw blanket, throw pillows, local newspaper and/or magazine, coffee mug, and pictures or framed picture with HPS next to bedside.
Participant Roles
Simulation roles (eight roles)
Primary RN: Ms. Garcia (54 years old) is well known to you as she has been in and out of the hospital and palliative care unit five times in the past 4 months. This is the worst you have seen her. During her previous admissions, she has spoken to you about how she is ready to go to heaven. The pain and chemotherapy have made her miserable. She is tired and wants relief. She has made her wishes known to her children; her cousin is the person who does not want her to die and thinks Ms. Garcia should have more surgery and a new kind of chemotherapy.
You went on your lunch break reporting to the float RN, as you return to the unit you see people running into Ms. Garcia’s room. You know of Ms. Garcia’s wishes and the do not resuscitate (DNR) order in the chart.
Float RN: The primary nurse reported to you because she is going to lunch. You do not really know Ms. Garcia except that she has widespread cervical cancer and has a morphine drip for pain control. You are called to Ms. Garcia’s room by loud screaming from her visitor. You find the patient without pulse or respirations. You call a code and begin cardiopulmonary resuscitation (CPR). The patient’s visitor encourages you to do CPR; “Maria is not ready to die,” the visitor says.
Cousin: You are heartbroken that your cousin is … well, very sick (you do not accept the fact that she cannot be cured of her widespread cervical cancer). You are visiting and your cousin stops breathing. You FREAK OUT and scream for HELP. When help arrives you say: “Keep her alive, she is not ready to die! Help! Help! Help her!” and “Do CPR; save her!” You want to stay in the room as the health care team arrives.
Recorder: You are to take notes on the sequence of events. You may not say anything to the students in the “roles” or direct them in any way. Your notes do not have to be neat and you are not graded on spelling, grammar, and so forth. We just want a record of the events.
Code Team: There are two of you who respond to the “Code Blue” in this room. You run into the room and cannot understand why the visitor is still in the room. You are yelling for the chart and want a history from the float RN about this patient. You ask the float nurse about diagnosis, allergies, code status, primary physician, vital signs, and so forth.
339Hospital Chaplin: You were visiting another patient when you heard the scream from Ms. Garcia’s room. You see everyone running into the room and go in to see whether you can help in any way. You see the patient’s cousin (she is screaming and distraught) and realize the patient has died, but the code team is there. You approach the cousin and try to offer comfort.
Nursing Assistant: You were in the room (straightening the sheets) with the patient and her cousin when the patient stopped breathing. You do not know what to do, this is only your first week on the job. Your anxiety gets the better of you and you say: “Save her, save her,” and wring your hands saying again and again: “SAVE HER, SAVE HER.”
Scenario Implementation
Expected/Required Student Assessments/Actions
Students will:
__Demonstrate proper patient identification.
__Demonstrate RN to RN report that may have lacked detail regarding DNR status.
__Synthesize documentation to properly distinguish living will status and code status.
__Collaborate with family for proper care considerations.
__Discuss postmortem care.
__Discuss the role of chaplain and what to do with the frantic family member.
Instructor Interventions
The instructor or facilitator should not intervene if possible. The students should be briefed as to the roles before the start of simulation.
__Collaboration with health care team members, therapeutic communication, and critical elements was demonstrated.
__Proper hand hygiene used within the home.
__Patient was properly identified.
__DNR orders were properly identified and adhered to.
__Therapeutic communication with families that are not coping well was demonstrated.
__Health assessment were demonstrated within the scenario.
__Simulation ends when the DNR order is found and CPR ends or 15 to 20 minutes has lapsed
G. DEBRIEFING GUIDELINES
As debriefing after simulation is a vital part of the learning process, specific questions for discussion are included. However, it is recognized that the debriefing process is dynamic and fluid, and other areas of discussion may be brought up by the student participants and/or the simulation leader. This end-of-life scenario includes the following as a guideline for debriefing:
1. How did you feel entering the room?
2. Why do you think this happened?
3. How could some/any of this been prevented from happening?
4. What is the role of a DNR/allow natural death (AND) order?
5. What is the role of advanced directives?
6. Does an individual need both or just one?
7. How can the nurse/health care worker help a distraught family member? What actions can be taken?
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