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Elderly End of Life Care

An 89-year-old patient is brought into emerge by ambulance from their nursing home. Staff found her unresponsive and hypotensive at morning handover. Learners should identify severe sepsis and realize that critical care interventions may be inappropriate. One of the patient's family members will arrive. This should prompt a goals of care discussion, including the potential for initiating end-of-life care.

Goals and Learning Objectives

Technical/Equipment Recommendations

Supporting Roles and Scripts - Patient's Granddaughter Essential

Role	Description (Role, Behaviour, Key Moments, Script)
Patient	You are essentially moribund for this scenario. You have very cool peripheries (as demonstrated with ice) and look grey and ashen. Your mouth is wide open and your eyes are staring into space. You are breathing comfortably with an occasional mild cough. You may be provided with oxygen, and/or IV fluids started. They may put your legs up and tilt the head of the bed down.
Patient's Granddaughter	Background: You received a call from the home that your grandmother was very unwell and had been taken to hospital. You have power of attorney, and kind of knew this day would come as it’s been a rocky past 6 months with her. She has been going downhill fast at the nursing home and no longer recognizes any of the family. She is intermittently aggressive and for the last week she hasn’t been eating or drinking anything. No one has ever brought up her end-of-life wishes with you before, but in the back of your mind you did realize that she might die soon. The GP said she had a urinary tract infection when he visited a couple of days ago and seemed to think that this is the reason she was off her food and prescribed some antibiotics. Stage 2: Participants will be undertaking an initial assessment recognizing the severity of the patient’s condition. They will seek information from you, notes and other sources to determine cause and likely prognosis. Ideally, they will quickly engage in a discussion regarding the patients end of life wishes. End of Life Discussion: You really want to have this discussion at the patient bedside. You are a little surprised that the doctors seem to think the end is so near. You are relieved but kind of guilty that you are feeling relieved that she might die. You don’t want her to suffer and feel bad about just ‘letting her die’. You ask if there is anything that can be done. If participants attempt active management you say "she wouldn't have wanted all this" If the doctors ask what they think she would have wanted you are very clear that she would like to die peacefully and would not want any life support/ICU/ventilation or CPR. If the doctors ask “what do you want us to do” you are less clear and suggest that you do want things done if they will help her. The conversation ends with a plan to complete an “Allow Natural Death” Plan (also known as comfort care) to reflect and respect the wishes of the patient end of life care.
ED RN	Act as a normal ED RN, providing initial handover and assisting with bedside care of the patient. Stage 2: If participants continue to attempt active management you say "I think you better talk with the family member, it seems like she is really uncomfortable with what we are doing here"

Moulage and Scenario Set-Up

Printable Supporting Documents (Will also be accessible at relevant Scenario Stage)

Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.

Credits:
Original Authors: Prof. Victoria Brazil, Dr. Nemat Alsaba, Dr. Rebecca Shaw
Date: 2018
Originally published on: EM Sim Cases
Most Recent Modification: July 2021
Modified by: Mateo Orrantia

Prebriefing

A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it^1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information^1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.

Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective^2-4, and establish and maintain the simulation as a safe space for learning^1,4,5.

Prebrief Guide (Sample Phrases in Italics)

Welcome and Introduction

Orient to Basic Logistics

Clarify Objectives

Review the Evaluation Structure for the Day

Clarify Expectations

This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.

Establish Confidentiality

Establish the Fiction Contract

Explain and Assign Roles

Go over Logistical Details

Orient to the Environment

Ask for questions!

References

1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.

2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004

3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.

4. INACSL Standards Committee (2016, December). INACSL standards of best practice: Simulation^SMFacilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.

5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.

Case Briefing

The charge nurse informs you: The charge nurse informs you “I just put a very unwell looking patient into resus. She’s from a nursing home facility and the paramedics think she is septic. She’s hypotensive and barely responsive. Honestly, she looks like she might be dying. Her granddaughter is on her way. I don’t think she has a known advanced care directive or code status.”

Patient Chart
Patient Name: Sandra Thompson			Age: 89		Gender: F		Weight: 55kg
Presenting complaint: Found unresponsive and hypotensive at nursing home morning rounds
Temp: 35.1^oC	HR: 90	BP: 62/40		RR: 28		O₂Sat: 86% RA		FiO₂:
Cap glucose: 2.1mmol/L				GCS: 12 (E4 V2 M6)
Triage Note: Unresponsive and hypotensive at nursing home. Previously treated for UTI by GP over the last few days.
Allergies: NKDA
Past Medical History: Hypertension Osteoperosis and previous L wrist fracture UTI Depression				Current Medications: Acetaminophen Citalopram Amlodipine Amitriptyline at night

Extra Patient Information (Further History + Physical Exam)

Physical Exam
Cardio: Normal heart sounds. Wide complex rhythm on ECG.	Neuro: Lethargic and moaning. PEARL 3mm
Resp.: Shallow respirations w/ decreased entry to the right base with inspiratory crackles	Head & Neck: Nil
Abdo: Soft and non-tender. BS present	MSK/Skin: Nil
Other: Nil

Patient Chart

The charge nurse informs you: The charge nurse informs you “I just put a very unwell looking patient into resus. She’s from a nursing home facility and the paramedics think she is septic. She’s hypotensive and barely responsive. Honestly, she looks like she might be dying. Her granddaughter is on her way. I don’t think she has a known advanced care directive or code status.”

Patient Chart
Patient Name: Sandra Thompson			Age: 89		Gender: F		Weight: 55kg
Presenting complaint: Found unresponsive and hypotensive at nursing home morning rounds
Temp: 35.1^oC	HR: 90	BP: 62/40		RR: 28		O₂Sat: 86% RA		FiO₂:
Cap glucose: 2.1mmol/L				GCS: 12 (E4 V2 M6)
Triage Note: Unresponsive and hypotensive at nursing home. Previously treated for UTI by GP over the last few days.
Allergies: NKDA
Past Medical History: Hypertension Osteoperosis and previous L wrist fracture UTI Depression				Current Medications: Acetaminophen Citalopram Amlodipine Amitriptyline at night

1. Baseline State

Patient is drowsy and moaning, with cool peripheries.

Patient State/Vitals
Rhythm: Sinus, broad complex	HR: 90	BP: 62/40	RR: 28
O₂SAT: 86%	T: 35.1^oC	GCS: 12

Expected Learner Actions	Modifiers	Triggers
Collateral history and examinations Apply monitors Ask about code/DNR status Attempt to speak to family (Establish POA) ECG, CXR, Labs incl. critical VBG Check glucose (2.6) May give IV fluids, O2, dextrose, calcium gluconate	O2 applied ⇒ O₂SAT 89% Dextrose ⇒ Gluc. 8.2	All actions complete ⇒ ED RN prompts that relative has arrived ⇒ 2. Worsening Hemodynamics 5 minutes ⇒ ED RN prompts that relative has arrived ⇒ 2. Worsening Hemodynamics

Expected Learner Actions

Modifiers

Triggers

Collateral history and examinations
Apply monitors
Ask about code/DNR status
Attempt to speak to family (Establish POA)
ECG, CXR, Labs incl. critical VBG
Check glucose (2.6)
May give IV fluids, O2, dextrose, calcium gluconate

O2 applied ⇒ O₂SAT 89%

Dextrose ⇒ Gluc. 8.2

All actions complete ⇒ ED RN prompts
that relative has arrived ⇒ 2. Worsening Hemodynamics

5 minutes ⇒ ED RN prompts that relative has
arrived ⇒ 2. Worsening Hemodynamics

Further History and Physical Exam Results

Physical Exam
Cardio: Normal heart sounds. Wide complex rhythm on ECG.	Neuro: Lethargic and moaning. PEARL 3mm
Resp.: Shallow respirations w/ decreased entry to the right base with inspiratory crackles	Head & Neck: Nil
Abdo: Soft and non-tender. BS present	MSK/Skin: Nil
Other: Nil

ECG Results w/ Facilitator Notes

CXR Results w/ Facilitator Notes

Lab Results w/ Facilitator Notes

CXR

ECG

Lab Results

Sandra Thompson


MRN: 1234-567-890		Age: 89
Complete Blood Count

WBC	15.1	x10⁹L	H
Hgb	120	g/L	L
Plt	150	x10⁹L
Electrolytes

Na	129	mmol/L	L
K	7.8	mmol/L	H
HCO₃	13	mmol/L	L
Cl	104	mmol/L
Urea	15.3	mmol/L	H
Cr	259	µmol/L	H
Glucose	2.2	mmol/L	L
Venous Blood Gas
pH	7.1		L
pCO₂	61	mmHg	H
PO₂	70	mmHg	H
HCO₃	13	mmol/L	L
Lactate	9	mmol/L	H

Patient Vitals

Patient State/Vitals
Rhythm: Sinus, broad complex	HR: 90	BP: 62/40	RR: 28
O₂SAT: 86%	T: 35.1^oC	GCS: 12

2. Worsening Hemodynamics

Patient in similar state to previous, but slowly declining.

Patient State/Vitals
Rhythm: Sinus, wide complex	HR: 72 (↓)	BP: 60/40 (↓)	RR: 10 (↓)
O₂SAT: 82% (↓)	T: 35.1^oC	GCS: 12

Expected Learner Actions	Modifiers	Triggers
End of life discussion with family member/ substitute decision maker Call social worker	No Modifiers for this Stage	Adequate discussion with family member completed ⇒ 3. End of Life Care Planning

Patient Vitals

Patient State/Vitals
Rhythm: Sinus, wide complex	HR: 72 (↓)	BP: 60/40 (↓)	RR: 10 (↓)
O₂SAT: 82% (↓)	T: 35.1^oC	GCS: 12

SPIKES Framework

S	Setting Up	Arrange for privacy Involve significant others, sit down, establish rapport, manage time constraints and interruptions	What time would suit you and your family members to chat about your results?
P	Perception of condition/seriousness	Determine what they know Listen to their level of comprehension, accept denial but do not confront at this stage	Explain to me what you understand about your test/results?
I	Invitation from the patient to give information	Ask what they want to know about the details of their situation, accept their right not to know Offer to answer questions later	Would you like me to explain exactly what your results/tests are/mean?
K	Knowledge: giving medical facts	Use language that the patient can understand Give information in small chunks Consider patient background Check if patient understands what you have said, respond to reactions as they occur	When we examined your chest x-ray we saw a small visible mass, this is usually an indication of cancer. Is this making sense to you?
E	Explore emotions and empathize	Prepare to give an empathetic response Identify emotions expressed by the patient Identify the cause/source of emotion, give the patient time to express their feelings	Has this all made sense to you? How are you feeling?
S	Strategy and Summary	Close the discussion Ask whether they want to clarify anything else Decide on a strategy going forward/next actions Offer plan for next meeting	Has this all made sense? What other questions do you have?

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Empathetic, Exploratory, and Validating Responses

Empathetic Statements	Exploratory Questions	Validating Response
“I can see how upsetting this is to you.”	“How do you mean?”	“I can understand how you felt that way.”
“I can tell you weren't expecting to hear this.”	“Tell me more about it.”	“I guess anyone might have that same reaction.”
“I know this is not good news for you.”	“Could you explain what you mean?”	“You were perfectly correct to think that way.”
“I'm sorry to have to tell you this.”	“You said it frightened you?”	“Yes, your understanding of the reason for the tests is very good.”
“This is very difficult for me also.”	“Could you tell me what you're worried about?”	“It appears that you've thought things through very well.”
“I was also hoping for a better result.”	“Now, you said you were concerned about your children. Tell me more.”	“Many other patients have had a similar experience.”

Source: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

3. End of Life Care Planning

Patient State/Vitals
Rhythm: Sinus, wide complex	HR: 72	BP: 60/40	RR: 10
O₂SAT: 82%	T: 35.1^oC	GCS: 12

Expected Learner Actions	Modifiers	Triggers
Agreement on plans Communication of plans to team Prescribe medications for comfort (opioids, benzos, fan +/- glycopyrrolate)	No Modifiers for this Stage	All actions completed⇒ Debrief

Patient Vitals

Patient State/Vitals
Rhythm: Sinus, wide complex	HR: 72	BP: 60/40	RR: 10
O₂SAT: 82%	T: 35.1^oC	GCS: 12

Code Status Discussion Guide

Source: Rapid Code Status Conversation Guide (aliem.com)

Debriefing

Choosing a Debrief Framework:

A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.


	Time	Facilitator Level	Prep Time	Scenario Type	Flexibility
PEARLS (Our Favourite)	Moderate	Novice	Moderate	Any	High
GAS	Short-Moderate	Novice	Low	Short w/ Clear Objectives	Low
Team Dynamics	Moderate	Novice	Moderate	Any, esp. Team-focused	Moderate
SHARP	Very Short	No experience	None	Any	Low
Diamond	Short	Novice	Low	Low number of non-technical skills	Low
Plus-Delta	Very Short	No experience	None	Any	Moderate
Debriefing w/ Good Judgement	Moderate-Long	Novice	Moderate	Any	Moderate

PEARLS Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Phase	Objective		Task		Sample Phrases
1. Setting the Scene	Create a safe context for learning		State the goal of debriefing; articulate the basic assumption		“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
2. Reactions	Explore feelings		Solicit initial reactions and emotions		“Any initial reactions?” “How are you feeling?”
3. Description	Clarify Facts		Develop a shared understanding of the case		“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
4. Analysis	Explore a variety of performance domains: Decision making Technical skills Communication Resource utilization Leadership Situational Awareness Teamwork		See bottom of guide for details on the analysis phase		For each item to be debriefed: 1. Preview Statement: (to introduce topic) “At this point, I’d like to spend some time talking about [insert topic] because [insert rationale]" 2. Pick Analysis method + Analyze: (see below for more info on each method) a. Learner Self-Assessment b. Focused Facilitation c. Provide information 3. Mini Summary: (to summarize discussion of topic) *“That was a great discussion. Are there any additional comments related to [insert here]”* Phase Wrap-up: "Any outstanding issues or concerns before we start to close?"
5. Application or Summary	Identify take-aways		Can be learner- or instructor-centered		Learner-centered: “What are some takeaways from this discussion for our clinical practice?” Instructor-centered: “The key learning points for the case were [insert learning points]”
Analysis Phase Details
Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage):
Approach		Objective		Sample Phrases
Learner Self-Assessment Time: Short/Moderate Performance Domain: Cognitive/Technical Rationale Evident: Yes/No Facilitator Experience: Low		Promote reflection by asking learners to assess their own performance		“What aspects were managed well and why?” “What aspects do you want to change and why?”
Focused Facilitation Time: Moderate/Long Performance Domain: Cognitive/Behavioural Rationale Evident: No Facilitator Experience: More experience required, can be difficult		Probe deeper on key aspects of performance, uncover mental frames guiding performance		Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” *"I noticed [observation]* I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?”**
Provide Information Time: Short Performance Domain: Cognitive/Technical Rationale Evident: Yes Facilitator Experience: Low		Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed		“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]”

PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.

GAS Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Phase	Goal	Actions	Possible Scripts
Gather (Listen) 25%	Actively listen to participants to understand what they think and how they feel Identify what occurred during scenario	Elicit emotional state	*How do you feel?*
		Request narrative(s)	*How do you think it went?* *Can you tell me what happened?*
		Request clarifying or supplemental information	*Can anyone add anything to that account?*
Analyze (Guide Reflection) 50%	Provide feedback on performance Facilitate participant’s reflection on and analysis of their actions and systems issues Investigate basis for performance gaps	Review accurate record of events	*I noticed…*
		Report observations (correct and incorrect steps) Ask questions to reveal participant thinking	*I noticed…. What was the thought process behind….* *When….happened, I saw….What do you think…..* *I saw…I think….How do you see it?*
		Stimulate reflection and provide redirection	*Tell me more about…* *How did you feel about….* *I understand, but tell me about X aspect of the scenario*
Summarize (Help gather Conclusions) 25%	Facilitate identification and review of lessons learned	Identify positive aspects of session (participants)	*What are two things that you thought were effective or went well?*
		Discuss behaviours that require change	*What do you think are some areas you/your team need to work on?*
		Summarize session	*In today’s session, we….* *Going forward, we should….*

References/Adapted From:

Phrampus P.E., O’Donnell J.M. (2013) Debriefing Using a Structured and Supported Approach. In: Levine A.I., DeMaria S., Schwartz A.D., Sim A.J. (eds) The Comprehensive Textbook of Healthcare Simulation. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5993-4_6
Baily K (2019) Gather – Analyze – Summarize: The Simple GAS Method for Healthcare Simulation Debriefing (w/ Quick Template). www.healthysimulation.com/18874/gas-debriefing/

Team Dynamics Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Instructions:

Use the table below to guide your debriefing (Example phrases provided in plain text)
Observe and record elements of team dynamics
Identify 2 or 3 elements of team dynamics to discuss per debriefing section

Actions

Gather

Analyze

Summarize

Closed-loop communication

Orders acknowledged and confirmed when given
Orders announced when executed

Clear Messages

Team members speak clearly
Orders are questioned when doubt exists

Clear Roles

All team members have appropriate roles
Roles are reallocated when appropriate

Knowing one’s limitations

Calls for assistance
Seeks advice when appropriate

Knowledge Sharing

Sharing information between team members
Asks for ideas and suggestions

Constructive Intervention

Identifies priorities
Questions colleagues who make mistakes

Reevaluation and Summarizing

Reevaluates patient
Summarizes patient condition and treatment plan

Mutual Respect

Speaks in a professional, friendly tone of voice
Provides positive feedback

Student Observations

Can you describe the events from your perspective?
How did you think your treatments went?
Can you review the events of the scenario?
What could you have improved?
What did the team do well?

Instructor Observations

I noticed that [insert action here]
I observed that [insert action here]
I saw that [insert action here]

Done Well

How were you able to [insert action here]?
Why do you think you were able to [insert action here]?
Tell me a little bit more about how you [insert action here]?

Needs Improvement

Why do you think [insert action here] occurred?
How do you think [insert action here] could have been improved?
What was your thinking while [insert action here]?
What prevented you from [insert action here]?

Student-led Summary

What are the main things you learned?
Can someone summarize the key points made?
What are the main take-home messages?

Instructor-led Summary

Let’s summarize what we learned….
Here is what I think we learned….
The main take-home messages are….

References/Adapted from:

Cheng, A MD, FRCPC; Rodgers, DL. EdD; van der Jagt, É MD, MPH; Eppich, W MD, MEd; O’Donnell, J CRNA, MSN, DrPH (2012) Evolution of the Pediatric Advanced Life Support course, Pediatric Critical Care Medicine. 13(5). 589-595 doi: 10.1097/PCC.0b013e3182417709
American Heart Association Team Dynamics Debriefing Tool. 2011. https://ahainstructornetwork.americanheart.org/idc/groups/ahaecc-public/@wcm/@ecc/documents/downloadable/ucm_488325.pdf

SHARP Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Before Case

Set learning objectives
What would you like to get out of this case?

After Case

How did it go?
What went well? Why?

Address Concerns
What did not go so well? Why?

Review learning points
Were your learning objectives met for this case?
What did you learn about your clinical/technical skills?
What did you learn about your teamwork skills?

Plan ahead
What actions can you take to improve your future practice?

Framework from:

Imperial College London (ND). The London Handbook for Debriefing: Enhancing Performance Debriefing in Clinical and Simulated Settings. www.imperial.ac.uk/media/imperial-college/medicine/surgery-cancer/pstrc/lw2222ic_debrief_book_a5.pdf

Diamond Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Diamond Debrief: Sample Phrases

Description

“So what happened?...and then what happened next?”

Continue asking until confident that the details of the scenario have been raised by the learners

“Let’s not judge our performance now, let’s just focus on what happened”

Transition

“This scenario was designed to show…”

“Let’s address technical and clinical questions. What is the protocol for…?”

“How do we normally deal with this clinical situation?”

“Everyone ok with that?”

Analysis

“How did that make you feel?” To participants, then group

“Why?” Then use silence

“How did you/they do that exactly?”

“Why did you respond in that way? “ or “Why did you take that action?”

“It feels like…was an issue. Did it feel like that to you?”

What I’m hearing from you is…is that correct?”

“This is part of…” (identify the non-technical skill/human factor)

“We refer to that as a human factor or non-technical skill, which means…”

Transition

“So, what we’ve talked about in this scenario is…”

“What have we agreed we could do?”

Application

“What other kinds of situations might you face that might be similar? How are they similar?”

“How might these skills we discussed play out in those situations?”

“What are you going to do differently in your practice going forward?”

Underlying Principles

Description

Reinforce a safe learning environment.

Situate the debrief in the shared and meaningful activity that occurred.

Keep the focus dispassionate—discuss what happened but avoid focus on emotions.

Listen for emotional responses but resist the temptation to discuss emotions.

Make sure everyone shares the same understanding of what happened.

Transition

Transition into analysis by clarifying any technical and clinical issues

Analysis

Spend most of your time in Analysis.

Deconstruct behaviours into specific actions, and explore what happened in detail.

Ask about affective responses and validate them.

Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario).

Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”.

Reflect responses back, allowing participants to amend or augment.

Transition

Transition into Application by reinforcing learning.

Application

Focus on moving from the specifics of the scenario to the more general world of practice.

Break behaviours down into specific actions.

Explore the other kinds of situations that these might apply to.

Ask what participants will do differently in their practice.

Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300

Plus-Delta Debrief Framework

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Pluses:

Things that are working first
Items that the individual or team wants to build on
Ex: What went well?

Deltas:

Opportunities for improvement things that can be changed so that the individual team might become more effective
Should be specific, within the realm of possibility
To be reviewed and acted upon
Ex: What would you do differently next time?

Plus (+)	Delta (∆)

References:

Klair MB (2000). The Mediated Debrief of Problem Flights. in Facilitation and Debriefing in Aviation Training and Operations (1st ed). Routledge. www.taylorfrancis.com/chapters/mono/10.4324/9781315255576-12/mediated-debrief-problem-flights-key-dismukes-guy-smith
ACPS Quality Tools: Plus/Delta (ND). fhop.ucsf.edu/sites/fhop.ucsf.edu/files/custom_download/ACPS_Plus_Delta_Template.pdf

1. When having difficult conversations or breaking bad news, the SPIKES framework can be very helpful:

S - Setting: Choose the right setting. Ensure that it is a private area and that there is enough time for a conversation. Make sure proper introductions are made and take a seat so both you and others feel more comfortable.
P - Perception: Ask the other person for their perception of the situation at hand
I - Invitation: Determine how much the other person wants to know about their situation. They might want to know everything, or only want broad strokes.
K - Knowledge: Deliver the news and teach them about their situation. Keep terms simple and direct. Don't use euphemisms but don't be excessively blunt. It can sometimes be a good idea to give them a heads up that they are going to receive bad news. Check in to make sure that they're processing the information and understand what you're saying.
E- Empathy/Emotion: Be empathetic. Help them name and normalize how they feel, respect their emotions, and help support them.
S - Summary/Strategy: Use simple and clear statements to let them know that they have a team to support them and that they won't be alone. Help them work on a plan for moving forward and answer any questions.

Phase	Purpose	Process	Sample Phrases
Reactions	Allow learners to express emotional reactions to simulation Provide facts underlying simulation	Ask for emotional reactions	*How are you feeling?* *What are some initial reactions to what just happened?* *So, in that scenario…*
Analysis	Uncover the ideas, thought processes, and other factors that lead to a learner behaviour (uncovering “frames”) Help learners find ways to improve	1. Observe an event or result. Comment on the observation. 2. Advocate for your position	*I saw that… I think…* *I noticed that…To me…* *I saw…I’m concerned that…*
		3. Investigate basis for learner’s thinking that led to the observed event or result	*What do you think?* *Why do you think that happened?* *How do you see it?* *What was the thought process behind….?*
		4. Close the gap through discussion and didactics	*I hear…. What would it take for you to do this next time?* *How could we do this differently next time?* *I think a few good ideas that came up were…* *I’d like to say a little bit about…from my experience/literature*
Summary	Distill lessons learned from debriefing Invite reflection on the experiences as a whole	Ask learners to summarize their takeaways, what went well/what could be done differently Summarize session and learning	*What are some takeaways from today?* *What went well today? What would you do differently next time?* *In today’s session, we….* *Going forward, we should…*

Elderly End of Life Care

Scenario Overview

Scenario Info:

Prebriefing:

Scenario Stages: (Toggle) Educational

Debriefing:

Clinical Pearls:

Elderly End of Life Care

Prebriefing

Case Briefing

Patient Chart

1. Baseline State

CXR

ECG

Lab Results

Patient Vitals

2. Worsening Hemodynamics

Patient Vitals

SPIKES Framework

Empathetic, Exploratory, and Validating Responses

3. End of Life Care Planning

Patient Vitals

Code Status Discussion Guide

Debriefing

PEARLS Debrief Framework

GAS Debrief Framework

Team Dynamics Debrief Framework

SHARP Debrief Framework

Diamond Debrief Framework

Plus-Delta Debrief Framework

Debriefing with Good Judgment Framework