By:Victoria Brazil (@SocraticEM)
Some parts of simulation design feel quite straightforward. We can see the task, the workflow, the error traps, the team behaviours. We can build a scenario around deterioration, trauma, handover, or a new clinical space and feel reasonably confident about what we are trying to achieve. But simulation to improve the care of patients in their last hours of life (LHoL) might not be so straightforward.
Of course there are similarities. Care in the LHoL involves assessment, communication, documentation, prescribing, teamwork, and coordination across professions. But it also sits in a less comfortable space for many simulation faculty – trying to re-create challenges to emotions, values, family dynamics, and professional identity, and then involving learners in authentic and helpful conversations
Ideally, we can use simulations to help learners develop the practical skills of caring for dying patients and their families, while also creating space to reflect on their own emotional responses as clinicians. Those two aims belong together. End-of-life care is not just about getting the medications right or saying the right words. It is also about learning how to reflect on and sometimes mange our own emotions
A recent paper from Bernabé and colleagues made me think about what good design can look like in this space (1). Their simulated scenario on the last hours of life was embedded in the palliative care curriculum for medical and nursing students, used standardized patients and family members, and focused on realistic encounters such as managing terminal delirium, explaining deterioration, communicating death, and comforting a family member. Students described it as realistic, emotionally engaging, safe, and useful for future practice. They also highlighted learning that extended well beyond knowledge alone- towards emotional management, humanistic care, and appreciating the needs of families as well as patients.
That kind of initiative feels scalable because it is thoughtfully built. It sits inside a broader educational approach. It chooses tasks that genuinely benefit from experiential learning. And it recognises that realism here is relational, not just technical.
Another paper – the Star Trek-inspired “doomed-to-fail” simulation about physician grief – also made me think. Not because it lacks sincerity or educational ambition, but because it reminds us how easily simulation about death and dying can drift into difficult territory if the design centres futility too strongly. In their model, all learner choices were deliberately collapsed to reinforce the inevitability of death and prompt reflection on grief and helplessness. The debriefing was carefully constructed and learner wellbeing was clearly considered, but the paper still raises an important question for me: what exactly are we rehearsing when we simulate dying? For me, the answer is not that we are rehearsing failure. We are rehearsing care.
So what principles should guide us?
First, end-of-life simulation should be embedded within a broader educational activity, not treated as a one-off emotional event. Preparation matters. Context matters. Debriefing matters. Learners need a frame for why they are there and what good care looks like.
Second, we should focus simulation on the things best learned experientially: difficult conversations, family presence, symptom relief, documentation, decision-making, and team coordination. These are the parts of care where practice, observation, and reflection can genuinely change future performance.
Third, modality matters. Simulated patient (SP) methodology seems particularly well suited here, because so much of the learning sits in human interaction, emotional attunement, and responding to family distress. The Bernabé paper reinforces that realism and safety can coexist when the design is careful.
Fourth, there must be a deconstruction phase. Not a quick emotional check-out, but a proper unpacking of what happened, what mattered, what felt hard, and how learners make sense of their own responses. That reflective work is central to the educational design.
And finally, this work is strongest when designed with others: palliative care clinicians, nurses, allied health staff, communication experts, and where possible, people with lived experience. End-of-life care is multidisciplinary and deeply relational. Our simulation design should reflect that too.
References
- Bernabé, S.R., Garayoa, L.S., Martínez, A.U. et al. Learning Last Hours of Life Care Through Patient Simulation Scenario: Experiences of Medical and Nursing Undergraduate Students. Med.Sci.Educ. 35, 2451–2462 (2025).
- Wong KSS. A ‘Star Trek’-inspired, doomed-to-fail simulation for teaching coping with physician grief. Med Educ. 2025. https://doi.org/10.1111/medu.70161
Photo – AI generated
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