Siraco Susan, Bitter Cindy, Chen Tina
Saint Louis University School of Medicine, Saint Louis, MO.
Saint Louis University, Division of Emergency Medicine, Saint Louis, MO.
J Educ Teach Emerg Med. 2022 Apr 15;7(2):S1-S47. doi: 10.21980/J81W7H. eCollection 2022 Apr.
The primary audience for this simulation is emergency medicine (EM) residents, but this curriculum could also be used for EM-bound medical students.
Breaking bad news is a difficult but necessary skill for EM physicians. Bad news can range from informing family that a patient is in the emergency department (ED), to shared decision making regarding a life-threatening situation, to family notification of patient death.1 Although there are many structured approaches to death notification and breaking bad news, such as GRIEV_ING2 and SPIKES,3 EM physicians often lack confidence in their ability to effectively communicate bad news.1,4-6 Goals of care discussions and shared decision making become especially complex in the ED environment because critically ill patients often arrive without advanced directives, lack pre-existing rapport with the EM physician, and may require rapid engagement with surrogate decision-makers on emergent interventions.7 This simulation curriculum was developed to provide EM trainees with a psychologically safe environment to practice effective communication in breaking bad news, incorporating clinical scenarios commonly encountered in the ED.
At the conclusion of these two simulation cases, learners will be able to 1) recognize signs of poor prognosis requiring emergent family notification, 2) take practical steps to contact family using available resources and personnel, 3) establish goals of care through effective family discussion, 4) use a structured approach, such as GRIEV_ING, to deliver bad news to patients' families, and 5) name the advantages of family-witnessed resuscitation.
This curriculum consists of two simulation cases. Prior to the simulation, learners were assigned pre-reading on the GRIEV_ING approach to death notification, and how this approach could translate into breaking bad news in the ED. Although we chose to implement GRIEV_ING at our institution, other structured approaches (such as SPIKES) are reasonable as well. Each simulation case was conducted using a high-fidelity mannequin capable of intubation, respiratory examination findings such as abnormal breath sounds, and dynamic vital sign changes. Both cases required a standardized patient or other case confederate. Following each case, the learners underwent a debriefing session discussing how to break bad news in a high-pressure, time-sensitive ED environment. This case was designed as a high-fidelity simulation with a standardized patient, but it can be adapted to a low-fidelity simulation with a standardized patient.
Learners filled out a survey before and after the simulation describing their confidence in establishing goals of care with patients and surrogates, notifying family members of bad news in the ED, and their use of a consistent approach to breaking bad news. Scores were analyzed using the related-samples Wilcoxon signed rank test.
Learners exhibited improvement on all surveyed items, with statistically significant improvement on the survey item asking about their confidence in implementing a consistent approach to breaking bad news. Qualitative feedback was positive, with learners consistently endorsing the value of practicing difficult conversations in a simulated environment. First- and second-year residents appeared to benefit from the cases more strongly than senior residents.
These cases provided a safe environment for learners to practice a structured approach to breaking bad news. Learners tended to aggressively resuscitate the elderly septic patient and perform invasive procedures, such as intubation and mechanical ventilation, prior to contacting family or establishing goals of care, which generated good discussion points during debriefing.
Simulation, breaking bad news, goals of care discussion, death notification, sepsis, cardiac arrest, family witnessed resuscitation.
本模拟的主要受众是急诊医学（EM）住院医师，但该课程也可用于即将从事急诊医学工作的医学生。
传达坏消息对急诊医生来说是一项困难但必要的技能。坏消息的范围很广，从告知家属患者在急诊科（ED），到就危及生命的情况进行共同决策，再到通知家属患者死亡。1尽管有许多结构化的死亡通知和传达坏消息的方法，如GRIEV_ING2和SPIKES，3但急诊医生往往对自己有效传达坏消息的能力缺乏信心。1,4 - 6在急诊科环境中，护理目标讨论和共同决策变得尤为复杂，因为重症患者往往在没有预先指示的情况下到达，与急诊医生缺乏先前的融洽关系，并且可能需要迅速与替代决策者就紧急干预措施进行沟通。7本模拟课程旨在为急诊医学实习生提供一个心理安全的环境，以练习在传达坏消息时进行有效沟通，并融入急诊科常见的临床场景。
在这两个模拟病例结束时，学习者将能够：1）识别需要紧急通知家属的预后不良迹象；2）采取实际步骤利用可用资源和人员联系家属；3）通过有效的家属讨论确定护理目标；4）使用结构化方法，如GRIEV_ING，向患者家属传达坏消息；5）说出家属见证复苏的优点。
本课程由两个模拟病例组成。在模拟之前，为学习者分配了关于GRIEV_ING死亡通知方法以及该方法如何转化为在急诊科传达坏消息的预读材料。尽管我们选择在我们的机构实施GRIEV_ING，但其他结构化方法（如SPIKES）也是合理的。每个模拟病例都使用了一个能够进行插管、有呼吸检查结果（如异常呼吸音）和动态生命体征变化的高保真人体模型。两个病例都需要标准化患者或其他病例配合者。每个病例之后，学习者都要参加一个汇报环节，讨论如何在高压、时间敏感的急诊科环境中传达坏消息。这个病例被设计为有标准化患者的高保真模拟，但也可以改编为有标准化患者的低保真模拟。
学习者在模拟前后填写了一份调查问卷，描述他们在与患者及替代决策者确定护理目标、在急诊科通知家属坏消息以及使用一致的传达坏消息方法方面的信心。使用相关样本Wilcoxon符号秩检验对分数进行分析。
学习者在所有调查项目上都有改进，在询问他们对实施一致的传达坏消息方法的信心的调查项目上有统计学上的显著改进。定性反馈是积极的，学习者一直认可在模拟环境中练习困难对话的价值。一年级和二年级住院医师似乎比高年级住院医师从这些病例中受益更多。
这些病例为学习者提供了一个安全的环境，以练习传达坏消息的结构化方法。学习者倾向于在联系家属或确定护理目标之前，积极对老年脓毒症患者进行复苏并进行侵入性操作，如插管和机械通气，这在汇报环节产生了很好的讨论点。
模拟、传达坏消息、护理目标讨论、死亡通知、脓毒症、心脏骤停、家属见证复苏。
