Simulation Design Template

Date:March 11, 2013File Name: End-of-life

Discipline:NursingStudent Level: 3rd semester ASN

Expected Simulation Run Time: 45 minGuided Reflection Time:60 min

Location: Simulation classroomLocation for Reflection: Debriefing room

Admission Date: March 10th
Today’s Date: March 11th
Brief Description of Client
Name: Sandra B. United
Gender: F Age: 33 Race: Caucasian
Weight: 47.62kg (105 lbs)
Height: 152.4 cm (5 feet 5 inches)
Religion: Catholic
Major Support: Mother, father, brother, and friends.
Phone: 555-820-5307
Allergies: Sulfa
Immunizations: Current
Attending Physician/Team: Dr. Timothy Jones
Past Medical History: Fibromyalgia, chronic anemia, depression, tonic-clonic seizures.
History of Present illness: Biopsy of left shoulder nevi 8 months ago revealed a melanoma that has now metastasizedto the bone and brain. The patient has received seven, monthly cycles of chemotherapy. Ineffective disease control and declining patient condition promptedthe patient to request Hospice services one week ago. Yesterday, the mother came from out-of-town to visit and was alarmed by her daughter’s decrease in level of consciousnessand respiratory difficulty which lead to an EMS call and hospital admission. The patient’s motheris struggling to accept the daughter’s decision to stop aggressive treatment and allow a natural death.
Social History: Single with no children. Worked as a pharmaceutical representative for Lilly and has traveled extensively.Family lives out of the area. Many supportive friends. Strong spiritual support from a local church congregation.
Primary Medical Diagnosis: Stage IV malignant melanoma.
Surgeries/Procedures & Dates: Surgical excision of right shoulder nevi with port placement 8 months ago.
Nursing Diagnoses:
  • Acute Pain
  • Compromised family coping
  • Death Anxiety
  • Decreased cardiac output
  • Fear
  • Grieving
  • Hopelessness
  • Impaired oral mucous membranes
  • Impaired swallow
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Powerlessness
  • Spiritual Distress
  • Social Isolation
  • Self Care Deficit
/ Psychomotor Skills Required Prior to Simulation
Physical, psychosocial, and spiritual assessment
Symptoms at end-of-life
Communication skills
Use of electronic vital sign equipment
Oxygen administration
Post mortem care and expiration checklist documentation
Port needle removal
Foley catheter removal
Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]
Pre-simulation assignment:
Read the End-of-Life Power Point lecture(L)
Read the journal article: (R)
Sherman, D. W., Matzo, M. L., Pitorak,
E., Ferrell, B. R., & Malloy, P. (2005).
Preparation and care at the time of
death: Content of the ELNEC
curriculum and teaching strategies.
Journal for Nurses in Staff Development,
21(3), 93-100.
Complete the Caring Conversations for Young
Adults (R) available via web link

Read the Missouri Advance Directive (R) available via web link

Simulation Learning Objectives

  1. Perform a physical assessment and analyze the findings to manage end-of-life symptoms;
  2. Practice therapeutic support and compassionate end-of-life communication;
  3. Assess spiritual needs and provide culturally sensitive nursing care;
  4. Demonstrate a patient and family-centered approach to care;
  5. Analyze the completed advanced directive and advocate to uphold the patient’s wishes;
  6. Utilize nursing process to develop an individualized plan of care;
  7. Evaluate personal beliefs and values that influence a nurse’s ability to provide care to the dying;
  8. Perform the nurse-to-nurse death verification and death documentation utilizing a standardized expiration checklist.
  9. Demonstrate post mortem care and safe handling precautions;
  10. Practice interdisciplinary collaboration as death approaches and at the time of death.

Fidelity (choose all that apply to this simulation)

Setting/Environment
ER
X Med-Surg
Peds
ICU
OR / PACU
Women’s Center
Behavioral Health
Home Health
Pre-Hospital
XOther: Oncology Unit
Simulator Manikin/s Needed:SimMan as 33 year old dying female
Props:
Positioned on right side propped with pillows Turban or bandana on head
Foley catheter in place with 50 ml dark yellow urine
Left chest port accessed with infusion plug and occlusive dressing
Round bandaid labeled as Scopolamine patch placed behind left ear
Purple nailbeds
Purple blotching on toes and knees
Dry lips
Personal belongings: blanket, watch, ring, necklace, clothing, slippers, and photo album.
Rosary
Bible
MAR
Active orders
Advanced directives
Graceful Passages Music CD and CD player

Equipment attached to manikin:

IV tubing with primary line fluids running at mL/hr
Secondary IV line running at mL/hr
IV pump
XFoley catheter 50 mL output
PCA pump running
IVPB with running at mL/hr
X02 per nasal cannula
Monitor attached
XID band: Sandra B. United DOB 12/25/1980
XOther: Port accessed with infusion plug

Equipment available in room

Bedpan/Urinal
Foley kit
Straight Catheter Kit
Incentive Spirometer
Fluids
IV start kit
IV tubing
IVPB Tubing
IV Pump
Feeding Pump
Pressure Bag
X02 delivery device (type) nasal cannula
Crash cart with airway devices and emergency medications
Defibrillator/Pacer
Suction
Other: / Medications and Fluids
IV Fluids:
XOral Meds: Roxanol (morphine) 20 mg (20 mg/ml) oral solution; Ativan (lorazepam) 1mg (2 mg/ml) oral solution; Transderm Scop (scopolamine) 1.5mg patch
IVPB:
IV Push:
IM or SC:
Diagnostics Available
Labs
X-rays (Images)
12-Lead EKG
Other:

Documentation Forms

XPhysician Orders
Admit Orders
Flow sheet
XMedication Administration Record
Kardex
Graphic Record
Shift Assessment
Triage Forms
Code Record
Anesthesia / PACU Record
Standing (Protocol) Orders
Transfer Orders
Other:
Recommended Mode for Simulation (i.e. manual, programmed, etc.)
Scenario is ran manually
Roles/Guidelines for Roles
XPrimary Nurse
XSecondary Nurse
Clinical Instructor
XFamily Member #1: Patient’s mother is at the bedside
Family Member #2
Observer/s
Recorder
Physician/Advanced Practice Nurse
Respiratory Therapy
Anesthesia
Pharmacy
Lab
Imaging
Social Services
Clergy
Unlicensed Assistive Personnel
Code Team
Other:
Important Information Related to Roles:
The patient is ready to let go and experience a natural death. The patient’s mother is struggling with her daughter’s decisions to stop chemotherapy and admit to Hospice services. The mother is not ready to let her daughter go! On admission, the mother asked the physician about further chemotherapy and a second opinion. The physician advised the mother that there were no more chemotherapy options and a second opinion would not provide new treatment options. The patient’s mother has been awake all night at the daughter’s bedside.
Significant Lab Values:WBC 1.0 mm/3, Hemoglobin 8.2 g/dL, Hematocrit 26%, Platelets 52,000 mm/3
Physician Orders:
Comfort measures only
Roxanol (morphine) 20 mg/ml every 4 hours prn pain
Transdern Scop (scopolamine) 1.5 mg transdermal patch every 72 hours
Ativan (lorazepam) 1 mg (2mg/ml) oral solution every 8 hours prn restlessness
Heparin 5ml (100 unit/ml) IV prn after intermittent port infusion / Student Information Needed Prior to Scenario:
Has been oriented to simulator
Understands guidelines /expectations for scenario
Has accomplished all pre-simulation requirements
All participants understand their assigned roles
Has been given time frame expectations
Other:
Report Students Will Receive Before Simulation
Time: 0700
The patient is a 33 year old female diagnosed with malignant melanoma with brain and bone metastasis. Chemotherapy treatments have ineffectively controlled the melanoma and the patient’s condition has deteriorated. The patient stopped aggressive chemotherapy treatments last week and was admitted to Hospice services. Her mother, who lives out-of-town, arrived yesterday to find her daughter weak, struggling to get out of bed, sleeping most of the time, and experiencing respiratory difficulty. Yesterday, the mother was alarmed by her daughter’s deterioration and called 911 to have her daughter admitted to the Oncology Unit. Overnight, the patient’s condition deteriorated. At 0600 this morning, the physician was notified of persistent patient moaning and deteriorating condition. Comfort care orders were received. Orders for Roxanol (morphine) oral solution, Transderm Scop (scopolamine) patch, and Ativan (lorazepam) oral solution were obtained and administered at 0615. The patient isnonresponsive and responds only to painful stimuli.

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario (site source, author, year, and page):

American Association of Colleges of Nursing. (2008). Peaceful death: Recommended competencies and curricular guidelines for end-of-life nursing care. Retrieved from

Competencies Necessary for Nurses to Provide High-Quality Care to Patients and Families During the Transition at the End of Life:

2. Promote the provision of comfort care to the dying as an active, desirable, and important skill, and an integral component of nursing care.

3. Communicate effectively and compassionately with the patient, family, and health care team members about end-of-life issues.

4. Recognize one's own attitudes, feelings, values, and expectations about death and the individual, cultural, and spiritual diversity existing in these beliefs and customs.

5. Demonstrate respect for the patient's views and wishes during end-of-life care.

6. Collaborate with interdisciplinary team members while implementing the nursing role in end-of-life care.

7. Use scientifically based standardized tools to assess symptoms (e.g., pain, dyspnea [breathlessness] constipation, anxiety, fatigue, nausea/vomiting, and altered cognition) experienced by patients at the end of life.

8. Use data from symptom assessment to plan and intervene in symptom management using state-of-the-art traditional and complementary approaches.

9. Evaluate the impact of traditional, complementary, and technological therapies on patient- centered outcomes.

10. Assess and treat multiple dimensions, including physical, psychological, social and spiritual needs, to improve quality at the end of life.

11. Assist the patient, family, colleagues, and one's self to cope with suffering, grief, loss, and bereavement in end-of-life care.

12. Apply legal and ethical principles in the analysis of complex issues in end-of-life care, recognizing the influence of personal values, professional codes, and patient preferences.

Center for Practical Bioethics. (2012). Caring conversations for young adults. Retrieved March 1, 2013, from

Matzo, M. L., Sherman, D. W., Lo, K., Egan, K. A., Grant, M., & Rhome, A. (2003). Strategies for

teaching loss, grief, and bereavement. Nurse Educator, 28(2), 71-76. doi:

10.1097/00006223200303000-00009

Matzo, M., Sherman, D. W., Sheehan, D. C., Ferrell, B. R., & Penn, B. (2003). Communication

skills for end-of-life nursing care: Teaching strategies from the ELNEC curriculum. Nursing

Education Perspectives, 24(4), 176-183. Retrieved from

Missouri Advance Directives. (2012). Planning for important healthcare decisions. Retrieved March 1, 2013, from

Sherman, D. W., Matzo, M. L., Pitorak, E., Ferrell, B. R., & Malloy, P. (2005). Preparation and care at the time of death: Content of the ELNEC curriculum and teaching strategies. Journal for Nurses in Staff Development, 21(3), 93-100.

Sherman, D. W., Matzo, M. L., Coyne, P., Ferrell, B. R., & Penn, B. K. (2004). Teaching symptom

management in end-of-life care: The didactic content and teaching strategies based on the End-of

Life Nursing Education Curriculum. Journal for Nurses in Staff Development, 20(3), 103-115. doi:

10.1097/00124645-200405000-00001

Smith-Stoner, M. (2009). Using high-fidelity simulation to educate nursing students about end-of-life care. Nursing Education Perspectives, 30(2), 115-120.

Quality and Safety Education for Nurses. (2012). Retrieved from

QSEN Competencies:

Patient-centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Knowledge:

  • Integrate understanding of multiple dimensions of patient centered care: patient/family preferences, values; information, communication, and education; physical comfort and emotional support; involvement of family and friends.
  • Demonstrate comprehensive understanding of the concepts of pain, suffering, including physiologic models of pain and comfort
  • Describe the limits and boundaries of therapeutic patient-centered care.
  • Discuss principles of effective communication

Skills:

  • Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care
  • Provide patient-centered care with sensitivity and respect for the diversity of human experience
  • Assess presence and extent of pain and suffering
  • Assess levels of physical and emotional comfort
  • Elicit expectations of patient and family for relief of pain, discomfort, or suffering
  • Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs
  • Recognize the boundaries of therapeutic relationships
  • Assess own level of communication skill in encounters with patients and families

Attitude:

  • Value seeing health care situations “through the patients’ eyes”
  • Respect and encourage individual expression of patient values, preferences and expressed needs
  • Willingly support patient-centered care for individuals and groups whose values differ from own
  • Recognize personally held values and beliefs about the management of pain or suffering
  • Appreciate the role of the nurse in relief of all types and sources of pain or suffering
  • Appreciate shared decision-making with empowered patients and families, even when conflicts occur
  • Value continuous improvement of own communication and conflict resolution skills

Teamwork and collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

Knowledge:

  • Describe own strengths, limitations, and values in functioning as a member of a team.
  • Recognize contributions of other individuals and groups in helping patient/family/achieve health goals.

Skills:

  • Demonstrate awareness of own strengths and limitations as a team member.
  • Act with integrity, consistency and respect for differing views.
  • Function competently within own scope of practice as a member of the health care team.
  • Integrate the contributions of others who play a role in helping patient/family achieve health goals.

Attitude:

  • Acknowledge own potential to contribute to effective team functioning.
  • Appreciate importance of intra-and inter-professional collaboration.
  • Value the perspective and expertise of all health team members.
  • Respect the centrality of the patient/family as core members of any health care team.

Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

Knowledge:

  • Delineate general categories of errors and hazards in care.

Skills:

  • Demonstrate effective use of technology and standardized practices that support safety and quality.
  • Demonstrate effective use of strategies to reduce risk of harm to self or others.
  • Use appropriate strategies to reduce reliance on memory (such as, forcing functions, checklists).

Attitude:

  • Value the contributions of standardization/reliability to safety.

Additional Recommended Readings:

Callahan, M., & Kelley, P. (2008). Final gifts. Understanding the special awareness, needs, and communications of the dying. New York: Bantam.

Schagger, M. & Norland, L. (2009). Being present: A nurse’s resource for end-of-life communication. Sigma Theta Tau International.

Wallace, M., Grossman, S., Campbell, S., Robert, T., Lange, J., & Shea, J. (2009). Integration of

end-of-life care content in undergraduate nursing curricula: Student knowledge and perceptions.

Journal of Professional Nursing, 25(1), 50-56. doi: 10.1016/j.profnurs.2008.08.003

Scenario Progression Outline

Timing
(approximate) / Manikin Actions / Expected Interventions / May Use the Following Cues
0730 / Assessment Findings:
  1. Positioned on side, facing patient’s mother. Pillowspropped behind back.
  2. Responds to painful stimuli but is unable to communicate. Moans with repositioning.
  3. Left chest port is accessed with Huber needle and infusion plug.
  4. Nail beds cyanotic. Extremities cool. Purple blotching of toes and knees.
  5. Temp 99.6, B/P 80/46, HR 108, R 28, Pulse Ox 88% 1L.
  6. Does not follow commands or track with eyes.
  7. Rapid breathing, with airway congestion. Scopolamine patch intact behind left ear.
  8. Turgor is greater than 3 seconds.
  9. Abdomen is firm with hypoactive bowel sounds. Last BM was 3 days ago.
  10. Foley has 50 ml dark yellow urine.
/ Student:
  1. Interact with nonresponsive adult female patient (manikin) and patient’s mother (live).
  2. Perform hand hygiene.
  3. Introduce self.
  4. Consider if the patient’s care may be discussed with the mother.
  5. Take vital signs.
  6. Ask patient, “How are you doing?” Attempt to rate pain using the FLACC scale.
  7. Perform physical assessment.
  8. Increase oxygen to 2 L/min per NC due to Pulse Ox reading of 88%.
  9. Recognize symptoms of the dying process and communicate those findings to the patient’s mother.
/ Role member providing cue:
Patient’s mother (live) expresses concern regarding the patient’s condition change and attempts to determine relevance:
Cue: (Allow the students time to complete assessment before initiating conversation).
  1. “Her moaning has decreased since the night nurse gave her theliquid pain medicine.”
  2. “Why has she stopped talking?”
  3. “She seems different today, like she’s gazing off into space!”
  4. “She’s had nothing to eat or drink, do you think she’s hungry and thirsty?”
  5. “Why is her breathing different?”
  6. “Why does she have those purple patchy areas on her skin?”

0800
ROTATE /
  1. Pulse Ox improved to 92 % on 2L per NC.
/
  1. Reassess Pulse Ox.
  2. Educate the patient’s mother regarding what to expect at the time of death.
  3. Inform the patient’s mother that Sandra’s wishes were outlined in her Advanced Directive and that she did not want life prolonging measures.
  4. Reinforce that comfortis a priority.
  5. Offer emotional support.
  6. Be empathetic and compassionate.
/ Role member providing cue: Patient’s mother
Cue:
  1. “The doctor said she might be getting near the end.”
  2. “What happens if her heart stops?” “Will you do CPR and try to save her?”
  3. “Do you think she’s going to die soon?” “What happens when deathgets close?”
  4. “Do you think it hurts to die?”
  5. “Her priest brought the Graceful Passages: A companion for living and dying (2003) CD, do you think we should play it for her?”
Cue: Play the Graceful Passages music CD (Tracks 10-12)
1030 /
  1. Breathing is shallow with apnea anddecreased respiratory rate.
  2. Temp 99.8, B/P 46/30, HR 46, R 8, Pulse Ox 88% on 2L NC.
/
  1. Assess the patient for changes. Focus on comfort, positioning, symptom control, and mouth care.
  2. Offer emotional support.
  3. Provide Kleenex.
  4. Listen, be present, and provide therapeutic communication.
  5. Encourage the patient’s mother to share any important last conversations (for example, I am sorry, I love you, it is ok to let go, or,I will be alright without you).
  6. Recognize the beliefs and values that influence the mother’s ability to grieve.
  7. Encourage reminiscence of life’s memories, happy times, and achievements.
  8. Assess spiritual needs. Ask, is there anyone we could call to be with you? Offer to pray with patient/mother. Offer to contact the patient’s priest or the hospital chaplain.
/ Role member providing cue: Patient’s mother
Cue:
  1. “This is so hard to watch!”
  2. “She should notbe dying at such a young age!” “I should not out- live my child!” “She should still have her whole life ahead of her!” “I just don’t know what I will do without her!”
  3. “Sandra and I had a fight last week.”“I tried to talk her into a second opinion.”“She said that she was too tired andtoo weak to fight this anymore.”“I got angry and told her she was giving up and that I would have no part of it!” “We both cried, I decided it would be better to talk about it later, but we never did!”

1048 / Patient takes last breath. /
  1. Recognizethe patient has stopped breathing and death has occurred.
  2. Have a second nurse assess the patient to verify death.
  3. Reinforce Sandra’s wishes were not to be kept alive by life prolonging measures.
  4. Be supportive. Utilize therapeutic communication.
  5. Notify the hospital chaplain.
  6. Document the death using the standardized expiration checklist.
  7. Notify the physician, transplant services, and interdisciplinary team members that death has occurred.
/ Role member providing cue:
Patient’s mother
Cue:
  1. “Oh no, is she gone?” “Sandra!”“Sandra!”“Do something!”“Are you sure you can’t do CPR?”
  2. “I love you Sandra!”“I love you with all my heart!”“I will miss so much!”
  3. “What should I do now?”
  4. “I need to step out tomake some phone calls.”
Cue: The instructor role playing the mother then steps behind a screen in the room so that the students can perform post mortem care and complete the death notification process.
1120 / Manikin has a foley and port needle to be removed. /
  1. Begin post mortem care. Recognize the patient is not a candidate forautopsy.
  2. Remove the port needle and the foley catheter. Recognize bathing would be performedif necessary.
  3. Position the patient for the final family viewing.
  4. Prepare the room. Gather and bag personal belongings.
  5. Demonstrate effective and compassionate communication.
  6. Be supportive duringfamily viewing and final goodbye.Remove the patient’s jewelry. Give the personal belongings to the patient’s mother.
  7. After the patient’s mother leaves, obtain the body bag and prepare the toe tag.
/ Role member providing cue: Patient’s mother
Cue: “Can I see Sandrato say goodbye?”
Cue: Patient’s mother steps to the bedside to saythe final goodbye.Patient’s mother cries, holds her daughter’s hand, rest her head on her daughter’s arm, and kisses her daughter on the forehead.
Mother states, “I don’t know what I will do without you!” “I love you!”“I am going to miss you so much, but I know someday I will see you again in heaven!”
Patient’s mother leaves with her daughter’s personal belongings.

Debriefing/Guided Reflection Questions for This Simulation