Should the manikin ever die in a simulation scenario?

Effective simulations require suspension of disbelief and willingness by learners to play along with the game created by the facilitators. Without this buy-in, learners could argue against discrepancies, simply on the basis that the scenario is not real. Learners give their trust that the educators will also play the same game, and that the rules will not change.

Where does death factor into the rules of the game?

There are 3 types of simulation deaths according to Leighton (2009) 1 :

  • Expected death
  • Unexpected death
  • Death resulting from action/inaction

What happens when the educator feels the learners have managed the case wrong? Or when the team has not made any management decision? Should the patient crash and die if that was the trajectory of their illness, or even if it was not in the trajectory? And what does this do to the learner psyche to see such severe consequence of their actions or inactions?

Essentially, can learning happen through fear, stress, and remorse?

Or the opposite – can learning happen when there are no negative consequences and there is always a fairy tale ending?

We can all agree death happens in medicine. We must prepare our learners on how to manage it, both clinically and emotionally. The answer cannot be to completely avoid the serious topic entirely. But the opposite is also true. Death must be recognized as a serious event, and especially for early learners, it can leave a lasting mark. We all have had nightmares of patients we have tried to save, but didn’t or couldn’t.
Corvetto and Taekman2 wrote a review on this topic in the February issue of Simulation Healthcare and provided some recommendations:

1.  Do not use death punitively.

Imagine the situation where the learners are messing around and not taking your hard work seriously. Or perhaps they didn’t do the preparatory work that was assigned to them prior to arrival.You are irritated and frustrated. The first rule is take a deep breath… don’t take it out on the manikin.

2.  Give early learners a break.

If the scenario is about death, or if it is anticipated the patient will be critically ill, give a pre-briefing session in which the medical topic may be discussed (e.g. ACLS protocol). Discuss the possibility of death. Is this cheating? Absolutely not, because at the end of the day, the goal is to create competent doctors and confident leaders — not to pass an arbitrary test.

3.  Acknowledge the emotional toll.

Often we are expected to be emotional robots. After we declare a code on the traumatic arrest patient, we turn right around and discharge the asthmatic who only needed a few nebs and steroids. These emotions are kept zipped up tight inside. Simulation is a great time to have a discussion without distractors. We can acknowledge and talk through the emotional and psychological ups and downs of having a critically ill patient who could not be resuscitated.

4.  Give it some thought.

Spend time thinking about the ethical and psychological components of the game that are you asking your learners to participate within. Luckily, we do not live in a society like that depicted in the Hunger Games.

5.  Back to basics.

Always come home to your learning goals. Every scenario grows from them. This will drive the case, the pre and post debriefing, and the take away points for the learners.
Please share your thoughts and experiences.

Leighton K. Death of a Simulator. Clinical Simulation in Nursing. 2009;5(2):e59-e62. doi: 10.1016/j.ecns.2009.01.001
Corvetto M, Taekman J. To die or not to die? A review of simulated death. Simul Healthc. 2013;8(1):8-12. [PubMed]
Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD


Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions