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BACKGROUND Emergency departments (ED) care for many patients who are chronically ill and nearing end of life. Simulation training offers an opportunity to teach physicians interpersonal skills required to manage end of life care. OBJECTIVE We hypothesized a simulation of an imminently dying patient utilizing the LIVE. DIE. REPEAT. (LDR) format would be perceived as an effective method to teach end-of-life communication and palliative care management skills. METHODS This was simulation training replicating the experience of caring for a critically ill patient in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress and previously established goal of comfort care. LDR is a serious-game scheme in which learners are allowed infinite opportunities to progress through a single patient scenario. If learners successfully complete the predetermined critical actions, the game is paused and there is a debriefing to reinforce knowledge/skills before progressing to the next stage of the simulation. Conversely, if learners do not achieve critical actions, the game is over, and learners undergo debriefing before repeating the scenario. We used the Simulation Effectiveness Tool – Modified (SET-M) survey to evaluate perceived effectiveness in teaching end-of-life management. RESULTS The simulation was divided into four levels and learners were tasked with completing one critical action in each level. Eighty percent of residents completed SET-M survey and nearly 100% either strongly or somewhat agreed that the simulation improved their skills and confidence at the end of life. All residents felt debriefing contributed to learning and provided opportunities to self-reflect. Eighty eight percent strongly agreed they were more confident communicating with the patient and prioritizing care interventions which in the simulation were providing care that aligned with patient’s values. CONCLUSIONS This palliative simulation using LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management.

Background Emergency departments (EDs) care for many patients nearing the end of life with advanced serious illnesses. Simulation training offers an opportunity to teach physicians the interpersonal skills required to manage end-of-life care. Objective We hypothesized a gaming simulation of an imminently dying patient using the LIVE. DIE. REPEAT (LDR) format, would be perceived as an effective method to teach end-of-life communication and palliative care management skills. Methods This was a gaming simulation replicating the experience of caring for a dying patient with advanced serious illness in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress, with a previously established goal of comfort care. The gaming simulation game was divided into 4 stages, and at each level, learners were tasked with completing 1 critical action. The gaming simulation was designed using the LDR serious game scheme in which learners are allowed infinite opportunities to progress through defined stages depicting a single patient scenario. If learners successfully complete the predetermined critical actions of each stage, the game is paused, and there is a debriefing to reinforce knowledge or skills before progressing to the next stage of the gaming simulation. Conversely, if learners do not achieve the critical actions, the game is over, and learners undergo debriefing before repeating the failed stage with an immediate transition into the next. We used the Simulation Effectiveness Tool–Modified survey to evaluate perceived effectiveness in teaching end-of-life management. Results Eighty percent (16/20) of residents completed the Simulation Effectiveness Tool–Modified survey, and nearly 100% (20/20) either strongly or somewhat agreed that the gaming simulation improved their skills and confidence at the end of life in the following dimensions: (1) better prepared to respond to changes in condition, (2) more confident in assessment skills, (3) teaching patients, (4) reporting to the health care team, (5) empowered to make clinical decisions, and (6) able to prioritize care and interventions. All residents felt the debriefing contributed to learning and provided opportunities to self-reflect. All strongly or somewhat agree that they felt better prepared to respond to changes in the patient’s condition, had a better understanding of pathophysiology, were more confident on their assessment skills, and had a better understanding of the medications and therapies after the gaming simulation. A total of 88% (14/16) of them feel more empowered to make clinical decisions. After completing the gaming simulation, 88% (14/16) of residents strongly agreed that they would feel more confident communicating with a patient and prioritizing care interventions in this context. Conclusions This palliative gaming simulation using the LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management.