What can we learn from simulation-based training to improve skills for end-of-life care? Insights from a national project in Israel

The following themes recurred throughout discussions and questionnaires at every workshop. Lack of training: A majority of participants admitted, “Never having received any education for EOL care”. Lack of knowledge about the law: Most participants said “they have poor knowledge of the Israeli Dying Patient Act” [47] as previously reported [48]. Only half of participants knew that this law requests staff to support patients’ families. We presented and discussed main principles of the law. Lack of knowledge about palliative care: Nearly two-third would not use opioids to relieve dyspnea for fear of respiratory depression (and few more would use nebulized opioids) despite the literature [49]. Many did not know that palliative care has been associated with improved survival [50]. We discussed those issues and others such as palliative sedation for refractory suffering, and encouraged participants to get help from local experts in palliative care. Perception of overtreatment: Most participants reported often providing futile care “they would not have wanted for themselves” or giving life-sustaining treatment in conditions they view as “associated with poor quality of life.” Other participants warned about “the subjectivity of quality of life judgments.” About 20% of them reported often performing “slow codes”. We discussed "the problem with futility" [51, 52]. Dilemmas and uncertainty: Many participants admitted being “often confused and perplexed about correct choices for patients”, while some would expect guidance from the regulation to determine “whether a patient is dying”. Others mentioned “miracles” (as described [53]) and an idea emerged that a dichotomized view of EOL (“dying or not dying”), attractive to Cartesian minds, is potentially risky (as in the Liverpool Care Pathway [54]) and could be replaced by more useful paradigm: paradoxical thinking, associated with better tolerance of uncertainty and creativity [31]. Lack of time: Many participants perceived lack of time as a major barrier in proper communication with patients and families: They complained that the 7-min simulation was too short, while others remarked, “in real-life we might not have even this luxury.” We discussed evidence showing that empathy is effectively expressed in less than 1 minute [55, 56] and that an affective channel of communication, (the primal way we learn to connect in infancy, towards which we regress in disease [57]) is much faster than cognitive messaging. Facial micro-expressions reflect emotions in less than one second [58], whereas to explain respiratory and renal failure from sepsis would probably require at least several minutes. Lack of hope: When facing EOL, participants felt bewildered by the recommendation “Communicating with hope” [24]. We discussed the multiplicity and subjectivity in the meaning of hope [59]: miraculous recovery, relief from suffering or closure and making peace at the end - a patient may view as “some of the best days in my life” [60]. While a clinician has difficulty seeing more than a grim prognosis, we proposed, as Surbone, reframing challenge from “truth telling to truth making” [61]: acknowledging uncertainty and committing to non-abandonment. Poor teamwork culture: At debriefing of simulations where a physician and a nurse handle a challenge together, participants reported, “Feeling uneasy and not used to multi-disciplinary meetings”, while some physicians were “reluctant to invite nurses to such meetings with patients or families.” Others stated they “routinely invite nurses or other team workers to join such meetings”: they believe that their presence sends a message of genuine concern, often assists in fine-tuning nuances in the conversation, and always help promoting the continuity of care. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care, and at handling conflicts or dilemmas (see Additional file 3: Appendix C). Altogether, participants acknowledged the need to improve listening skills, attention to affect and teamwork.

The first 10 workshops took place in 2011 with 47 staff physicians, 33 residents and 40 nurses participating in six EOL scenarios (each ran twice), usually alone (sometimes in combination: physician with nurse, staff physician with resident). They provided 120 recorded 7-min simulation sessions and several hours of recorded debriefing sessions. Based on insights from the group discussions, we decided to evaluate the content analysis of video-clips using the RIAS tool under two classes of categories: cognitive and affective. We combined as cognitive utterances categories dealing with medical condition and therapeutic regimen (such as “data gathering” or “patient education and counseling”). We combined as affective utterances RIAS categories defined as “psychosocial issues”, “feelings”, and “building a relationship”. Analysis of video-clips showed predominance of cognitive utterances - by an order of magnitude more prevalent than affective expressions, as shown in Table 1. Males and physicians used more cognitive talk while females and nurses had a higher proportion of affective utterances. Providers talked far more often than actors did by a 2:1 ratio, and episodes of silence lasting more than 5 s occurred in only 35% of video-clips (usually only once).

Our study has significant limitations. First, the participants who came to the workshops may have had heightened interest in the issue of EOL, yet with significant challenges, which may be worse or different for other field clinicians who did not participate. Their self-evaluation is subjective and short-term. Second, our professional actors gave more authentic responses than “standardized patients” do with fixed repertoires, but the artificial setting barely reproduces the nuances of sensitive EOL communications with patients and families. Nevertheless, the workshop demonstrated room for improvement of skills to handle conversations, conflicts and dilemmas. Third, our study may not be generalizable to countries outside Israel – although the challenges observed remind those described in recent English literature [1].

A word of caution is warranted since our research vantage point used a participatory inquiry paradigm, which may be unfamiliar to many readers as it was new to us. According to value of the researcher’s reflexivity inherent to this paradigm, we attempted to describe as faithfully as possible the development of our own progress in understanding issues involved in EOL care, both in the results and in the discussion. Postmodern qualitative inquiry and action research are subjective, participatory, flexible, iterative, and context sensitive with explicit expression of dynamics of the researchers’ own views [81‐84] including in the domain of healthcare [85]. Although our own conclusions may not apply elsewhere, we believe the process itself of deliberative dialogue between researchers and practitioners is reproducible and valuable, as it leads to interactive and collaborative learning [36].

Can simulation-based exercises improve handling EOL care? Studies show efficacy of simulation to enhance skills mostly among residents [13‐18, 86, 87], but may fail to improve practice [19] without field implementation and on-going supervision [88] by senior workforce. It is challenging to have chiefs of service participate in a training workshop, let alone to change attitudes and behaviors ingrained by years of practice. Our experience with organic teams provided an occasion for senior physicians to observe residents and nurses in what they do often alone on shifts and weekends, and realize the needs for improvement. Conversely, simulations gave a chance for junior teams to see role models in action. In addition, the exchange between senior people from different institutions provided an opportunity for reflection, cross-fertilization and learning about options for better practice. Our initial intention targeted communication skills for EOL care (as previous work [11‐18]), but as the project evolved, we became aware of deeper issues of competency and teamwork culture. Changing adult behavior for quality improvement may benefit from brainstorming, interactive learning and unlearning [30], listening for understanding [89] and mimicry [90]. More research needs to explore the value of simulation-based deliberative practice with providers in handling quality of care challenges and complex organizational learning [91]. This activity relates to what has been described in the literature as “evaluation capacity building” defined as a sustainable evaluation practice where members continuously ask questions that matter, collect, analyze, and interpret data, and use evaluation findings for decision-making and action [91]. This dynamic participatory paradigm may be more valuable than formally collected quantitative and qualitative static data most often used in reporting quality improvement projects. This mode of constructive cooperative exercise may be a framework for building organizational learning capacity with potential value in other challenges of quality in healthcare.

A series of unanticipated consequences emerged from our project: One participant conducted a study of preparedness to EOL at nursing homes (eventually published [92]) that was presented at the Ministry of Health and called forth a national survey of preparedness to EOL at hospitals. As a result, many institutions enacted guidelines and set up palliative care units. Participants spread by word of mouth the value of training for EOL care – resulting in demands for workshops from different disciplines: intensive care, dialysis, oncology, emergency and family medicine. Electronic media (including TV channels), newspapers and magazines covered the topic of EOL care with reference to our workshops. We are invited each year to present insights from our project in lectures at dozens of national professional conferences, palliative care courses, research seminars, and institutional staff meetings as well as at general public audiences. While we cannot determine causality, coverage by media and public discourse led in recent years to the erection of several national committees for improved policy, training and regulation of EOL care.