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Simulation to improve medical student confidence and preparedness to care for the dying: a feasibility study
  1. Geoffrey Wells1,
  2. Julia Montgomery1 and
  3. Andreas Hiersche1,2
  1. 1 Department of Medical Education, Brighton and Sussex Medical School, Brighton, UK
  2. 2 Department of Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  1. Correspondence to Dr Geoffrey Wells, Department of Medical Education, 344a Watson Building, Brighton and Sussex Medical School, Brighton BN1 9PX, UK; g.wells{at}


Background Undergraduate teaching currently fails to adequately prepare doctors to deliver ‘end-of-life’ care. Despite much evidence supporting simulation-based teaching, its use in medical undergraduate palliative and ‘end-of-life’ care curricula remain low.

Aim This study assesses whether simulation can improve the confidence and preparedness of medical students to provide holistic care to dying patients and their families, from clinical assessment to symptom management, communication and care after death.

Methods Six fourth-year medical students undertook individual simulations involving a dying patient (high-fidelity simulator) and family member (actor). Intentional patient death occurred in four of the six scenarios (although unexpected by students). Pre-simulation/post-simulation thanatophobia questionnaires measured student attitudes towards providing care to dying patients. Thematic analysis of post-simulation focus group transcripts generated qualitative data regarding student preparedness, confidence and value of the simulations.

Results Thematic analysis revealed that students felt the simulations were realistic, and left them better prepared to care for dying patients. Students coveted the ‘safe’ exposure to dying patient scenarios afforded by the simulations. Observed post-simulation reduction in mean thanatophobia scores was not found to be statistically significant (p=0.07).

Conclusions Results suggest a feasible potential for simulations to influence undergraduate medical student teaching on the care of a dying patient and their family. We believe that this study adds to the limited body of literature exploring the value of simulation in improving the confidence and preparedness of medical students to provide ‘end-of-life’ care. Further research into the cost-effectiveness of simulation is required to further support its application in this setting.

  • terminal care
  • education and training
  • quality of life
  • symptoms and symptom management
  • supportive care

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Simulation training has been shown to improve the preparedness of medical practitioners in acute, trauma and intensive care settings.1 Literature suggests that skills underpinning palliative medicine teaching (understanding, emotional preparedness and debriefing skills) can be taught using simulation.2

Despite established use of simulation within undergraduate nursing programmes, ‘end-of-life’ care teaching follows a more theoretical approach in medical undergraduate curricula.2 ,3

In 2017, a UK medical school survey found that 97% (n=33) of medical students felt that they should be exposed to ‘end-of-life’ scenarios, with 88% (n=30) stating that simulated patients should be allowed to die as this would help to prepare them to deal with death by being able to practice in a safe, realistic environment.4

Lack of exposure to dying patients and reduced access to ‘end-of-life’ care education are significant barriers to medical undergraduate teaching.5 6 Among all qualified doctors, Foundation Year 1 (FY1) trainees spend the most time with dying patients, often looking after an actively dying patient on their first day.5 The General Medical Council recognise ‘end-of-life’ care as a core competency7; therefore, it is important that medical schools provide the necessary practical reinforcement of theoretical skills in ‘end-of-life’ care to enable our graduates to meet these expectations.8

Simulation may be the answer to increasing student exposure to as-it-happens ‘end-of-life’ situations, allowing general theoretical concepts to be put into practice, with expert facilitators on hand to help to guide students through scenarios.

The aims of this study were to:

  • Explore baseline and post-simulation attitudes of medical students towards caring for a dying patient.

  • Ascertain whether simulated experience of caring for a dying patient and their family could positively influence medical student confidence and preparedness.

  • Ascertain whether simulation could be an acceptable method by which to teach this subject.


This was a feasibility study. Thematic analysis of post-simulation focus group transcriptions facilitated data collection on the acceptability of the simulations to the students, whether they felt simulations were realistic, and how this may fit into the current undergraduate curriculum.

A separate thanatophobia scale questionnaire9 was deployed to identify any pre-simulation/post-simulation changes in attitudes towards caring for a dying patient.

Participant selection

Six participants were required to allow simulations to run within the limitations of the student timetable and simulation suite availability. To be eligible, students had to be in their fourth year of study at our medical school and have completed their palliative care rotation. This was to ensure all students had received the same amount of palliative care teaching at the time of the study.

Eligible students (n=155) were randomly assigned a number using Excel, and were contacted in ascending numerical order with basic study details until six students volunteered their participatory interest. Further study information and a consent form were supplied to interested individuals. Students who declined the invitation were not expected to provide a reason for doing so.

Study setting

Simulations took place in the high-fidelity simulation suite (with observation room) based within the university campus in July 2018. Following group introductions, students received a 15 minute refresher lecture on symptom control in the dying patient (delivered by a palliative medicine consultant).

Each scenario was designed to involve a single student, simulated patient (high-fidelity SimMan), simulated relative (actor) and simulated nurse (professional ward nurse) in a ward side-room environment. Basic physiological SimMan parameters were set for each scenario, with respiratory rate, audible chest sounds and pulse rate changing between scenarios to foster realism. A mock set of patients’ notes containing the last consultant ward round entry plus a mock drug chart (with prescribed ‘end-of-life’ medications) were available for each scenario. In all scenarios, the simulated patient was unconscious.

Study scenarios

The overarching aim of each scenario was to provide each student with exposure to an aspect of care in relation to a dying patient.

In the first four scenarios, the simulated patient died (planned death) at around 6 minutes. Students were intentionally unaware this would happen. The goal of these scenarios was to enable the student to practice clinical assessment of a dying patient, manage uncertainty and appropriately manage the situation and relatives’ response once death had occurred (responses differed between scenarios, ranging from distress, anger and guilt to concerns regarding medications).

In the final two scenarios, the patient remained alive. Students were expected to carry out a focused clinical assessment, and address concerns from the relative regarding clinically assisted nutrition and hydration at the ‘end-of-life’, spiritual concerns and fear of what death may look like.

Data collection and analysis

A 20 minute post-simulation focus group (conducted by GW) facilitated the collection of qualitative data. Questions focused on students' feelings following participation in the scenarios, their views on simulation reality and whether they felt simulation could improve confidence and preparedness of future doctors to look after dying patients. Answers were recorded using a Dictaphone, before being transcribed and anonymised (by GW). To foster credibility in data analysis, thematic analysis was conducted independently by all the three authors to the point of saturation before meeting as a group to agree on final themes.

Volunteer participants were sent a pre-simulation thanatophobia scale questionnaire. This Likert-scale tool is validated to obtain quantitative data measuring medical students’ attitudes towards caring for dying patients.10 Participants were asked to complete a second, identical, post-simulation questionnaire. Both sets of questionnaires were anonymised. Pre-simulation and post-simulation scores were tabulated before being analysed using SPSS software.


A total of 40 students (26% of the fourth-year cohort) were contacted prior to achieving the desired participant number of six (15%). Average participant age was 23.3 years, with a male/female ratio of 2:4.

Quantitative analysis

A reduction in mean thanatophobia score was observed following the simulations for all questions within the questionnaire, from 3.6 (pre-simulation) to 2.4 (post-simulation). A paired samples t-test concluded that while a difference existed between pre-simulation and post-simulation means, the result was of no statistical significance (p=0.07).

Qualitative analysis

Four main themes emerged via thematic analysis of focus group transcripts. The students were designated with a letter (A–F) when attributing quotes to evidence emerging themes (table 1).

Table 1

Emerging themes with supporting quotations


This feasibility study highlights medical students’ continued lack of exposure to dying patients in the clinical environment, resulting in them experiencing challenges in relating classroom-based theory to clinical practice. This echoes published reports, which demonstrate that lack of undergraduate exposure prevents students from realising personal learning needs, leaving them under-prepared for working with dying patients in the post-qualification setting.5 11 12

While some students felt the scenarios were realistic, others felt that, in reality, you would likely be much busier when working in an on-call situation. This may reflect the views of those students who have experienced on-call shifts as part of their clinical attachments. This, however, is encouraging and adds strength to the positive value of ward experience at the undergraduate level. It also helps to demonstrate that increasing undergraduate exposure to challenging patient encounters will leave individuals better prepared as they enter their FY1 year.

Students found the simulations to be safe and controlled, and felt able to make mistakes without fear that their actions would have any clinical consequence. Many students commented on the desire to repeat the simulation at a future date in a bid to further improve confidence. Repetitive practice in medical simulations is associated with improved learner outcomes, with a ‘dose–response’ nature to simulation.13 14 However, repeated simulations would incur greater financial and resource commitments.

Quantitative data analysis suggests a trend towards a reduction in thanatophobia among the participants as a result of the simulations, with students feeling less uncomfortable, uneasy or helpless when thinking about looking after dying patients. However, these results were not statistically significant (p=0.07), and given the low participant number, it is likely that this study was insufficiently powered to find a significant difference.

This study has three limitations. The small sample size was dictated by student, facilitator and resource availability. This reduces the chance of obtaining statistically significant and generalisable data. Second, a lack of validated tools makes it challenging to fully assess confidence and preparedness of students in the context of palliative and ‘end-of-life’ care. However, the available validated tools allow us to identify positive changes in the attitude of students regarding care of the dying. Finally, the cost implications of running these simulations on a larger scale need to be ascertained to justify any potential inclusion into an undergraduate curriculum.


This study adds to the lack of literature detailing the use of simulation to teach undergraduate medical students how to provide ‘end-of-life’ care. The results are encouraging, suggesting simulation could be a feasible and acceptable way of increasing medical student exposure to the care of a dying patient and their family. Those responsible for developing medical undergraduate curricula may find such research findings informative when considering the use of simulation as a tool to enhance the teaching of ‘end-of-life’ care, placing greater emphasis on addressing the learning needs of their students as future junior doctors.

Ethics statements

Patient consent for publication

Ethics approval

Ethical approval was granted from the University’s Research Governance and Ethics Committee (RGEC).


The authors would like to thank all the students who volunteered their participation in this study.



  • Contributors GW is a research fellow in Medical Education at Brighton and Sussex Medical School. He has completed 2 years of training as a registrar in palliative medicine, and is completing a 2-year MD at the University of Sussex prior to completing registrar training. He is the primary author. JM is an emeritus senior lecturer in Medical Education. She is also a retired Consultant Obstetrician and Gynaecologist. JM undertook and advised on thematic analysis of data, given her expertise in this field from her previously published research. JM also reviewed and edited the final manuscript prior to submission. AH is a Macmillan Consultant in Palliative Medicine and Lead Clinician in Palliative Care at the Royal Sussex County Hospital, Brighton. He is also an honorary senior clinical lecturer at Brighton and Sussex Medical School. AH helped to facilitate the simulations, reviewed the content for accuracy and reviewed/edited the final draft of the manuscript prior to submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.