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State of the science: the doll is dead: simulation in palliative care education
  1. Lowri Evans1 and
  2. Mark Taubert2
  1. 1 Speciality Registrar in Palliative Medicine, Wales Deanery, Cardiff University School of Medicine, Cardiff, UK
  2. 2 Palliative Medicine, Velindre University NHS Trust, Cardiff, UK
  1. Correspondence to Mark Taubert, Honorary Senior Lecturer and Consultant in Palliative Medicine, Velindre University NHS Trust and Cardiff University School of Medicine, Cardiff, Caerdydd CF14 2TL, UK; mtaubert{at}


Objectives Both simulation and high-fidelity simulation involving manikins, clinical training suites, wards, computer programs and theatres have established themselves in medical undergraduate and postgraduate education. Popular among students, they have been shown to be effective learning tools. Contrasted with this is the potential risk to patients and their proxy associated with learning ‘at the bedside’, which can pose a real challenge in medical and palliative settings. The need for education and training methods that do not expose the patient to preventable communication blunders from less experienced practitioners is a priority.

Methods Here, we provide a summary review on the current literature and evidence for simulation and high-fidelity simulation in palliative and end-of-life care settings, and discuss potential uses of technologies including virtual and augmented reality in future training.

Results The most common form of simulation in palliative medicine is often an actor-based role-play scenario with particular emphasis on communication skills. This is expensive and time-consuming to set up. Less evidence was found on the use of high-fidelity simulation in end-of-life care teaching.

Conclusion Palliative medicine has been slow to adapt to an educational method and environment that now is widely used across other areas of healthcare. There has been less emphasis on training with manikins and even less on using computer simulation and virtual reality environments to recreate challenging end-of-life care scenarios. We provide some examples of where this could benefit the curriculum.

  • simulation
  • high fidelity
  • education
  • virtual reality
  • augmented reality
  • mannequins
  • ethics
  • end of life care
  • palliative

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Simulation and high-fidelity simulation (HFS) involving manikins, suites, wards and theatres have become established in medical education. They are popular among students and have shown to be an effective learning tool. 1 Palliative medicine has been slow to adopt this widely used educational method. Simulation in palliative medicine is often an actor-based role-play scenario with emphasis on communication skills. This is expensive and time-consuming. There has been less emphasis on training with manikins or HFS by computer to recreate distressing end-of-life care scenarios. We provide a summary of current evidence for simulation in palliative care education and look at potential future opportunities.


The potential risks to patients and their proxies associated with learning ‘at the bedside’ are a real challenge in palliative settings. The need for education and training methods that do not expose the patient to preventable blunders of less experienced practitioners is an urgent priority.2


Definition—artificial representation of a real-world process to achieve educational goals through experiential learning to replicate clinical scenarios. 3

Evidence suggests that a significant proportion of adverse events in healthcare are triggered by problems with communication, decision-making, leadership and teamwork, that is, non-practical, non-technical skills.4 Simulation, with prepared actors portraying common scenarios, is an effective strategy that addresses the ethical considerations of ‘practicing’ on human patients. It may increase patient safety, improve clinical judgement and arguably create better communicators. Challenges include expense and time to set up.

High-fidelity simulation

Definition—a manikin programmed to provide realistic physiological responses to the participant’s actions in a realistic environment with the use of medical equipment. 5

HFS involving manikins is now a common educational tool in medical and nursing undergraduate curriculums. Scenarios generally revolve around acute specialties. Anaesthetics were an early adopter.6 Death within simulation has been controversial, with concerns about causing distress, psychological harm or negative impact on students’ confidence.7 8 Although there is no educational consensus whether simulation manikins should ‘die’ in undergraduate scenarios, there is evidence that senior medical students find this a useful learning experience.9 HFS improves end-of-life care learning for nursing undergraduates.10 There may be a perception that HFS is not useful in palliative medicine education since it is a less acute specialty. There is a perceived lack of prioritisation for access to equipment and interventional techniques exposure. However, many university campuses will have simulation suites and technical staff that can be used in undergraduate teaching. Many hospitals already have portable equipment for ‘point of care’ simulations set up anywhere onsite, or off-site, which provides great flexibility and is significantly cheaper.11

Uses in palliative medicine

The medical literature contains few papers describing the use of simulation and HFS in palliative medicine. Fewer still appear to test the transferability of skills learnt in a simulated setting to real-life practice. Venkatasalu et al 10 found that HFS better prepared nursing students for their first healthcare placements both emotionally and in terms of ‘hands on’ skills. Rayment et al 12 demonstrated improved confidence in advance care planning by generalists using simulation with actors. Scenarios involved a simulated ward environment, an HFS manikin and an actor playing a carer.

In a small study of seven medical students, tutorials used HFS to teach communication skills for cardiopulmonary resuscitation with patients and carers.13 Students reported that the HFS scenarios were more realistic than low-fidelity (‘role-play’) simulation. This improved learning from the sessions and confidence among some students.


While simulation remains expensive and arduous to set up, it presents many potential palliative medicine learning opportunities. For example, Do Not Attempt Cardiopulmonary Resuscitation decisions for a deteriorating patient and discussions with their proxy can be readily integrated into an HFS. These can be linked into existing acute scenarios, thereby integrating palliative medicine with acute specialties.

Simulation strives to be as realistic as possible; demonstrating a more realistic patient pathway can facilitate this.14 The reality that not every patient with an acute illness will recover, even with correct treatment, is a difficult lesson every junior physician faces with varying levels of support. Newly qualified doctors often cite death and terminal illness as a source of stress.15 HFS, facilitated sensitively with an expert debrief, can explore this in a controlled environment, at the student level and beyond. Debrief is where most learning occurs in simulation.16 This reflective process lends itself well to support students in dealing with death and dying.

Advanced life support courses that teach practical techniques may also give an opportunity to learn about some of the most challenging conversations in healthcare, making this an ideal setting. Palliative medicine trainees are expected to be able to manage and prove competencies in emergencies like anaphylaxis, opioid toxicity and terminal haemorrhage.17 HFS is now used to train and assess palliative medicine trainees in these acute scenarios.18 Simulation allows trainees to refresh and demonstrate competencies for infrequent but important events and is underutilised. It is time for realistic, simulated scenarios covering daily end-of-life care scenarios to be implemented at undergraduate and postgraduate levels.

The future

The term virtual patients (VP) describes different modalities, from video-recorded actors to manikin training models for laparoscopic procedures. In this context, it relates to computer-generated simulated patients to develop patient encounter skills.19 Meta-analyses demonstrate that VPs can improve communication skills and clinical and ethical reasoning.20 21 Traditionally, communication skills teaching within palliative care includes role-play using simulated or standardised patients played by actors. However, VPs are increasingly being used alongside. VPs can standardise the learning experience across a curriculum and may be adapted according to curriculum requirements. Many medical schools develop their own VP scenarios. Use of VPs may help students improve communication skills and allows repeated practice in a safe environment.22 For example, students can safely trial various communication strategies for breaking bad news without the fear of humiliation or causing distress.

Virtual and augmented reality and gamification of real-life scenarios are likely to play an important part in future education. Trainees can be exposed to stressful situations in a near-real setting and chose options. It is already possible to simulate bystander cardiopulmonary resuscitation in virtual reality. Palliative care training computer games in virtual reality could be a mainstay of future education. One of the biggest challenges of current VPs is a sense of realism and authenticity.22 As technology improves and develops, VPs will become a common adjunct in communication skills teaching. Trainees in palliative medicine may wish to start engaging with virtual reality content designers and computer game developers in the first steps to an exciting new format of learning and assessment.



  • Contributors LE wrote the initial draft, and MT wrote and edited the document.

  • 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.

  • Patient consent Not required.

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