End-of-Life Care and Life

Support Withdrawal
An Evidence-Based Research on an Educational
Simulation Training Program for Nurses
Lab Group C
Haley Kennedy, Abbey Spivey, Alyson Seall, Ashley Baire, Claire DeCraene, Himani Sullhan, Micah Johnson, & Sonia Garcia
 Introduction Video

FRONTLINE “Facing Death”

https://www.youtube.com/watch?v=N4objV7cLYg
:57-2:43

(Public Broadcasting Service, 2019)

 Introduction
Issue Lies in Ineffective Nursing Care
○ Feelings of underpreparedness and lack of confidence (Weil, et al.,
2016)
○ Lack of exposure to death and the dying process
○ Eager to learn

Familial Long-Term Anxiety after End-of-Life Care

○ Ineffective deliverance of communication during end of life care
(Hartog, et al., 2015)
○ Patient and their families felt true regret comes from what is not
communicated at the end of life (Keely, 2017)
 Introduction

Goal
○ Increase the nurses’ exposure to evidence-based simulation
protocols to enhance safe and quality patient care and family
outcomes (Weil, et al., 2016).

Significance to Nursing
○ Replaces sympathy with empathy (Addison & Morley, 2017)
○ Increases nurse’s confidence in providing competent care
○ Foster therapeutic communication skills (Addison & Morley, 2017)
○ Ideal for translation to bedside nursing
 PICOT Question Asked & Investigated:

What is the best practice for high acuity adult patients with a
terminal condition in the intensive care unit, what is the effect of
a simulation training program directed at nurses to improve
outcomes and family satisfaction for end-of-life patients
compared to the absence of a nurse simulation education training
program throughout the end-of-life process?
Summary of Current Practice for End-of-Life and Life Support Withdrawal

● Treat individuals with dignity and respect

○ Attentive, connected, friendly, helpful, unobtrusive, privacy, respect
● Monitor Pain
○ Listen to patient and give medications as needed; titrate medications
● Provide physical comfort
○ With breathing problems, skin irritation, digestive problems, temperature
sensitivity, and fatigue

(Hillman, et al., 2016; National Institute of Aging, 2019)

Summary of Current Practice for End-of-Life and Life Support Withdrawal

● Assist with basic needs as needed

○ Culturally appropriate foods, hydration, items from home
● Provide mental and emotional support and attend to spiritual needs
○ Chaplains, clinical psychologists, religious nuns
● Support and encourage the family's efforts to remain at the bedside
○ Attend to physical and emotional needs of patient’s family

(Hillman, et al., 2016)

 Summary of Current Practice

Not very many hospitals implement simulation trainings for end-of-life care

Current practice includes:

● Empathy training:
○ Completed a pre-experience/post-experience survey
○ Donned equipment that impaired sight, hearing, touch, and mobility
○ Created simulated rise and fall of the chest to mimic shortness of breath
○ Goal: to increase empathy levels within the staff agency

(Addison & Morley, 2019)

 Summary of Current Practice
Simulation training (EOL SBE):

Simulations were directed at enhancing and improving the skills of nurses to

improve quality of care, as well as patient and family satisfaction.

● Consisted of pre-briefing/post-briefing sessions

● 20 minute phases of illness progression/recreates a patients journey (Kirkpatrick, Cantrell, & Smeltzer,
2019)

● Educated, qualified staff guide the simulations

● Implement orders, symptom management, patient advocacy, therapeutic communication,
bereavement support, and build confidence (Kirkpatrick, Cantrell, & Smeltzer, 2019)

(Kirkpatrick, Cantrell, & Smeltzer, 2019)

 Summary of Current Practice

Simulation training (EOL SBE) Continued:

● Variations in simulations included:

○ Focus on teamwork skills and behavior with 3-4 participants (Semler, et al., 2015)
○ Hands-on practice with actors to explore barriers and challenges in providing optimal
end-of-life care (Brezis et al., 2017)
○ Standardized actors to portray a family member with the goal to focus on therapeutic
communication (Dame & Hoebeke, 2016; Tamaki, et al., 2019; Addison & Morley, 2019)
● Goal: Determine self-ability and improve nursing care experience, knowledge, self-
awareness, confidence, and performance
Synopsis of Current Literature Research Findings Related to Issue

● After End-of-Life Nursing Simulation Training Programs:

○ Nurses demonstrated an increase in empathy toward patients (Addison & Morley,
2019)

○ Nurses showed an increase in teamwork, a more positive attitude toward

caring for dying patients, and an increase in confidence and competence in
caring for dying patients in the ICU (Weil, et al. 2018)
● Recurrent theme of nurses feeling ill-equipped to provide end-of-life care
without end-of-life education programs (Hall, 2018)
● Nurses identified the desire to obtain more education in end-of-life care (Price et
al., 2017)
 Summary of Strengths & Limitations

Strengths:

● Use of blind observer, three different modalities to provide a negative control

which shows that no unexpected reactions occurred (Semler, et al., 2015)
● Use of pre and post simulation surveys (Dame & Hoebeke, 2016; Tamaki, et al., 2017;
Addison & Morley, 2019)

● The qualitative, descriptive nature of the study allowed for nurses to express
their perceptions of preparedness in providing end-of-life care without limit
(Hall, 2018)
 Summary of Strengths & Limitations

Strengths continued:

● Randomized controlled trial (Tamaki, et al., 2019)

● Large sample size of 583 nurses (Price et al., 2017)
● Interrater reliability within the process of exercising coding (Weil, et al., 2016)
● The study was done using a descriptive methodology which allowed for
common themes and perceptions to be discussed following the simulation
(Brezis et al., 2017)
 Summary of Strengths & Limitations
Limitations:

● Study performed in a specific hospital setting making it hard to generalize to

all hospitals (Weil, et al., 2018; Price et al., 2017)
● Use of three different teaching modalities making it difficult to compare
results in other manners (Semler, et al., 2015)
● Surveys measured perceived competence not actual competence (Price, et al.,
2017)

● Participants were only given five minutes in the simulation (Addison & Morley,
2019)
 Summary of Strengths & Limitations
Limitations continued:

● Small sample size (Weil, et al., 2018; Dame & Hoebeke, 2016; Tamaki et al., 2019)
● The participants were volunteers and knew they were being evaluated which
could possibly skew the results (Tamaki, et al., 2019)
● Actors participating in the simulations had more authentic responses from
pre-rehearsed scripts compared to an actual representation of patient and
family communication (Brezis et al., 2017)
 Evidence-Based Nursing Recommendations

Nursing Best Practice on End-of-Life Care Simulations

● Simulations should aim to increase ICU nurses’ confidence in providing end-of-life

care to improve patient and family satisfaction (Dame & Hoebeke, 2016)
● A goal of simulations is to increase nurses’ awareness of personal empathy capacity
(Addison & Morley, 2019)

● Simulations should include specific palliative care education on medication dosing,

code status, and timelines of treatment (Hall, 2018)
● Simulations should be specific to ICU nurses providing end-of-life care (Hall, 2018)
 Overall Application/Implementation to Nursing Practice

1) Specifics of Selection of the Target Audience/Population for Intervention

2) Initiation of Program: pilot-testing, phasing in or total implementation?

3) Staffing Needs

4) Distribution Channel for the Project

5) Facility and Equipment needs to fulfill program objective and services

6) Predictive Timeline for Program Implementation

 Specifics of Selection of the Target Audience/Population for
Intervention
Target Population:

● Registered Nurses that work in the Intensive Care Unit of a selected hospital in
Arizona.
● Informed consent will be obtained from participants prior to participation.

(Weil, et al., 2016)

 Initiation of Program: Pilot-Testing
Pilot-testing will focus on a small sample size of 16 registered ICU nurses from the target

population. Implementation of pilot-testing will create a finite control of the end-of-life

nursing simulation training program (Parker, 2016)

Why is this necessary?

● Identify unforeseen obstacles and failures with the simulation program prior to
implementation for the first time (Parker, 2016)
● Provide the opportunity for alterations in program methods and simulation scenarios
(Parker, 2016)

● Allow for participant survey response/feedback (Parker, 2016)

 Staffing Needs
● Executive Program Director: oversees the entire program and is charge of managing and

delegating specific aspects of the program. Hires the following program committee:

■ Marketing Coordinator

■ Hospital Project Manager

■ Four nurse educators with an MSN and background in ICU care

■ Volunteer BSN and MEPN students

■ External Project Evaluator

■ Internal Project Evaluator (Parker, 2016)

 Program Distribution Channel: Hospital
The program will be distributed in a hospital in Arizona

● The simulation center is located within the selected hospital

● Accessible and convenient to the registered ICU nurses who will be required
participate in the program
● Nurses will attend simulation program for 1
hour during assigned shift
● Before leaving the unit, patient care will be
delegated to the charge nurse or other staff
nurses
(Weil, et al., 2016)
 Facility and Equipment Needs

Simulation Equipment:

● Four SimMan 3G [Laerdal Medical] manikins

● Four hospital beds
● Manikin clothing
● Computer Program: LLEAP
● Miscellaneous simulation supplies (IV pumps, medication administration materials,
monitors, etc.)
 Distribution and Evaluation Tools of Program

● Distribution of Information: Social media outreach and discussion in huddle through

charge nurses
● Pre- and Post- Surveys for Simulation: Designed to evaluate the nurses’ perceptions
of the effectiveness of the simulation training program
● Post-Simulation Debriefing Sessions: Discussion of nurses’ perceptions of their
current ability to provide quality end-of-life care to patients and communicate with
family members
● Surveys for Families: Designed to obtain information regarding the family’s
satisfaction with the end-of-life care provided by nurses for their loved one. Sent out
3 months after hospitalization via email. (Weil, et al., 2016)
 Predictive Timeline for Program Implementation

● Program will be implemented over a time span of 2 years

○ First year [2020]: create and develop the program; pilot-testing
○ Second year [2021]: review and revise the program; phase in and
final implementation

(Parker, 2016)
 Table 1.1 Timeline for Planning, Implementation, and Evaluation for years 2020
End-of-Life Nursing Simulation Responsible Personnel J F M A M J J A S O N D
Training Program; A E A P A U U U E C O E
Programming Tasks Year 1; N B R R Y N L G P T V C
2018

Conduct a Community Needs Executive Program Director X X

Assessment

Executive Program Director will Executive Program Director X X

Assemble the program committee

Develop hypothesis, goals, and Program Committee X X

objectives

Apply for Grant Funding; Sigma Program Committee X X

Theta Tau, Agency for Health
Care Research and Quality

Design intervention w/ Executive Program Director and Program X X

activities/methods/ Assemble Coordinators
Resources the Simulation

Market the Program (social media Marketing Coordinator X X X

and hospital programming)

Pilot Test Program Hospital Simulation Room X X X

Process Evaluation External Project Evaluation and Program X

Committee
 Table 1.2 Timeline for Planning, Implementation, and Evaluation for years 2021
End-of-Life Nursing Responsible Personnel J F M A M J J A S O N D
Simulation Training A E A P A U U U E C O E
Program; Programming N B R R Y N L G P T V C
Tasks Year 2; 2018

Review and Revision of Year Internal Program Evaluator X

1 of Program Plan, Editing

Market the Program Marketing Coordinator X X

Continue to use the same Program Committee X X

hospital facility and resources

Phase-In Part 1 Exec. Program Director and Program X X

Committee

Phase-In Part 2 Exec. Program Director and Program X X

Committee

Total Implementation Exec. Program Director and Program X X

Committee

Impact Evaluation External Project Evaluator and X

Program Committee

Data Collection and Entire External Project Evaluator and X

Program Evaluation Program Committee
 Item Cost
Detailed Cost
Renovations/Setup $50,000
Analysis Hospital Beds (x4) $1,000 x (4) = $4,000

SimMan 3G (x4) [Laerdal Medical] $22,000 x (4) = $88,000

Initial Costs
Clothing for Manikins $50

Computer Program: LLEAP $0

Manikin Installations (x4) $1415 x (4) = $5,660

Control Room Equipment $3,260

Medical Equipment $22,000

(monitors, IV pumps etc.)

(Laerdal Medical Corp, 2014; Jeet, Total: $172,970

Prinja, & Aggarwal, 2017)
 Executive Program Director and Program Committee
Continued... Annual Salaries
(Ozarks Technical Community College [OTCC], Role Cost
2019; Jeet, Prinja, & Aggarwal, 2017)
External Project Evaluator $66,345
Annual Costs
Internal Project Evaluator $57,000
Item Cost
4 Nurse Educators with an $45,000 x 4 = $180,000
MSN and a Background in
Medical Supplies $20,000 Critical Care
(Bandages, syringes, IV (Part-Time)
fluids, etc.)
Executive Program Director $80,213
Add-on Supplies $1,500
(manikin maintenance)
Marketing Coordinator $54,000
Nurse Participation in $0
Simulation: Hospital Project Manager $41,500
1 hr during shift
Social Media Outreach $0
Total: $21,000
Total: $479,058
 Possible Revenues

Rented Out Simulation- $800

Fees (4 hrs)

Simulator Usage (4 hrs) $50 / simulator

First Year Total Cost
The Agency for Healthcare Up to 400,000
Research and Quality Initial Annual Total
(AHRQ) Costs Costs
(Grant)
$172,970 $479,058 -
The Sigma Foundation for $20,000
Nursing/American Nurse - $21,000 -
Credentialing Center-Based
Total $172,970 $500,058 $673,028
Practice Implementation
(Grant)

Sigma Theta Tau $10,000 Second Year: $500,058

International/American
Association of Critical-Care
Nursing
(Grant) (OTCC, 2019; Laerdal Medical Corp, 2014; Agency for
Healthcare Research and Quality, 2019)
 Previous Implementations and Proactive Argument
● Angelo State University: high fidelity ● According to the gathered
simulation laboratory, $750,000. evidence-based research,
● According to the NLN Center for end-of-life care is deficient
Innovation in Simulation and Technology, in interpersonal skills,
freestanding simulation centers total an palliative care knowledge,
estimated $200,000 to $1.6 million. lack of training, and ethics.

(Angelo State University, 2019; Brezis et al., 2017; Lippincott Nursing Intervention, 2017)
 Risk vs. Benefit
Risks

● When End-of-Life Nursing Simulation Training Programs are not implemented:

○ Nurses lack confidence in discussing end-of-life care with patients and their families
■ Withdrawal of care, realistic prognosis, and code status
○ Reduction in therapeutic communication among nurses and patients
○ Absence of empathy among nurses providing end-of-life care
○ A decrease in patient safety
○ Decreased communication among interdisciplinary teams
● Implementation Costs for the Institution
(Price et al., 2017; Addison & Morley, 2018)
 Risk vs. Benefit
Benefits

● Improve nurse team collaboration

● Improve nurses’ confidence in providing end-of-life and palliative care
● Increase ability to set goals and desired outcomes for care
● Increase awareness of personal empathy capacity
● Increased family and patient satisfaction
● Improve ability to stop and listen
● Increase in patient comfort during end-of-life
● Nurses feel more prepared for end-of-life care
● Decreases the anxiety of “not knowing what to say”
(Weil, A., et. al., 2018; Addison & Morley, 2018)
 Evaluation
● The family of the patient with a terminally ill condition
will report an increased satisfaction level with their loved
one’s care, using a likert scale on a survey after ICU
nurses complete one end-of-life care simulation training.
● Each family member of the patient with a terminally ill
condition will report a two level reduction of anxiety via
the 0-10 anxiety rating scale known as HAM-A during the
issued survey.
● The patient’s non-verbal pain scale score will decrease by
2 points by the end of the shift.
 Evaluation
● The ICU nurses will be able to decrease the anxiety of the family of a patient that is
terminally ill by attending one end of life care simulation.
● The ICU nurses will demonstrate an increase in knowledge, self awareness, and
assessment regarding end of life care in a post-simulation survey completed after
the simulation.
● The ICU nurses will verbalize an increase in confidence in providing end of life
care in a five minute discussion after the end of life care simulation.
 Summary of Introduction, Issue, and Supportive Studies

● Minimal exposure to the dying process and death in nursing school

● ICU nurses feel they lack sufficient knowledge and preparation to provide quality
end-of-life care.
● Supportive studies revealed that ICU nurses desire additional nursing education
programs to improve end-of-life care.
● The evaluation of end-of-life simulation programs showed an increase in the nurses’
perceived ability to care for terminally ill patients and support their families.
○ Increased self-confidence, a higher level of competence, and enhanced therapeutic
communication skills
 Discussion of Best practice, Application to Facility, and Cost
Analysis

● Best practice should target ICU nurses caring for individuals at the end-of-
life (Hall, 2018).
● Best practice should include empathy and communication training in
simulation programs to increase ICU nurses’ confidence and therefore
improve patient outcomes and family satisfaction (Dame & Hoebeke, 2016; Addison &
Morley, 2018).

● The simulation will be applied to one hospital in Arizona over a 2 year time
span that includes the planning, funding, implementation, and evaluation
(Parker, 2016).
 Discussion of Risk versus Benefit

● A risk is that the simulation is expensive, coming to a total of $1,173,086 for the 2
years (Laerdal Medical Corp, 2014; Jeet, Prinja, & Aggarwal, 2017; OTCC, 2019).
● Without the simulation there is a lack of confidence, empathy, therapeutic
communication among nurses and a lack of safety for patients (Addison & Morley, 2018).

vs

● Benefits include increased confidence, improved communication skills, and increased

awareness of personal empathy capacity among nurses (Weil, et. al., 2018; Addison & Morley, 2018)
● Increased safety for patients, and a reduction in anxiety and stress on the family (Keely,
2017)
 Conclusion
● The implementation of an End-of-Life
Nursing Simulation Training Program in
a selected hospital can enhance ICU
nurses’ perceived preparedness and
confidence in providing quality end-of-
life care to patients with terminal illness.
● The end result will be improved patient
outcomes and greater family satisfaction.

Closing video of patient outcomes (1:43): https://www.youtube.com/watch?v=0FfJyBPD9dI

(Smith, 2015)
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