Difficult Conversation Case: Death Notification
Correspondence should be addressed to Stephanie Stapleton, MD at snstaple13@gmail.com
DOI: https://doi.org/10.21980/J8.52354
ABSTRACT:
Audience: This case is meant for senior emergency medicine (EM) resident physicians as a preparatory tool for the American Board of Emergency Medicine Certifying Exam. However, it is applicable for EM residents at all levels of training.
Introduction: Difficult conversations are an integral part of the practice of emergency medicine. Competent EM physicians routinely engage in challenging conversations with patients and their families (eg, delivering bad news, disclosing medical errors, providing death notifications).1 Despite their importance, communication skills are often not formally taught in residency training.2 Instead, learners frequently rely on role modeling to develop the skills necessary to navigate these difficult situations.3 Incorporating structured education and training around these challenging encounters has the potential to significantly enhance both learner preparedness and patient care.2,4,5
Educational Objectives: This Observed Structured Clinical Examination (OSCE) is intended to cover the topic of Difficult Conversations. The overarching educational goal of this case is to assess learners’ communication skills, emotional responsiveness, and ability to facilitate a death notification conversation. Participants will be evaluated on their ability to communicate in an empathic, patient-centered manner while leading a difficult discussion. Successful participants will establish rapport, actively listen, disclose sensitive information clearly and compassionately, and respond appropriately to emotional reactions. By the end of the session, learners should be able to: (1) establish rapport with the patient’s family by initiating introductions and creating a supportive environment, (2) assess the family’s baseline understanding of the patient’s condition by using open-ended questions and active listening to elicit their perspective, (3) communicate the patient’s death clearly and compassionately, using concise, non-technical language, (4) demonstrate empathy by responding appropriately to emotional reactions, validating concerns, and addressing questions thoughtfully, and (5) provide closure to the conversation by summarizing key points, offering emotional support, and clarifying the next steps in the patient’s care.
Educational Methods: We designed a single-station OSCE focused on the delivery of a death notification. This format is aligned with the Difficult Conversations module of the newly implemented ABEM Certifying Exam, which emphasizes communication skills and emotional responsiveness in a challenging simulated clinical encounter. In this OSCE, the learner is presented with a brief case summary describing the unsuccessful resuscitation of a patient in cardiac arrest and is tasked with delivering the bad news to the patient’s family. The family member is portrayed by a standardized participant who follows a structured script and provides standardized emotional and verbal cues. The examiner assesses learner performance using a detailed, behaviorally anchored checklist that includes both verbal and nonverbal communication skills. This OSCE structure mirrors the ABEM Certifying Exam to promote realism, consistency, and educational relevance.
Research Methods: This simulation case was initially developed by three subject matter experts with backgrounds in EM and simulation-based education. To ensure clinical accuracy, coherence, and educational relevance, the case underwent a structured peer review process. Using the Simulation Scenario Evaluation Tool (SSET),6 a panel of three external reviewers evaluated the case and provided targeted feedback on elements such as case realism, scenario progression, clarity of learning objectives, and alignment with assessment metrics. Following peer review, the case was pilot-tested at two EM residency programs and a national EM academic conference. These pilot implementations aimed to evaluate the case’s clarity, feasibility, and instructional design within authentic educational environments. During these sessions, faculty facilitators and learners engaged with case materials, including a standardized participant script, examiner overview, and critical actions checklist. Feedback from this beta testing phase guided revisions to enhance standardized actor prompts, case logistics, and assessment materials.
Results: Expert reviewers reported strong agreement that the learning objectives of the simulation case were specific, measurable, action-oriented, relevant, time-bound, and appropriately aligned with the experience level of the intended learners. They also noted that the clinical context, scenario progression, and integrated critical actions effectively supported these learning objectives. Faculty facilitators expressed strong agreement that the accompanying case materials and resources offered adequate guidance to support independent implementation of the case at their own institutions. Learner feedback indicated that both the written and verbal instructions were easy to follow and that the experience was valuable for preparing them for the ABEM Certifying Exam.
Discussion: This simulation case effectively met its educational goals and proved to be a useful resource for preparing learners for the Difficult Conversations module of the ABEM Certifying Exam. Facilitators gave high ratings across key areas, emphasizing the clarity and quality of the learning objectives, scenario flow, and supporting materials. Learners consistently noted that the case offered valuable practice in communication skills and emotional engagement. These results support the use of structured OSCEs within EM residency curricula. Through simulation, this case contributes to closing educational gaps, fostering standardization, and improving learner readiness for board certification.
Topics: Death notification, delivering bad news, communication, difficult conversations, American Board of Emergency Medicine, Certifying Exam.
