Development and Pilot Testing of a Simulation to Study How Physicians Facilitate Surrogate Decision-Making Based on Critically Ill Patients’ Values and Preferences

Context: There are no evidence-based programs to train physicians to facilitate shared decision-making based on incapacitated intensive care unit (ICU) patients’ values and preferences. Objectives: To develop a high-fidelity simulation to fill this gap. Methods: Case development involved 6 steps: 1) drafting a case about an elderly patient receiving prolonged mechanical ventilation; 2) engaging an expert advisory board to optimize case content; 3) revising the case based on advisory board input; 4) training actors to portray the case patient’s daughter; 5) obtaining physician feedback on the simulation; 6) revising the case based on their feedback. We conducted a cross-sectional pilot study with 50 physicians to assess feasibility and acceptability, defined a priori as an enrollment rate > 40 physicians/year, study procedures <75 minutes/participant, >95% actor adherence to standardization rules, and high physician ratings of realism and acceptability. Results: Advisory panel feedback yielded two modifications: 1) refocusing the case on decision-making about tracheostomy and percutaneous gastrostomy; 2) making the patient’s values more authentic. Physician feedback yielded two additional modifications: 1) reducing how readily the actor divulged the patient’s values; 2) making her more emotional. All 50 physicians enrolled in the pilot study over 11 months completed study procedures in <75 minutes. Actor adherence to standardization rules was 95.8%. Physicians’ mean ratings of realism and acceptability were 8.4 and 9.1 respectively on a 10-point scale. Conclusion: Simulation is feasible, acceptable, and can be adequately standardized to study physicians’ skills for facilitating surrogate decision-making based on an incapacitated ICU patient’s values and preferences.