MedEdPORTAL (Nov 2014)
Acute Overdose in the Setting of a Signed ‘Do Not Resuscitate’ Order
Abstract
Abstract Introduction This simulation case is targeted towards third- and fourth-year medical students, emergency medicine (EM) residents, EM nurses, and adjunct EM staff. The purpose of this case is to improve interdisciplinary communication skills, recognition and management of an acute intentional overdose, recognition of the ethical dilemmas regarding Do Not Resuscitate (DNR) orders complicated by an acute intentional overdose, general crisis resource management skills through conflict resolution, team-based communication, and patient-centered care. The simulation folds together the reality of practicing EM by way of bona fide critical-care medicine, psychosocial complications, and medical ethics. Methods The simulation takes approximately 20 minutes to run, followed by a debriefing lasting roughly 30 minutes. Three to four trainees at a time move through the scenario, led by an upper level resident and at least two other residents (PGY1 or PGY2) or students (fourth-year). Two faculty members and two senior residents observe the training scenario. The simulation is based on a composite of cases seen in our Emergency Department regarding intentional overdoses and DNR orders with concomitant family conflicts. An intentional medico-ethical dichotomy has been built into the case to enhance its breadth of use among learners at various levels of training. For example, earlier learners (students and interns) may focus on the medical management of the aspirin overdose and its associated pathophysiological ramifications. More advanced learners may likely understand management of salicylate toxicity and thus be able to focus on and learn from the ethical issues the case presents. Results The overall resident and student evaluation of this case has been high: 4.75 on a 1-5 (low-high) scale. Discussion This case has not been used to formally evaluate residents, medical students, or medical staff. Depending on the learners involved in the simulation, different aspects can be emphasized at the instructors' discretion. EM physicians encounter these complex issues daily, and recognition of and familiarity with complex psychosocial issues is incumbent on their training.
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