Standardized Patient – Scenario Background

Scenario: Hospice/Home Care

Participants: Standardized Patient (SP). Standardized Partner

(SP). SP portrays the patient role. SP portrays the partner role.

Scenario Timeline: Hospice/Home Care (State #1 – 15 min. State

#2-15 min. State #3 15 min.)

Setting: Patient’s Home

Time: 8 a.m. or Sim Time

Summary: This four state scenario begins with initiation of

hospice in the patient’s home and ends with the patient’s death at

home. The first 2 states involve the use of standardized patients to

portray the patient role, and the patient’s partner role. The 3rd state

involves the standardized patient to portray the partner role. The 4th

state does not utilize any standardized patients.

#1 Home Hospice Initial Evaluation

Standardized Patient Role - Patient: You are a 65-year-old

female patient, Jules Morales, who has been diagnosed with Stage
4 Adenocarcinoma of the lung 4 years ago. You had been treated

with chemotherapy, and radiation, but have made the decision to

stop treatment, and start home hospice care. You are a retired

nursery/garden center worker. You live with your same sex

partner, Lucy, for the past 20 years. You have one son, Neil, who

is 42, and lives 20 miles away.

A home hospice nurse will evaluate you today. You are alert, and

oriented, awake and comfortable. You are lying down, covered

with a blanket. You will be wearing nasal oxygen at 2 liters per

minute. Your pain level is 1/10. You are receiving Morphine

Sulfate controlled release 100mg orally every 6 hours as needed

for pain, and you last took a dose one hour ago. You are eating

well. You are able to use the bathroom, but you express concern

that you feel weak, and short of breath walking from room to

room, and getting on and off the toilet. When asked about

advanced directives you explain that Lucy is the one who will

make decisions for you when you are unable, but right now you are

still talking over those decisions with the social worker.

Standardized Patient Role – Partner: You are Lucy, a 70-year-

old female, and the 20-year partner, and primary caregiver, for

Jules Morales. You have some minor knee problems. You are

supportive of Jules’ decision to discontinue treatment. You are the

one who will make decisions for Jules when she is unable. You are

a supportive caregiver, but concerned that Jules will need more

help with walking, and you are not strong enough to physically

support Jules.

When asked about advance directives you agree with Jules that

though you will help to make those decisions, you both are not

ready, and are working with the social worker.

State #1 (15 min): Students are expected to explain the purpose of

their visit, obtain vital signs, perform a focused respiratory

assessment, perform a focused pain assessment, perform a

functional assessment using the Katz ADL Assessment tool, and

assess knowledge of advance directives/durable power of attorney.

Students are expected to initiate falls precautions and order a

walker and a bedside commode based on the Katz ADL functional

assessment results. Students should provide reassurance to patient

and partner.

State #2 (15 min): Your condition is starting to decline. You are

experiencing more pain. You appear uncomfortable, restless, and

grimacing in pain. You have been put on a Fentanyl Patch for pain,

but complain of a 6/10-pain scale when asked. You remain on

nasal oxygen. Your breathing rate is increased to 24/minute. You

are now incontinent; unable to make it to the bathroom. Your

partner is at your side, and obviously concerned and worried about

your pain level.

Students are expected to perform a focused pain assessment. They

should check the fentanyl patch for date and time of expiration.

They should offer and administer additional pain medication

following the six rights. Students should confirm advanced

directive is present and signed. Students should provide emotional

support to Lucy.

State #3 (15 min): This state focuses on supporting Lucy through

the dying process of her partner. (Jules will be a Vital sim

mannequin.) Lucy understands Jules is dying. She has been

spending time at the bedside reading and talking to Jules, but Jules

has not been responsive for several days. Lucy greets home

hospice nurse. She is teary and quiet. She verbalizes her concern

that Jules is not experiencing any pain. She verbalizes her surprise

at how quickly Jules condition has changed. She continues to talk

to Jules, saying comforting statements. When the Vital Sim

Mannequin stops breathing, if the student hasn’t noticed, Lucy will

ask why Jules breathing has gotten quiet.

Students are expected to perform a limited physical assessment for

the dying patient, and explain to Lucy changes in respiration

during the dying process. Students are expected to check the

Fentanyl patch for date/time of expiration. Students should

encourage Lucy to continue to talk to Jules. Students are expected

to determine the patient has stopped breathing, and confirm

patient’s death by checking pulse and respirations, notify Dr. Davis

of patient’s death, and notify Hospice of patient’s death. Students

should provide emotional support to Lucy.

 Patient Information - #1 Home Hospice Evaluation

Full Name: Jules Morales MRN#:

Gender: Female Code Status: Full Code
Age: 65
Date of Birth: 2/7/1954
Chief Complaint Stage 4 lung cancer

History of Present Diagnosed 4 years ago with

Illness/Presenting Signs and Stage 4 adenocarcinoma. Has
Symptoms decided to stop chemotherapy
and radiation treatment, and
start home hospice care.
Medical History Stage 4 Adenocarcinoma of the
lung.
Hysterectomy age 44
Medications Morphine Sulfate controlled
release 100mg orally every 6
hours as needed for pain.
Docusate Sodium 100mg 1-2
capsules orally daily as needed
for constipation.

Family History Lives with partner of 20 years

Lucy.
Has one son Neil age 42.
Occupational History Retired from work in local
nursery/garden center.
Diet Tolerating diet

General Appearance Awake, comfortable. Lying

down covered with a blanket.
Pain Assessment Pain level 1/10. Last dose of
Morphine Sulfate was one hour
 ago.
Oxygenation Wearing Nasal Oxygen at 2
liters per minute.
Output Continent

Standardized Responses – Home Hospice Evaluation Scenario

– State #1 (15 min)

Student Questions Standardized Patient (SP)

Responses
How are you feeling today? “I’m feeling ok right now.”
How is your breathing? “My breathing is good when I
am lying down like this, but I do
get short of breath when I have
to walk to other rooms, or go to
the bathroom.”
Can you tell me on a scale of 1- “I would say 1/10. But I did take
10 if 10 is the worst, and 1 is a pain pill about an hour ago.”
the least, what is your pain
level now?
What pain pill did you take? “I took the Morphine. Right
Lucy? You gave me the
Morphine?”

Lucy Should Reply: “Yes

Katz Index of Independence in
Activities of Daily Living
Functional Assessment
Questions:
Bathing
Jules, I gave you the Morphine
an hour ago.”
Bathing: “I can do it mostly by
myself.”
Dressing: “I can get dressed by
myself.”
Toileting: “I have some
Dressing difficulty getting on and off the
Toileting toilet. Lucy has to help me.”
Transferring Transferring: “I feel more
Continence weak and short of breath
Feeding walking from room to room or
going to bathroom. I have to
stop frequently, and I rely on
Lucy to walk with me because
I’m afraid I might fall.”
Continence: “I can hold it and
make it to the bathroom.”
Feeding: “Lucy cooks for me,
but I have no problem eating by
myself.”

Lucy Should Reply: Jules is

Do you have an advance
directive?
Who is your healthcare proxy?
getting weaker. I’m worried
Jules might fall. I’m not strong
enough to hold her up, and it’s a
long walk to the bathroom. Is
there anything we can do to
make it easier?”
“Lucy and I have spoken with
the social worker about having
to make decisions when I am
too sick, but we aren’t ready yet.
We don’t have anything written
down yet.”
“Lucy is the one who will make
decisions for me when I can’t do
it anymore.”

Lucy Should Reply: “That’s

right Jules. I’ll be the one
making the decisions when the
 time comes. But not now; not
yet.”

Standardized Responses – Home Hospice Pain Assessment

Scenario – State #2 (15 min)
Jules is now visibly in pain, restless, and uncomfortable. The home
hospice nurse observes the patient grimacing, restless, and in pain.
Vital signs BP 96/66, HR 102, RR 24, O2 Sat 93%, Temp 97.9 F.

Note: You are in a lot of pain. Your answers will be short. You’re
breathing quicker, and you’re grimacing in pain.
How are you feeling? “Not good. I’m in a lot of pain.”
On a scale of 1-10 with 10 “6/10”
being the worst, and 1 being the
least, what is your pain
number?
Do you still have your Fentanyl “I think so.”
Patch on?
Do you want to take more pain “Yes.”
medication?
I know this may be difficult to “I think so, I can’t really talk
talk about, but have you and right now, ask Lucy.”
Lucy completed that advance
directive we talked about at the Lucy should respond: “Yes it’s
last visit? here in the yellow folder. I don’t
want Jules to suffer. We just
want her to be comfortable.”
Question for Lucy: How are “I’m ok. I’m just worried about
you coping? Jules. She seems to be in so
much pain. I’m not sure what to
do.”
 Standardized Responses – Home Hospice Dying Patient
Scenario – State #3 (15 min)
Jules is now unresponsive. VS BP 60/30 HR 30 freq. PVCs RR 4
O2 sat No Pleth, Temp 96.7 F.

Note: The focus here is on Lucy and supporting her during the
dying process by providing information about the changes in
respiration, and encouraging her to continue to talk to Jules.
How is everything? “Not good. Jules has been out of
it for a few days now. She is
breathing funny. I just hope she
is not in any pain.”
Do you understand why Jules is “Not really. I thought maybe she
breathing like that? was in pain, but couldn’t talk to
let me know.”
After Jules dies: Is there Lucy is Crying, and expressing
anything I can do for you? emotions after Jules dies. “What
am I going to do without her?”
“How will I go on?” “I’m going
to miss her so much.” “I’ll have
to call Neil, her son, and let him
know.”

Standardized Patient Checklist – Jules Morales

SP Name: Date:
Yes No N/A Comments
As Jules Morales, were
you satisfied with how the
students interacted with
you?
The Student
A. Maintains
Professionalism
I. Washes hand and
introduces self and
role/title
II. Identifies patient
(name, ID Band, DOB,
MRN#)
III. Maintains professional
manners (provides
privacy, eye contact,
maintains collegial
practice).
B. Uses Effective
Communication
Strategies
I. Maintains good body
language
II. Conducts the encounter
in a warm and friendly
manner
III. Lets you tell your
story, listens carefully,
asks thoughtful questions
(medications, support
mechanism, treatment
goals.).
IV. Shows interest in me
as a person, not acting
bored or ignoring what I
had to say.
V. Encourages you to ask
questions.
VI. Works collaboratively
with other team
member(s).
VII. Speaks in
understandable terms (no
medical terms), and listens
actively (e.g. let the
patient finish speaking
and responded
appropriately, appears
empathetic and involved).
VIII. Address the family
member respectfully and
involves him/her to
patient’s care (if
applicable).
C. Develops/initiates a
Culturally Competent
Patient Education Plan.
I. Assesses readiness to
learn and identifies
knowledge gap.
II. Builds and effective
and respectful relationship
with the patient.
III. Shows cultural
sensitivity when
communicating with the
patient.
IV. Provides an easy to
follow explanation about
the plan of care.
V. Shares accurate
knowledge about patient’s
current condition (Hospice
care for end stage lung
cancer) and its
management.
VI. Answers patient’s
questions and concerns
accurately.
D. Conducts Evaluation
of Care
I. Evaluates patient’s
responses to interventions
II. Invites patient and
relatives to ask questions
and express concerns (if
applicable).