Table 4 We show an example of the game’s medical content, mapped to behavior change techniques (BCT) and the narrative engagement framework (NEF). In this teaching case, Benjamin is a 70-year-old male who presents initially with confusion. He comes to the ED at the insistence of Moira (his sister and primary caregiver). His past medical history is significant for a recent admission for osteomyelitis. Six days after the initial presentation, Benjamin experiences an aspiration event with respiratory decompensation. Based on the dialogue option selected by the player (ACP conversation v. code status elicitation), the case unfolds through an initial encounter, second encounter, and then feedback from an in-game character (Felix – Andy’s boss)

Advance care planning (ACP)

conversation

...Andy: Hmm…how much information about what the future may hold would be helpful hear?”

Moira: “Since his wife died, I’m his only family. I would want to know what might be coming.”

Andy: “Ok. It looks like he has a pretty serious pneumonia. ... Given that this is his second serious hospitalization and infection in the last little while, I’m worried he might not have the strength to recover.”

Moira: “What do you mean?”

Andy: “It’s possible he may have more trouble breathing and we’d be faced with a decision about the ICU and life support. If that happened, there is a risk he could die.

Moira: “Oh my God. I knew he was weak but just didn’t think he was that sick!”

...Andy: “What are the things that are most important to him?”

Moira: “He’s stubborn and never could do anything that wasn’t his idea first. He wants to be out fishing with his son and grandson, and reading those spy novels he loves.” ...

Andy: “Could I make a recommendation?”

Moira: “Yes, please.”

Andy: “Given what you’ve told me about what matters most to Benjamin, I think a short trial of ICU-level care would make sense as long as we think that he could recover sufficiently to return home and live independently.”

Moira: “That makes sense to me”

...Andy: “When we talked last time, we decided that Benjamin would be open to a short trial of a breathing machine in the ICU if we get him through the illness and back home. Do you still think that would be what he would want?”

Moira: “I’ve been thinking about this ever since we first talked and yes, I do think he would want a chance to get better. But what if he doesn’t?”

Andy: “I can hear your worry. If he doesn’t improve in the next few days, then I worry he could die or, if he survives, need a long stay in a rehab facility…”

Moira: “He said he’d never go to a nursing home…”

Andy: “I remember you saying that. Let’s hope for the best, but if he doesn’t turn around, we will be prepared to shift our focus to comfort measures only.”

Moira: “I’m so glad I’ve been telling him how much I love him these last few days.”

Felix: “I hear Benjamin’s sister is having a hard time.”

Andy: “Her brother is dying. So yeah. But at least she knows she is doing what he wanted.”

Felix: “It’s great that you had the conversation when he came in. Things might have gone differently otherwise.”

Andy: “I just figured…70 year old guy, bad pneumonia, second recent admission. Even if he made it through this hospitalization, his risk of needing a nursing home or having a complication was pretty high.”

Felix: “I know. It’s so helpful to the family to talk about before a crisis. Waiting until the patient is decompensating or already in the ICU on life support means that no one is prepared. Everyone’s in panic mode. Then families end up racked with guilt later making decisions about withdrawing life support.”

Andy: “They don’t tell you about this part in med school – death is a taboo topic! But knowing how good it can feel to really help people through these hard times would have made me more motivated to learn how to have the conversation in med school.”

Code status elicitation

Andy: “Do you know if your brother would want CPR?”

Moira: “CPR? Like with the paddles? Well yeah, he would want that. I mean otherwise he would just die, right?”

Andy: “Right. I don’t think he’ll arrest, but I always like to ask to be sure I know what people would want, you know, in the worst-case scenario. It sounds like he would want us to do everything.”

Moira: “Well yeah, do everything you can to help him!”

Andy: “Your brother has a pretty serious pneumonia that we’ve been treating with antibiotics. Unfortunately, it looks like he’s gotten sicker and we may need to move him to the ICU and intubate him. (sharing medical update) Had you ever talked about whether he’d want a breathing machine if he got this sick?

Moira: “No, never. This has all happened so fast I just don’t know what to think.”

Andy: “Ok, well let’s think together. What are the things that are most important to him?”

Moira: “I just don’t know. How can this be happening? You said he would be okay. He was fine when he came in. I just…”

Andy: “I know that this is hard, but we need to make some important decisions here.”

Moira: “I am never going to have a chance to say goodbye, am I?”

Felix: “I hear the family of the patient Benjamin is having a hard time.”

Andy: “Yes. His sister is struggling because they never really spoke about his wishes.”

Felix: “But this is his second recent admission, isn’t it?”

Andy: “Yes. He was in with osteo a couple of weeks ago.”

Felix: “Do you think it would have helped if you started the goals of care conversation earlier?”

Andy: “What do you mean?”

Felix: “Well, 70 year-old guy who comes in after a recent admission and now has another bad problem? Best case scenario he could have bounced back and made it home, but there was a reasonable risk he’d deteriorate and end up in the unit on the vent. Even if he survives the vent he’s got about a 70% chance of dying in the next year. If you’d had a real sit-down discussion with them about that risk and assessed his goals and preferences, maybe this part wouldn’t be so hard.”

Andy: “I guess I just didn’t think it was time yet.”

Felix: “When you think ‘it’s time,’ it’s probably already too late. There’s no harm in hoping for the best but preparing for the worst. It can make hard decisions you might have to make later a little easier for both you and the family.”