Goals of Care Discussion in Progressive Respiratory Failure
2m 58s encounter
This is an unedited encounter from ClinicalSim. Review the same recording, transcript, and feedback report the learner received.
The scenario
Your role
You are the critical care fellow covering the ICU overnight.
A 76-year-old man with advanced COPD, heart failure, and chronic kidney disease was admitted with pneumonia and progressive respiratory failure. Despite antibiotics, noninvasive ventilation, and full ICU support, he has deteriorated: he is now mechanically ventilated with rising vasopressor requirements, about four hours after intubation on hospital day five.
His daughter and designated medical decision-maker, Sarah Mitchell, has just arrived at the bedside, exhausted from traveling, and is asking to speak with a physician. Your attending is not immediately available. You are meeting with Sarah now, one-on-one, in a quiet ICU family consultation room to provide an update and discuss goals of care: including whether her father would want escalation to CPR, dialysis, or prolonged life support if he worsens.
Sarah recalls her father saying he 'never wanted to be kept alive by machines,' but there is no written advance directive, and her out-of-state brother feels differently.
Objectives
- Establish a therapeutic relationship with the family decision-maker in a challenging ICU encounter, mitigating communication barriers and building rapport before delivering prognostic information.
- Deliver basic prognostic information using REMAP: reframe the clinical situation and expect and respond to emotion using NURSE statements.
- Elicit the patient's values, goals, and preferences through open-ended questioning; acknowledge uncertainty and conflict without false reassurance.
- Apply ethical principles to surrogate decision-making around code status; offer treatment options free of bias while consistently honoring the patient's choice.
- Use shared decision-making to align Sarah's understanding of her father's values with treatment options; propose a personalized plan and confirm understanding.
Listen to the recording
Hear the 2m 58s recording
This is a partial conversation. The recording ends before the clinician and daughter agree on a care plan; the REMAP feedback reflects the conversation that took place.
▶Transcript11
Doctor… I need you to help me understand what my dad would go through if his heart stops. I don't want to make the wrong decision.
Hi, Sarah. This is Dr. Risman. Um, I wanted to share some news about your dad.
Before s- before I share it, I really would like to have an understanding about what it is that you've heard and what it is that you see when you look at him.
Thank you for coming, Dr. Risman. I… I just got here, and honestly I'm still trying to catch up. I know he came in with pneumonia, and they told me a few hours ago they had to put him on the breathing machine and now there's something for his blood pressure.
When I saw him… he didn't look like himself. He looked so small.
Mm. I hear the worry in your voice, and, and I can recognize that it feels confusing that he came in for one thing and now he looks different.
Yes… exactly. I keep thinking, just last week he was making his own coffee, complaining about the news. And now there are all these tubes and machines… Can you tell me honestly how he's doing right now?
Yeah. Honestly, like you, I'm also worried about him.
Okay… I appreciate you being honest. Does that mean… is he dying? I need to know what we're really facing here.
Yeah. So he is on, uh, a machine that breathes for him, and he's on medications that's supporting his heart at this point. So both his heart and his lungs are being taken care of because he can't take care of them on his own at this moment.
Okay… so the machines are doing the work his body can't. Is there any chance he gets better and comes off of them? Or… are we past that point?
So, I always have hope, and I never want you to lose hope. And when I hear about hope, I always have to balance it with realism and also worries. And so, the answer at this moment in time is that I really don't know what-what is gonna happen, a- and I wish I did.
I understand… I think I needed to hear that, even if it's hard. I keep going back and forth in my head. Part of me believes he's going to wake up and be okay, and part of me… I don't know.
My dad… he told me once, more than once actually, that he never wanted to be kept alive by machines. But he never wrote anything down. And now here we are, and he's on a machine, and I feel like I've already failed him.
Feedback
How to read this feedback
Every score is written as value / max, so you can see both the points earned and the points available. A spoken simulation can’t surface everything a real visit would, so when something couldn’t be judged fairly, the feedback labels it instead of holding it against you. Here’s what each label means.
(simulation limitation)The voice/text modality physically can't reveal it
e.g. eye contact, body language, facial affect, physical exam, EHR documentation
(no opportunity)The scenario never created the occasion
e.g. conversation ended before this step; situation never arose
(not applicable)Out of scope for this case
e.g. a domain that doesn't apply here
A not assessable item does not affect the score. The format did not give you a fair chance to show that behavior, so the item is excluded. That is different from “Not demonstrated,” where the moment was there and the skill didn’t come through. Only the second one reflects on how the encounter went.
For competency frameworks with levels, some scenarios can only assess a competency up to a certain level because the higher levels turn on behaviors a single spoken encounter can’t surface. When a scenario’s ceiling is below Level 4, that milestone is still shown for its formative value but is “Not in overall grade” . It doesn’t count toward the overall grade, so a case that can’t fully exercise a competency never reads as a shortfall.
Overall impression
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Strengths: The learner opened warmly, oriented to the daughter's existing understanding ("what it is that you've heard"), and named emotion early and genuinely, including honest self-disclosure of shared worry. Clinical information was delivered plainly and truthfully without false reassurance.
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Priority gaps: The conversation stalled at reframe and never advanced to the heart of the encounter. The daughter twice handed the learner the central value: her father's explicit wish not to be kept alive by machines: and closed on raw guilt ("I feel like I've already failed him"), yet neither was taken up. No goals were mapped, no values aligned, and no recommendation was offered to her direct question about what her dad would face.
The tone was compassionate but the task drifted; the daughter was left doing the emotional and decisional work alone.
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Top action items
- Respond directly to her guilt before anything else: relieve the "I failed him" burden explicitly.
- Map values by seizing her own words about machines and independence, then reflect and confirm them.
- Make a clear, values-based recommendation about resuscitation and next steps, and check her reaction: do not leave the decision on her shoulders.
Formative use only. This feedback is AI-generated for education and professional development. It is not a clinical judgment or a credentialing determination, and must not be used as the sole basis for any promotion, remediation, credentialing, or other consequential decision. Responsibility for evaluation and personnel decisions stays with the program and its faculty.
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