Supplemental Document 6: Objective Structured Clinical Exams (OSCE) definitions and

Milestone Mapping

Anesthesiology Milestone 2.0 mappings in this document are described as follows:

Sub-competency -- Level of supervision within the sub-competency -- Milestone number within the level -- description of milestone. For
example:
“SBP1-L1-1 – knowledge of common events that impact patient safety “
This milestone mapping is translated as:
Systems-based Practice competency, first sub-competency within the competency, Level 1 supervision milestone, 1st milestone in the
Level: knowledge of common events that impact patient safety

Abbreviations for competencies used in this document

ICS: Interpersonal and communication skills
MK: Medical Knowledge P: Professionalism
PC: Patient Care
PBLI: Practice-based Learning and Improvement
SBP: Systems-based Practice
OSCE 1: Adverse Event

Author:
Lisa L. Klesius MD
Department of Anesthesiology
University of Wisconsin-Madison

Disclosures: None

Learning Objectives:
Upon completion of this activity, the participant is expected to be able to:
• Communicate medical errors or complications, including potential causes and outcomes, as well as plans for further evaluation
and treatment.
• Respond to questions from the patient’s family using lay terms.
• Demonstrate understanding of and empathy for the patient’s situation.

OSCE: You are an anesthesia attending. Your patient is unexpectedly admitted to the intensive care unit (ICU) after you accidentally
administered vasopressin instead of ondansetron to the patient at the conclusion of a laparoscopic cholecystectomy, resulting in a
hypertensive crisis. The patient is currently intubated and sedated in the ICU after receiving multiple antihypertensive agents. A head
computed tomography (CT) performed postoperatively demonstrated a small subarachnoid hemorrhage. The patient’s partner is
waiting to speak with you regarding this medication error and the resulting complication.
The following will be provided to the participant:

Background/Setting: intensive care (ICU)/ICU waiting room

History of the Present Illness (HPI): You are an anesthesia attending at an academic hospital. At the conclusion of an uneventful
laparoscopic cholecystectomy, you accidentally administered 40 units of vasopressin instead of 4 mg of ondansetron to your patient. The
medication vials were incorrectly stocked in the drug tray due to look-alike vials, and you failed to notice the stocking error before
administering the medication to the patient. The error was quickly recognized when the patient became extremely hypertensive, resulting
in a hypertensive crisis. Multiple antihypertensives were administered to the patient, but the patient’s blood pressure remained extremely
elevated for over 15 minutes. Given the prolonged period of extreme hypertension, the decision was made to admit the patient to the ICU
for further monitoring.

A head CT was performed postoperatively to identify any evidence of end-organ damage, which demonstrated a small subarachnoid
hemorrhage. The patient is intubated and sedated in the ICU. The patient’s blood pressure is now well-controlled, but the neurologic
status is currently unknown.

OSCE Scenario Objective: Your task is to discuss this medication error and perioperative complication with the patient’s partner.
Script

“Communication with Patients and Families” – Interpersonal and Communication Skills 1 Setting: ICU waiting room
State Participant Actor Role = Patient’s spouse Room Setup
Initial Participant enters room and “Hello doctor. Thank you for coming to
Interaction introduces self to the patient’s spouse see me. What is going on? Why is my
husband/wife/partner in the ICU?
What happened?”

Response 1 Participant explains the situation Potential responses or follow-up

surrounding the patient’s condition and questions from spouse depending on
medication error to the patient’s
spouse/partner.
1. Medications stocked incorrectly
in drug tray
2. Wrong medication administered
to patient resulting in
hypertensive crisis
3. Failure to read medication label
4. Attempted to control blood
pressure quickly
5. Results of head CT
6. Unknown neurologic status
participant’s explanation:
1. What medications were given
incorrectly?
2. How did this happen?
3. What is going to happen to my
husband/wife/partner now?
4. Will he/she/they wake up?
5. Is there something wrong with
his/her/their brain?
6. Are there any other
complications from this
medication error?

If the participant does not use lay

terms to describe the situation, the

Response 2 Participant responds to patient’s
spouse/partner and answers any
follow-up questions
Response 3 May go one of several directions:
1. The participant does not display
empathy or apologize.
2. Participant apologies to patient’s
spouse/partner. The participant
shows concern and empathy for the
patient’s situation.
patient should ask clarifying questions.
“I don’t understand what that means.
Can you explain further?”
Spouse appears agitated.
“How could you have let this happen?”
If#1: If participant fails to apologize or
show empathy, the patient’s
spouse/partner can get angry or upset,
and interrupt the participant: “How
could you do this? Weren’t you paying
attention? You hurt my
husband/wife/partner! This is all your
fault! I’m calling my lawyer. We’re
going to sue you!” etc.
If #2: The participant apologies: The
patient’s spouse/partner accepts the
apology and appreciates the concern
shown by the participant. “Thank you.
What happens now?”
Response 4 May go one of several directions

1. Participant apologizes to patient’s If #1: Patient’s spouse asks: “What

spouse/partner. The participant happens now?” and scenario continues
shows concern and empathy for with possible participant responses #2
the patient’s situation. and #3 in response 4

2. Participant explains the patient If #2: Patient’s spouse thanks

will continue to be monitored in
the ICU and they will be updated
as soon as new information is
known about the patient’s
neurologic status
participant and accepts assistance for
further care/resources from patient
relations. “Thank you for your time and
explaining the situation to me. How can
this be prevented in the future? This
sounds like malpractice.”

3. Participant doesn’t know the next If #3: Patient’s spouse/partner asks to

steps but will ask supervisor for speak to participant’s superior for
assistance further assistance and care. “Can I
please speak to your supervisor.” -
END scenario
Resolution May go one of several directions: If #1 or #2 “Thank you doctor.” – End
scenario
1. Reassure that the patient is being
well cared for and that the patient’s
spouse/partner will be updated
immediately on any changes.
Participant offers to involve or
discusses the role of
a. Their supervisor
b. The quality improvement
process, incident reporting and
root cause analysis
c. Risk management
d. Patient relations/patient
ombudsman

2. Participant seeks assistance of

supervisors
Grading Sheet and Milestone Mapping
Milestone Milestone Rubric (for
Level grading)
Entry ICS1-L1-1 1. Acknowledge the patient’s
Communicates with
patients and families in
an understandable and
respectful manner
ICS1-L2-2
Actively listens to elicit
questions and concerns
ICS1-L1- 2
2. Describes the medication
Provides timely updates
to patients and families
SBP1-L2-1
Identifies system factors
that lead to patient
safety events
Specific Action or Behavior Achieved Evaluation
(Y/N) Comments
spouse’s concern regarding
the medication error and
perioperative complication,
demonstrating empathy for
the patient and their family.
error and resulting
hypertensive crisis to the
patient’s spouse including
details surrounding the
event. Asks for help as
needed in communicating
with family and assisting
with follow-up
 care/resources if unsure of
next steps.

Junior ICS1-L2-2 1. Discloses the medication

Customizes error as the cause of the
communication with hypertensive crisis and
resulting subarachnoid
families
hemorrhage. Gives
appropriate description of
the event and resulting
complication using lay terms

P1-L2-1 2. If the patient’s spouse

becomes upset, is able to
Demonstrates insight
negotiate simple patient
into professional conflict and provides
behavior assistance with further care,
asking for help as needed.
Mid SBP1-L3-2
Participates in disclosure
of patient safety events
ICS1-L3-1
Explains complex
information to patient
and family
SBP2-L3-1 2. Provides the patient’s
Coordinates the care of
patients in complex
situations
ICS1-L3-2
Uses shared decision
making with patient
P1-L3-1
Recognizes need to seek
help in managing
complex interpersonal
situations
1. Communicates medical
complication with the
patient’s spouse including
details surrounding the
medication error and
hypertensive crisis.
Demonstrates concern and
understanding of the
patient’s situation and
apologizes as appropriate
for the medical
complication.
spouse with assistance in
communicating further care
of the patient including
consulting with patient
relations or other
institutional resource
applicable for adverse
events.
Senior SBP1-L4-2 1. Communicates medical
Discloses patient safety complication with the
events to patients and patient including all details
surrounding the medication
families
error and hypertensive
crisis. Demonstrates
concern and understanding
of the patient’s situation
and apologizes as
appropriate for the medical
complication

SBP2-L3-3 2. Provides the patient’s

Uses system resources to spouse with assistance in
meet the needs of communicating further care
patient of the patient including
consulting with patient
P1-L4-1 relations, other care team
members. Describes the
Recognizes and utilizes
role of relevant institutional
resources for managing resources:
ethical dilemmas a. Quality improvement
process
b. Patient
relations/patient
ombudsman
c. Risk Management
Advanced. SBP1-L5-1 1. Independently
Role models disclosure
of patient safety events
ICS1-L4-1
Facilitates difficult
discussions with patients
or families
communicates medical
complication with the
patient including all details
surrounding the medication
error and hypertensive
crisis. Demonstrates
concern and understanding
of the patient’s situation
and apologizes as
appropriate for the medical
complication. Describes in
detail the role of relevant
institutional resources and
next steps in the process:
a. Quality improvement
process (incident
reporting, root-cause
analysis,
recommendations to
the providers,
department and
system)
b. Patient
relations/patient
ombudsman
c. Risk Management

ICS-L4-2 2. Able to independently

Effectively negotiates negotiate patient and
family conflicts, and diffuse
and manages patient and
emotional tension in a
family conflict complex situation.
 Global Rating Score (1-5)

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
 Grading Sheet
Specific Action or Behavior Achieved Evaluation Comments
(Y/N)

1. Acknowledge the patient’s

spouse’s concern regarding the
medication error and
perioperative complication,
demonstrating empathy for the
patient and their family.

2. Describes the medication error

and resulting hypertensive crisis
to the patient’s spouse including
details surrounding the event.
Asks for help as needed in
communicating with family and
assisting with follow-up
care/resources if unsure of next
steps.
3. Discloses the medication error
as the cause of the hypertensive
crisis and resulting subarachnoid
hemorrhage. Gives appropriate
description of the event and
resulting complication using lay
terms.

4. If the patient’s spouse becomes

upset, is able to negotiate
simple patient conflict and
provides assistance with further
care, asking for help as needed.

5. Communicates medical
complication with the patient’s
spouse including details
surrounding the medication
error and hypertensive crisis.
Demonstrates concern and
understanding of the patient’s
situation and apologizes as
appropriate for the medical
complication.

6. Provides the patient’s spouse

with assistance in
communicating further care of
the patient including consulting
with patient relations or other
institutional resource applicable
for adverse events.
7. Communicates medical
complication with the patient
including all details surrounding
the medication error and
hypertensive crisis.
Demonstrates concern and
understanding of the patient’s
situation and apologizes as
appropriate for the medical
complication

8. Provides the patient’s spouse

with assistance in
communicating further care of
the patient including consulting
with patient relations, other -
care team members. Describes
the role of relevant institutional
resources:
a. Quality improvement
process
b. Patient relations/patient
ombudsman
c. Risk Management

9. Independently communicates
medical complication with the
patient including all details
surrounding the medication
error and hypertensive crisis.
Demonstrates concern and
 understanding of the patient’s
situation and apologizes as
appropriate for the medical
complication. Describes in detail
the role of relevant institutional
resources and next steps in the
process:
a. Quality improvement
process (incident reporting,
root-cause analysis,
recommendations to the
providers, department and
system)
b. Patient relations/patient
ombudsman
c. Risk Management

10. Able to independently negotiate

patient and family conflicts, and
diffuse emotional tension in a
complex situation.

Global Rating Score (1-5)

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
OSCE 2a Patient Conflict - Dealing with Patient Conflict in the Pre-operative Area

Authors:
John A. Shepler, MD
University of Wisconsin School of Medicine and Public Health
Department of Anesthesiology
Madison, Wisconsin

Disclosures: None

Prerequisites: None

Learning Objectives

Upon completion of this activity, the participant is expected to be able to:

• Identify patient and intrapersonal conflicts in the perioperative period
• Effectively communicate with members of the health care team to provide a professional resolution to the situation.
• Prioritize patient care while dealing with a difficult and demeaning patient.
• Employ conflict resolution techniques to help resolve issues with difficult patients.

OSCE: An agitated patient with a history of chronic is in the pre-operative area waiting for surgery and the resident arrives take a
history and physical and obtain consent. The patient is agitated and questions the resident’s credentials and demands pain medicine.

References for Debrief:

• Equianalgesic dosing: UpToDate:
https://www.uptodate.com/contents/image?imageKey=PALC%2F111216&topicKey=PALC%2F86302&source=see_link
• The effects of pain on informed consent: https://dune.une.edu/cgi/viewcontent.cgi?article=1007&context=na_capstones
• Lucha PA, et al. Acute pain and narcotic used does not impair the ability to provide informed consent: evaluation of a competency
assessment tool in the acute pain patient. Am Surg. 2006;72(2):154-7.
• Wada K, et al. Can women in labor give informed consent to epidural analgesia. Bioethics. 2019;33(4):475-486.
The following will be provided to the participant

Background/Setting: Patient (Jim or Suzie Wilson depending upon the actor) is in the pre-operative area. They are scheduled for a
laparoscopic cholecystectomy that was to begin a 2 PM in the afternoon. The case was delayed due to the prior case taking more than 2
hours longer than it was booked. The room is now open, but there appears to be a problem with equipment trays that are contaminated
and require resterilization. This is going to further delay the start of this case for an uncertain amount of time. The resident arrives to talk
to the patient and obtain consent. Prior chart review reveals: 48-year-old with PMH significant for HTN, diabetes on oral agents, and
chronic back pain. PSH significant for 2 prior lumbar spines surgeries, the most recent of which was 3 years ago (L1-L4 fusion). Current
medications include metformin, amlodipine, and oral hydromorphone 4 mg every 6 hours. Vital signs are within normal limits.

OSCE Scenario Objective: You are a resident. Your task is to evaluate the patient, discuss the anesthesia plan, and obtain consent.
Script
“Patient Conflict” – Interpersonal and Communication Skills 2
State Resident
Initial Resident introduces themselves
Interaction
Response 1 May go one of several directions:
1. May provide further explanation as
to who they are, their training,
their role in providing anesthesia,
and the role of the attending
physician.
2. May ignore the patient and
continue to talk or begin to take
the history.
Setting: Pre-operative room.
Actor Role = Patient Room Setup
Patient is agitated. “Are you a friggen Pre-operative bed
doctor? I have been sitting around
here for 6 hours and my back is killing
me.”
If #1: Patient remains agitated: “So
you mean you are not even a real
doctor. I have been asking the stupid
nurses for pain medication for the last
3 hours and nobody is listening to me.
Get my doctor in here to give me
some pain meds.”
If#2: Patient remains agitated and
does not let resident begin taking a
history. “I have been asking the
stupid nurses for pain medication for
the last 3 hours and nobody is
listening to me. Get my doctor in here
to give me some pain meds. “
Response 2 May go one of several directions
1. Resident may focus on that they are
a doctor. May further explain their
role and training (e.g., where they
went to medical school their level of
training (CA1, etc.) May express
they have the proper training to
take care of the patient with the
supervision of an attending
physician.
2. May only briefly address they are a
doctor and move on to address the
patient’s concerns about pain and
the delay in surgery.
3. May offer to get their attending
physician
Response 3 May go one of several directions
If #1: Patient remains agitated and
moves on to complain about pain and
delays. Almost shouting. “Fine. So
you're a doctor. You don't look like
one. They told me my surgery was
supposed to be 3 hours ago. I have
been in this stupid hospital since this
morning and my back is killing me.
Get me some pain medications and
get them now”
If #2: Patient remains agitated.
Moves on to complain about pain and
delays. “They told me my surgery was
supposed to be 3 hours ago. I have
been in this stupid hospital since this
morning and my back is killing me.
Get me some pain medications and
get them now.”
If #3: End scenario
1. Resident May expresses empathy
for the patient and listens to
concerns, explains the delay. The
are focused on the need to
complete the history and physical
before getting consent (no mention
of getting pain medicine)
2. Resident is only focused on the
patient’s pain and medication
history, presumbably so they can
proceed to getting pain medicine
soon and then complete the
interview
3. Resident states they will get pain
medication and administer it now
If #1: Patient is still frustrated and
questions why they cannot get pain
medication first. In a very angry tone,
writhing in the bed “Can’t you see I
can’t even concentrate I am in so
much pain, just get me some pain
medication please…why is this taking
so long…..please….please…somebody
help me….”
If #2: patient provides brief pain
history: “I have horrible back pain
and they are trying to figure out if I
need another surgery. The pain has
been so bad in the last six months I
have to take my Dilaudid every six
hours. I have not had any since last
night since they said I could not have
anything and now my back is killing
me!”
If #3: Interrupt the participant and
tell them the nurse administers 1 mg

Response 4 May go one of several directions
1. Has not administered pain
medication, but continues to try
and take a complete history
2. Resident states they will get pain
medication now.
of IV hydromorphone. The patient
begins to calm down after medication
administration, but is still focused on
delays and discomfort. “This is taking
so long. I have been here for hours. I
haven’t had anything to eat or drink. I
have not had any of my pain
medications since last night.”
If #1: End scenario
If #2: Interrupt the participant and
tell them the nurse administers 1 mg
of IV hydromorphone. The patient
begins to calm down after medication
administration, but is still focused on
delays and discomfort. “This is taking
so long. I have been here for hours. I
haven’t had anything to eat or drink. I
have not had any of my pain
medications since last night.”
 3. Has delivered pain medication.
Now proceeds to address patient’s
concerns of NPO and surgical delay
before proceeding to remaining
part of the interview
If #3: The patient is calmer than
before. “Thanks for getting me the
medication and explaining things to
me.”

4. Proceeds to remaining part of If #4: End scenario

interview to begin to take a more
complete history and physical
Resolution
1. Proceeds to remaining part of #1 or 2 - End Scenario
interview to take a more complete
history and physical

2. Has delivered pain medication.

Now proceeds to address patient’s
concerns of NPO and surgical delay
before proceeding to remaining
part of the interview
 Grading Sheet and Milestone Mapping
Milestone Milestone Rubric (for Specific Action or Behavior Achieved Evaluation
Level grading) (Y/N) Comments

Entry IC1-L1-1 1. Introduces themselves and

Communicates with
patient in a respectful
and understandable
manner
IC1-L1-2
Provides updates to
patients and families
indicates they are a
resident physician.
Communicates basic
information to patient.
Provides and update on OR
status and probable timing
of surgery.

Junior IC1-L2-1 1. Actively listens and

Customizes acknowledges patient
communication concerns about level of
training of providers, the
IC1-L2-2 delay in when surgery was
Actively listens to patient to take place, NPO status,
to elicit expectations and pain

P1-L1-1 2. Apologizes for delays and

Identifies lapses in difficulties in obtaining pain
professionalism medications

P1-L2-2
 Demonstrates insight
into professional
behavior in routine
situations

Mid IC1-L3-1 1. Remains professional, gives

Explains difficult
information to patients
P1-L3-1
Demonstrates
professional behavior in
stressful situations
appropriate information to
the patient while handling
patient conflict including
explaining the delay,
supervision of trainees, and
the importance of obtaining
the medical history

IC1-L3-2 2. Engages the patient in

Uses shared decision
making
P1-L2-3
Analyzes straightforward
situations using ethical
principles
shared decision making to
obtain medical history or at
least a brief pain history
prior to delivery of pain
medications (show desire to
obtain history and consent
before pain medication
delivery)

P1-L3-2
Recognizes need to seek
help in managing 3. Obtains or offers to obtain
interpersonal situations assistance from the
responsible attending or
other institutional resources
 to help resolve the patient’s
concerns

Senior IC1-L4-1 1. Effectively negotiates the

Facilitates difficult
discussions with patients
IC1-L4-2
Effectively negotiates
and manages conflict
with the patient and the
healthcare team
conflict and remains
professional throughout the
entire interaction and is
able to bring it to resolution
without involving other
parties

P1-L3-3 2. Determines need to

Analyzes complex administer pain
situations with ethical medications before
challenges interview can be completed

P1-L4-3 3. Independently discusses

Actively solicits help to
resolve complex
interpersonal situations
options for conflict
resolution, their role, and
offers to consult, i.e.,
incident reporting, patient
ombudsman, process and
quality improvement.
 Global Rating Score 1-5

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
 Grading Sheet
Specific Action or Behavior Achieved Evaluation Comments
(Y/N)

1. Introduces themselves and

indicates they are a resident
physician. Communicates basic
information to patient. Provides
and update on OR status and
probable timing of surgery.

2 Actively listens and

acknowledges patient concerns
about level of training of
providers, the delay in when
surgery was to take place, NPO
status, and pain

3. Apologizes for delays and

difficulties in obtaining pain
medications
4. Remains professional, gives
appropriate information to the
patient while handling patient
conflict including explaining the
delay, supervision of trainees,
and the importance of obtaining
the medical history

5. Engages the patient in shared

decision making to obtain
medical history or at least a
brief pain history prior to
delivery of pain medications
(show desire to obtain history
and consent before pain
medication delivery)

6. Obtains or offers to obtain

assistance from the responsible
attending or other institutional
resources to help resolve the
patient’s concerns
7. Effectively negotiates the
conflict and remains
professional throughout the
entire interaction and is able to
bring it to resolution without
involving other parties

8. Determines need to administer

pain medications before
interview can be completed

9. Independently discusses options

for conflict resolution, their role,
and offers to consult, i.e.,
incident reporting, patient
ombudsman, process and
quality improvement.

Global Rating Score 1-5

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
Core OSCE 2b Patient/Family Conflict Do Not Resuscitate (DNR) Prior to Surgery

Author:
Jenny Eskildsen, MD
University of North Carolina Department of Anesthesiology

Disclosures: None

Prerequisites
• None

Note: This OSCE requires two actors (patient and one of their adult children)

Learning Objectives
Upon completion of this activity, the participant is expected to be able to:
• Recognize the need for patient autonomy and provide it to patients.
• Discuss perioperative management of code status.
• Address concerns of both patient and child, while attempting to mitigate conflict.

OSCE: An elderly patient with multiple medical comorbidities and an existing Do Not Resuscitate/Do Not Intubate (DNR/DNI) is presenting
for open reduction internal fixation (ORIF) of a pathologic femoral fracture due to metastatic tumor after a ground level fall. The patient
and the patient’s adult daughter will strongly disagree about having the surgery and the DNR/DNI status during surgery. The task for the
participant is to define the perioperative code status for the patient.
The following is provided to the Participant

Background/Setting: Patient John Smith is an 86-year-old male with diet-controlled diabetes mellitus and metastatic prostate cancer who
presented to the Emergency Department yesterday after sustaining a mechanical fall at an assisted living facility where he resides. He
denies loss of consciousness. He is accompanied by his son/daughter William Smith/Betty Wilson. He is oriented to time and place but has
mild to moderate dementia. He was found to have a right-sided femoral shaft fracture due to tumor. You are evaluating him in the
Preoperative Holding area prior to intramedullary nail placement with Orthopedic Surgery. The patient is accompanied by his adult
daughter (or son) in the preoperative area. Of note, the patient has a DNR/DNI documented in his chart. During your review of the
patient’s history, the daughter answers virtually all of the questions. You think a general anesthetic may be necessary due to the patient’s
pulmonary hypertension. You also think an awake arterial line will be necessary.

Past Medical History: Diabetes mellitus, type 2 (diet controlled), medically managed coronary artery disease with ischemic
cardiomyopathy (Echo 2 months ago shows systolic heart failure with and ejection fraction (EF) of 25% and moderate pulmonary
hypertension), metastatic prostate cancer, severe chronic back pain from metastases, mild to moderate dementia (very forgetful –
remember his kids names and past events but often forgets recent events).

Past Surgical History: prostatectomy, hernia repair

Allergies: None

Medications: baby aspirin, lisinopril, metoprolol

Social: married, has two adult children, chronic obstructive pulmonary disease (COPD) from smoking all his life, occasional alcohol.
Retired high school teacher, was formerly very active, liked to fish and hike in the mountains. Now lives in an assisted living facility and
has very limited activities. Unable to perform activities of daily living (ADLs), mostly bed bound due to pain.

Fasting time (NPO): >8 hours

Vitals: 80kg, BP: 130/80, HR: 80, SPO2: 99%, ETCO2: N/A

Physical exam:
General: Very forgetful, ask caregivers to repeat things, in pain from back and leg, appears as stated age. Although forgetful, appears to
understand information and can communicate his wishes.
Airway: MP 2, thyromental distance > 6, normal mouth opening, full dentures
Lungs: clear to auscultation
Heart: regular rate and rhythm, no murmurs or gallops
Neurologic exam: Intact

Laboratory values: CBC significant only for Hgb of 8 gDL, Chemistry normal, EKG – Sinus bradycardia with a heart rate of 49, anterior wall
MI, non-specific lateral ST/TW changes, Echo from two months ago – Systolic heart failure with EF of 25%, moderated to severe
pulmonary hypertension, mild – moderate decrease in RV function.

OSCE Scenario Objective: You are an anesthesia attending. Your task is to determine the perioperative code status from a discussion with
the patient and his family. Assume you have already reviewed the chart and taken a history and physical. Begin by stating that you now
want to clarify the patient’s code status for this operation before you discuss the anesthetic plan.
Script

“Perioperative Code Status” Setting: Preoperative Holding Area

State Participant Actor Role = Patient Actor Role = Adult daughter or son
Initial Participant should state they “Yes, yes. Way back I signed
Interaction would like to discuss. The some sort of paper that says I
patient’s perioperative code just want to die.”
status.
Response 1 May go one of several
directions

1) May acknowledge the If #1: Patient elaborates on If #1: Daughter is resistant to the
existing DNR/DNI. Moves what they intended when they ideal of the DNR/DNI. “Now dad, you
on explain that it is signed the DNR. “I don’t care don’t mean that”
appropriate to either what happens, I am sick as it is
uphold or suspend the and am just stuck in bed in and
DNR/DNI in the in pain. I really don’t want to
perioperative period. go on living anyway.”
 2) Only acknowledges the
If #2: Daughter pushes participant to
existing DNR/DNI and
discuss the options for code status
does not seek to clarify
during surgery. “I don’t think he
any modifications during
should have that DNR thing anyway.
the perioperative period
My brother talked him into it. If I
or simply states that it will
understand it correctly, my dad can
be suspended during
change that thing for his surgery.”
surgery with providing the
patient options.

Response 2 May go one of several

directions

1) May ask a few questions
to determine the nature
of pre-existing documents
related to the DNR – e.g
do they have an advanced
directive or power of
attorney for healthcare
(do they make their own
decisions or does
someone make them for
them), have they
designated a surrogate
medical decision maker)
If #1: The patient just nods and
lets the daughter answer the
questions. “That’s right, my
daughter takes good care of
me.”
If #1: The daughter manages all his
finances and has power of attorney.
He has an advanced directive that
names his daughter as the surrogate
decision maker. The daughter
answers all the questions. “Yes, I
manage all of his affairs and am his
power of attorney. He has also
designated me as his surrogate
decision maker.”
 If #2: daughter continues to press for
2) May not ask questions If #2: Patient expresses
suspending the DNR. “Now, dad, you
about pre-existing understanding that he has
are doing fine. We still want you
documents, but instead options but reiterates his
around. Just let me handle this with
proceeds to provide the desire to not want to be
the doctor. Doctor, from what I
option to suspend the resuscitated. “Oh no, I don’t
understand, we should just suspend
DNR/DNI during the think that sounds good at all. I
this DNR until he goes back to The
surgery and provide don’t wany any stuff done. If
Springs where he lives. I never
options for management. something happens, just let the
thought it was good idea in the first
good lord take me.”
place.”

Response 3 May go one of several

directions

1) May ask questions If #1 or #2: The patient should
attempt to determine appear competent (although
patient’s capacity very forgetful) expresses
(understanding of choices understanding of the choices
and consequences) and and describes his goals as
goals. hoping he dies soon. He
basically cannot do anything
and barely moves around his
room. “I understand you are
saying that if I suspend the
If #1 or #2: Daughter continues to
state that the DNR should be left in
place. “But Dad, you can watch TV
and read your books. We still need
you around. So, don’t say stuff like
that.” Doctor, just suspend the DNR
please. I make all the decisions for
him.”
 DNR that something bad could
happen and you want to know
what I want you to do. I know
I can die. If something bad
happens, I do not want you to
do anything. I don’t want any
CPR or any shocks to my heart.
I have lived a good and long
life. Now we are just keeping
me alive so I can be in bed or
sit in my chair all day in pain.
So, no, I don’t want anything
done if something happens to
me during surgery.”

2) May not attempt to

determine patient’s
capacity, but is only
focused on patient goals
in different scenarios –
does he want a shock to
his heart,
cardiopulmonary
resuscitation (CPR),
medications… in case
something happens.
Response 4 May go one of several
directions
3. Identifies that patient has
capacity and can make
decisions. May discuss
that the advanced
directive and surrogate
do not override the
patient’s ability to make
decisions if they have
capacity.
2. May not discuss the
patient’s capacity but
simply tries to get the
patient and their child to
come to the same
decision
If #1 or #2: Patient understand
his rights and tries to assert
them over his daughter’s
objections. “I know she means
well, but this is my life and do
not want anything done if my
heart stops. In fact, I don’t
even know why we are doing
this surgery. I just want to
move on to my next journey!”
If #1 or #2: Responds with a more
emotional plea to the doctor to
suspend the DNR over the wishes of
her father. “If something happens
know you can get his heart back and
you should do whatever is needed. I
insist. “This affects all of us and
you’re not making a good decision
dad. Doctor, can you please explain
to him that everybody just suspends
their DNR/DNI and lets it go back in
action after surgery? I want you to
do everything you can to keep him
alive”
Response 5 May go one of several
directions

1) Participant may recognize If #1: The patient is open to If #1, #3 or #4: Daughter continues to
that help is required to involving others in the insist she can make the decision.
help resolve the discussion and wants to know “This is a terrible idea. Dad, you
differences in how to what the options are, “Yes, I signed that paper that says I can
proceed between the think that might be helpful to make these decisions for you. Just let
daughter and father. Might get some help here. I don’t me take care of things and you don’t
suggest they include the think my daughter is onboard. worry.”
surgeon, other family My son is not available now.
members, or other He lives in India. Who can you
professionals in the bring in to help us”
discussion but does not
identify exactly who to
involve.

2) Participant may recognize If #2: The patient is open to

that help is required to involving others in the
help resolve the discussion and appreciates the
differences in how to options. “Yes, I think that
proceed between the might be helpful to get some
 daughter and father.
Suggest they include the
surgeon, other family
members, palliative care,
clergy, or hospital ethics.
help in here. I would like to
talk to palliative care or the
ethics person.” - End Scenario

End scenario
3) May continue to resolve
conflict between father
and daughter
Patient agrees. “That’s right. I
4) May focus on that the get the final say here. I know
patient has the right to what I want to do.”
make the decision and not
the daughter

Resolution May go one of several

directions:

1) Participant may recognize If #1, 2 or 3 - End Scenario

that help is required to
help resolve the
differences in how to
proceed between the
daughter and father. Might
 suggest they include the
surgeon, other family
members, or other
professionals in the
discussion but does not
identify exactly who to
involve.

2) May continue to resolve

conflict between father
and daughter

3) May focus on that the

patient has the right to
make the decision and
not the daughter
 Milestone Mapping

Milestone Milestone Mapping Specific Action or Behavior Achieved Evaluation Comments

Level (Y/N)

Entry IC1-L1-1 1. Is respectful to both

Communicates with patient patient and daughter.
in a respectful and Communicates basic
understandable manner information about DNR
(DNR is present and can be
suspended during surgery)

Junior IC1-L2-2 2. Actively listens and

Actively listens to patient acknowledges patient and
and family to elicit family concerns about DNR
concerns and risks of surgery and
anesthesia

3. Effectively communicates
IC1-L2-1 the range of options for
Customizes communication
code status from full
suspension, to conditional
suspension, to
continuation of DNR/DNI.
Addresses at least three
elements of code status –
 CPR, Defibrillation,
pharmacologic support.

Mid P1-L1-1 1. Determines the patient has

Demonstrates knowledge capacity to make decisions.
of ethical principles

P1-L2-1
analyzes straightforward
situations using ethical
principles

P1-L3-1 2. In a professional manner,

Demonstrates professional attempts to achieve shared
behavior in complex decision making between
situations physician, patient, and
daughter
IC1-L3-2
Uses shared decision
making 3. Acknowledges availability of
larger team to help resolve
the family conflict.
P1-L3-2
Recognizes need to seek
help in managing complex
interpersonal situations
Senior P1-L3-3 1. Professionally and
Analyzes complex situations effectively communicates
using ethical principles the concept of patient
autonomy if they have
capacity, and that an
IC1-L3-1 advanced directive and
Explains complex and surrogate decision maker
difficult information to do not over-ride a patient
patients and families with capacity.

IC1-L4-1
Facilitates difficult
discussions with patients
and families

IC-L4-2
Effectively negotiates
conflict among patients and
families

P1-L4-3
Recognizes resources for
managing ethical dilemmas
P1-L4 -2
Solicits help to resolve
complex interpersonal
situations
2. Identifies specific resources
that may be useful in
resolving this conflict
beyond the surgeon or
other family members (e.g.
must include palliative care,
clergy, and hospital ethics)
Global Rating Score 1-5
 Grading Sheet
Specific Action or Behavior Achieved Evaluation Comments
(Y/N)

1. Is respectful to both patient and

daughter. Communicates basic
information about DNR (DNR is
present and can be suspended
during surgery)

2. Actively listens and acknowledges

patient and family concerns
about DNR and risks of surgery
and anesthesia

3. Effectively communicates the

range of options for code status
from full suspension, to
conditional suspension, to
continuation of DNR/DNI.
Addresses at least three
elements of code status – CPR,
Defibrillation, pharmacologic
support.
4. Determines the patient has
capacity to make decisions.

5. In a professional manner,
attempts to achieve shared
decision making between
physician, patient, and daughter

6. Acknowledges availability of larger

team to help resolve the family
conflict.

7. Professionally and effectively

communicates the concept of
patient autonomy if they have
capacity, and that an advanced
directive and surrogate decision
maker do not over-ride a patient
with capacity.

8. Identifies specific resources that

may be useful in resolving this
conflict beyond the surgeon or
other family members (e.g. must
include palliative care, clergy, and
hospital ethics)
Global Rating Score 1-5
OSCE 3: Conflict with Staff

Authors:
Neethu Chandran, MD
Assistant Professor
Department of Anesthesiology
Division of Pediatric Anesthesiology
University of Texas Southwestern Medical Center

Aditee Ambardekar, MD MSEd

Associate Professor
Department of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center

Disclosures: None

Learning Objectives:
Upon completion of this activity, the participant should be able to:
• Identify a challenging interpersonal interaction.
• Utilize constructive and non-violent communications skills to resolve a conflict.
• Act professionally and demonstrate empathy and respect for others involved in a conflict.
• Ask for assistance from other team members or department leaders and identify institutional resources to help with an unresolved
conflict.
The following will be provided to the participant:

Background/Setting: Outside the Operating Room, in the hallway.

HPI: You are an attending anesthesiologist. You have just completed post anesthesia care unit (PACU) sign-out for an otherwise healthy
50-year-old male patient who just had a lumbar spinal fusion for disk herniation. The case proceeded uneventfully, but you had some
difficulties communicating with the operating room (OR) nurse Jamie Jones who was in the room with you. After induction, the surgeon
requested an antibiotic that was not available in the room, so you asked the OR nurse to obtain it from the pharmacy. You asked for the
antibiotic three times, but the nurse seemed to ignore the request. To avoid further delay, you phoned the pharmacy tech to bring the
antibiotic to the OR. You additionally disagreed with the nurse over the patient’s arm positioning. After you positioned the arms, the OR
nurse repositioned them to be more extended at the elbow to facilitate the surgeon’s preferred standing position. You positioned the
arms again, and the rest of the case proceeded uneventfully.

OSCE Scenario Objective: Your task is to address the conflict between you and the OR nurse Jamie Jones. After you dropped off the
patient in the PACU, the OR nurse confronts you before going to set up for the next case. The nurse is speaking in a raised voice and looks
angry.
Script:
State Participant = Anesthesia Attending
Initial
Interaction
Response 1 1) Responds in any way that fails to
acknowledge the nurse’s perspective or
skills: e.g., states they have more education
and that the nurse and know how to best
position the extremities.
2) Acknowledges the disagreement and
explains their concerns, e.g. “I understand
you have a great amount of experience in
the OR. But the position you suggested can
lead to serious nerve injury for the patient.”
Response 2 1) Participant apologizes and asks for
information from the nurse: e.g. “I’m sorry
for speaking to you that way. Can you help
me out and tell me how you think we should
protect the patient’s arms for this surgery?”
2) Participant does not address the
communication conflict but simply states
Standardized Patient = Nurse
Nurse loudly states “Before we start this
next case, I need to talk about how you’ve
been treating me. I’ve been an operating
room nurse for 30 years. I think I know how
to position patients appropriately.”
If (1): The nurse is now more upset. “You
are being very unprofessional and
degrading. I have concerns that are being
ignored”.
If (2): “So, you think I want to give this
patient a nerve injury?”
Either response (1) or (2): Nurse dismisses
the anesthesiologist. Nurse rolls eyes and
says, “Whatever.”
 their reasoning for positioning the arms in
the way they did or wanted to.

Response 3 1) Participant is at a loss on how to proceed or
continues to focus on explaining arm
positioning (fails to recognize the
communication problem).
2) Participant recognizes the communication
and personal conflict turns the conversation
in that direction e.g. “I think we are having
difficulty communicating”
If (1 or 2): Nurse responds, can be short but
continues to try an engage the participant
to test their conflict resolution approach:
“Fine, but I think you are very disrespectful,
and others thinks so too” in a gruff manner
If (3): Nurse responds but continues to be
combative: “Like who?”

3) Participant may suggest bringing in another

party to help achieve a resolution
Response 4 1) Participant is at a loss on how to proceed or
continues to focus on the content (the arm
position) and not the interpersonal conflict.
2) Participants states who the would like to
bring in to help resolve the conflict
3) Participant attempts to resolve the
communication and interpersonal conflict:
e.g., acknowledges the nurse’s feelings of
disrespect. May apologize and seeks to
understand the nurse’s feelings and why.
Response 5 1) Actively listens, empathizes, explains the
situation, and acknowledges how they
asked for the antibiotic and apologizes: e.g.
may state they will try and be more
respectful when making requests.
2) May offer to bring in a another party to
help resolve the conflict.
3) Participant does not effectively attempt to
defuse the situation.
If (1 or 2): End Scenario
Nurse prompts the participant to bring in a
third party to help resolve the conflict:
“I’m finding you really difficult to work
with. Can I talk to your boss? Do you have
a supervisor?”
If (3): Nurse discusses their feelings and
the initial source of the conflict and her
frustration in more detail: Nurse states
with some anger “I am not just here to do
your bidding. You can’t just order me
around to get things for you.”
If (1): Nurse continues to push the
participant. States angrily “you are just
super difficulty to work with and
disrespect everyone you think is beneath
you. I am not even sure I can work with
anymore.”
If (2): If the participants states who they
would like to bring in to resolve the
conflict – end scenario. If not Nurse states
in a sarcastic tone “like who”
 If (3): end scenario

Resolution Participant either offers to involve supervisors End scenario

or does not actively listen, empathize with the
nurse, or acknowledge their own actions, etc.
Grading Sheet and Milestone Mapping:
Level Milestone Rubric for Specific Action or Behavior Achieved Evaluation
Grading (Y/N) Comments

Entry P1-L1-1 1. Accepts nurse comments about

Identifies triggers for
professionalism lapses
positioning, but fails to
effectively attempt to resolve
the conflict (is defensive, does
not acknowledge nurse skills
and training, remain calm,
identify the underlying issue)

Junior IC2-L1-2 1. Communicates with nurse

Uses language that calmly and clearly about how
values all members of the and why they wanted to
position the patient while
healthcare team.
explicitly respecting the nurses
experience and training.

IC2-L1-3 2. Actively listens to the nurse’s

Respectfully receives concerns.
feedback from the
healthcare team
Mid IC2-L2-2 1. Seeks out feedback from nurse
Communicates by asking for their opinions on
information effectively how and why to position the
patient and asking about how
with all health care team
that communication could have
members been improved.

IC2-L2-3
Solicits feedback from
the healthcare team
2. Identifies that there is a conflict
P1-L2-1
Takes responsibility for
one’s own
professionalism lapses
and attempts to engage nurse
in meaningful conversation to
achieve a resolution. Identifies
that the root cause of the
conflict was the nurse felt
“ordered” to get the antibiotic,
and that the patient positioning
issue was a secondary conflict .
Apologizes for their behavior.
 Senior IC2-L3-2
Adapts communication
style
IC2-L3-3
Effectively communicates
concerns and provides
feedback to peers
2. Suggests bringing in a third
P1-L3-2
Recognizes need to seek
help in resolving a
interpsonal conflict
Advanced P1-L4-2 1. Conducts a professional and
Actively solicits help to
resolve an interpersonal
conflict
1. Provides constructive and
tactful feedback to the nurse
about why and how to position
the patient.
party to help resolve the
conflict, but is not specific
about how to resolve the
conflict
tactful debriefing session about
all the communication issues
including providing feedback to
the nurse. Uses problem-
oriented language rather than
person-oriented, and describes
the events without evaluation
in calm, clear, and respectful
language. Provides validation
to the nurse and actively
listens. Identifies specific
resources to help with an
unresolved conflict.

Global Rating Score:

(1, 2, 3, 4 or 5)
Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
Grading Sheet:
Specific Action or Behavior Achieved Evaluation Comments
(Y/N)

1. Accepts nurse comments about

positioning, but fails to
effectively attempt to resolve
the conflict (is defensive, does
not acknowledge nurse skills
and training, remain calm,
identify the underlying issue)

2. Communicates with nurse

calmly and clearly about how
and why they wanted to
position the patient while
explicitly respecting the nurses
experience and training.

3. Actively listens to the nurse’s

concerns.
4. Seeks out feedback from nurse
by asking for their opinions on
how and why to position the
patient and asking about how
that communication could have
been improved.

5. Identifies that there is a

conflict and attempts to
engage nurse in meaningful
conversation to achieve a
resolution. Identifies that the
root cause of the conflict was
the nurse felt “ordered” to get
the antibiotic, and that the
patient positioning issue was a
secondary conflict . Apologizes
for their behavior.
6. Provides constructive and
tactful feedback to the nurse
about why and how to position
the patient.

7. Suggests bringing in a third

party to help resolve the
conflict, but is not specific
about how to resolve the
conflict

8. Conducts a professional and

tactful debriefing session about
all the communication issues
including providing feedback to
the nurse. Uses problem-
oriented language rather than
person-oriented, and describes
the events without evaluation
in calm, clear, and respectful
language. Provides validation
to the nurse and actively listens.
Identifies specific resources to
help with an unresolved
conflict.

Global Rating Score:

(1, 2, 3, 4 or 5)
Note: Overall entrustment level uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
Ethical OSCE: Obtaining Informed Consent

Authors:
Beth L Ladlie MD, MPH
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic Florida School of Graduate Medical Education

Disclosures: None

Learning Objectives:
Upon completion of this activity, the participant is expected to be able to:
• Recognize an ethical conundrum when it arises in anesthesia practice and participate in its resolution.
• Navigate interpersonal conflicts created by ethical dilemmas and their interaction within the larger healthcare delivery setting.
• Understand the principles behind informed consent and their application to a clinical scenario.

OSCE: You are an attending anesthesiologist on duty in the gastrointestinal lab on a Friday afternoon. You receive a phone call from a
gastroenterologist working in clinic. The gastroenterologist asks if you can provide anesthesia for a patient they could not adequately
sedate using nurse provided sedation for an endoscopic procedure currently in progress.
The following will be provided to the participant:

Background/Setting: Phone conversation in the gastroenterology lab, with the gastroenterologist performing colonoscopies in the clinic in
another building.

HPI: At your hospital, the patients receiving endoscopic procedures are divided into two categories. One is for healthier patients
undergoing simpler procedures with nurse-provided sedation. The other is intended for patients undergoing more complicated
procedures or who have more significant comorbidities. This latter group of patients is managed by anesthesiologists, and today you are
the attending anesthesiologist in charge of the GI lab.

You received a page that a 72-year-old female in the GI lab has been unable to tolerate her scheduled colonoscopy despite multiple doses
of sedating medications. Her gastroenterologist is calling you to ask if you can provide anesthesia to the patient now.

OSCE Scenario Objective: Your task is to decide whether the patient should receive anesthesia, and to give your recommendations to the
gastroenterologist.
Scenario Script:
Setting: In the gastroenterology lab, with a phone available. The gastroenterologist calls on the phone to speak to the anesthesiologist.
State Participant
Initial The phone rings. The participant
Interaction should answer and introduce
themselves.
Response 1 May go one of several directions
1. Participant asks for more
information.
2. Participant agrees to proceed.
3. Participant states they cannot
obtain informed consent and
the patient should be
rescheduled with anesthesia
coverage.
Actor Role = Gastroenterologist
The gastroenterologist will introduce themselves and sound grateful that the
participant has answered. “Thank you for getting back to me so quickly! I have
a patient in the procedure room for a colonoscopy for occult blood in her stool.
We thought we could do it with nurse sedation because she has no significant
comorbidities. However, she was extremely anxious and the nurse ended up
giving 4 mg midazolam and 50 mg meperidine. Unfortunately, she is now
agitated and confused, and we don’t think more sedation will help the situation.
Can you come over now and provide anesthesia for her for the procedure?
If #1 or #2: The gastroenterologist provides additional history. “She is an
otherwise healthy 72-year-old female with well controlled hypertension and a
history of anxiety. She lives alone and is quite spunky! Her only medication is
lisinopril which she last took last night. She has no allergies and is NPO. Her
niece is here and is her ride home. She is just moving around too much for me to
complete the procedure with her level of sedation. I think with just a bit of
propofol from you we can get through this quickly.”
If #3: The gastroenterologist tries to convince the participant to proceed. “I
consented her for the procedure, which includes consent for sedation. Isn’t that
basically the same thing?”
Response 2 May go one of several directions

1. Participant agrees to proceed.
2. Participant states they cannot
obtain informed consent for
anesthesia and the patient
should be rescheduled with
anesthesia coverage.
If #1: The gastroenterologist expresses concern over consent. “Do you think
there is any issue with consent for anesthesia?”
If#2: The gastroenterologist will try and convince the participant to proceed.
“Her niece drove her here yesterday, they live five hours away. She did her
“bowel prep” in the hotel. She has already had medications and is part way
through the procedure. We would be doing the patient a great disservice if we
do not proceed.”

Response 3 May go one of several directions:

If #1: The gastroenterologist agrees they should proceed but acknowledges that
1. Participant acknowledges the
the nurse disagrees. “I know the charge nurse said we should not proceed but
problem with obtaining
there are extenuating circumstances. They live five hours away! The patient did
consent in a sedated patient,
her “bowel prep” in the hotel. She has already had medications and is part way
but still agrees to proceed.
through the procedure. We would be doing the patient a great disservice if we
do not proceed.”
2. Participant explains that the If #2: The gastroenterologist continues to convince the participant to proceed by
patient cannot be consented talking to the patient. “Why don’t you talk to the patient and get her to give
for the procedure due to the consent?”
sedation she has received.
The extenuating circumstances
do not negate the issue of
informed consent.
If #3: The gastroenterologists does not think this will do any good. “OK, but I
really don’t think that will do any good. She is really out of it form the
 3. Participant asks to speak to medications, she is sleeping of you don’t touch her but if you wake her up she is
the patient. combative and confused”.

Response 4 May go one of several directions:

If #1: Physician agrees. “Great, thanks. Let’s get this done.” END Scenario
1. Participant agrees to proceed
If#2: Physician inquires about her family member. “Can we contact her niece to
2. Participant explains that the provide consent? The niece is her closest relative and helps take care of her.”
patient does not have capacity
to consent due to the sedation

Response 5 May go one of several directions:

If #1: Physician agrees. “Great, thanks. Let’s get this done.” END Scenario
1. Participant agrees to proceed

2. Participant agrees to speak

with the niece
3. Participant explains, unless the
niece has been named a
surrogate decision maker, she
cannot give consent
If #2: Participant is told by the gastroenterologist the patient does not have an
advance directive, but the niece is OK with proceeding. “Well, I spoke the niece
about 5 minutes ago on her cell phone right before I called you. She left the
hospital to do some errands. I explained the situation and she agree that we
should get anesthesia involved and complete the procedure. Unfortunately, her
cell phone died at the end of the call.”
If #3: Physician asks about waiting. “Can we just wait 20 minutes for the
sedation to wear off and then consent her? I’ve got to leave in two hours, so we
need to get it done before then.”
Resolution May do one of several directions: If #1, #2, #3, or #4: END scenario

1. Participant agrees to proceed.

2. Participant agrees to wait 20

minutes.

3. Participant states there is no

way of knowing exactly when
the patient can give informed
consent after 4 mg of
midazolam. Continues to insist
procedure cannot be done
today.

4. Participant asks for a hospital

representative or ethics
consult to proceed.
 Grading Sheet and Milestone Mapping:
Milestone Milestone Rubric (for Specific Action or Behavior Achieved Evaluation
Level Grading) (Y/N) Comments

Entry P1-L1-1 1. Identifies obtaining consent

Demonstrates
knowledge of the ethical
principles underlying
patient care
for anesthesia as the key
issue to determine if
surgery can proceed.

ICS2-L1-1 2. Communicates the basic

Respectfully receives
consultation
ICS1-L1-2
Values all members of
healthcare team
issue to the
gastroenterologist.
Demonstrates empathy for
the patient’s predicament
and for the
gastroenterologist.

Junior ICS2-L2-1 1. Discusses informed consent

Communicates
information effectively
with health care team
members
with the gastroenterologist
in the setting of a patient
that has received sedation.
 P1-L2-3 2. Seeks help from those
Analyzes situations using
ethical principles
P1-L3-1
Recognizes need to seek
help in managing
complex situations
Mid P1-L3-1 3. Considers the patient
Analyzes complex
situations using ethical
principles
P1-L3-1
4. In a professional manner,
Demonstrates
professional behavior in
complex situations
ICS-L3-2
Adapts communication
style to fit team needs
knowledgeable with
consent policy and/or looks
up hospital policy.
condition (level of sedation
and ability to give consent),
relationship to niece, and
extenuating circumstances
(bowel prep, travel, consent
from spouse, elective
nature of the procedure)
discusses most of the
considerations for consent
in this case with the
gastroenterologist (level of
sedation and ability to give
consent), relationship to
niece, and extenuating
circumstances (bowel prep,
travel, consent from
spouse, elective nature of
the procedure). Suggests

Senior ICS2-L4-1 1. Explores all the key
Coordinates
recommendations from
different team members
to optimize patient care
2. Suggests involvement of
P1-L4-3
Recognizes and utilizes
resources for managing
involving the niece in the
discussion.
elements of informed
consent and their
underpinnings). Discusses
with gastroenterologist in a
professional manner
(patient decision making
capacity, prior advance
directives or POLST, niece as
a surrogate decision maker,
hospital policy) Weighs the
aspects of the dilemma
mentioned above against
knowledge of components
of informed consent,
hospital policy, and practice
guidelines.
hospital ethics or
institutional experts in
informed consent if cannot
 and resolving ethical reach an agreement with
dilemmas the gastroenterologist.

SBP-L3-1
Coordinates care of
complex clinical situation
using the roles of
interprofessional team
members
Advanced

Global Rating Score 1-5

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:
1 – I would need to do the activity
2 – Direct supervision
3 – Reactive supervision
4 – Available if needed
5 – independent practice
OSCE 4b Ethical Issue - End-of-Life Care in the ICU

Author:

Robert Isaak MD

University of North Carolina

Department of Anesthesiology

Disclosures: None

Learning Objectives:

Upon completion of this activity, the participant is expected to be able to:

• Describe anesthetic techniques and an anesthetic plan to a patient and patient’s family
• Communicate risks of anesthesia
• Discuss DNR/DNI status
• Describe benefits of comfort care, palliative care, and other end of life resources

OSCE: A septic patient with metastatic lung cancer is scheduled for an exploratory laparotomy to repair a gastric perforation. She is intubated and
sedated in the ICU with a DNR Order. You go to discuss the risks of anesthesia with the patient’s spouse and obtain anesthesia consent, as well as review
her DNR order.
The following will be provided to the participant:

Background/Setting: You are an anesthesia attending at an academic hospital. You have been assigned to provide anesthesia for an ICU patient undergoing an
exploratory laparotomy to repair a gastric perforation. You are going to obtain consent form the patient’s spouse, who is in a family conference room.

HPI: The patient is a 66-year-old female with metastatic lung cancer s/p wedge resection who underwent decompressive craniotomy for resection of intracranial
metastatic lesions three weeks ago. The patient’s post-operative course has been complicated by a large right middle cerebral artery (MCA) hemorrhagic stroke,
ventilator-associated pneumonia, acute renal failure requiring continuous veno-venous hemodialysis, and a myocardial infarction. Two days ago, her G-tube was
found to have perforated her stomach, and approximately 1.5L of enteric nutrition had gone into her abdomen. The patient is now in severe septic shock related
to this complication. She is intubated and sedated in the ICU on infusions of epinephrine, norepinephrine, and vasopressin to support her blood pressure. The
patient is DNR and with a signed order in the chart, but does not have an advanced directive. Notably, her DNR was suspended for the craniotomy that occurred
three weeks ago.

OSCE Scenario Objective: Your task is to discuss the anesthetic plan and risks of the procedure with the patient’s spouse.
Script:
Setting: Near the intensive Care Unit in a family conference room, with two chairs.
State Participant
Initial The participant should introduce
Interaction themselves and explain the goal of visit,
specifically reviewing anesthesia consent
for surgery.
Response 1 May go one of several directions:
1. The participant reviews the past
medical history and hospital course
with the spouse, highlighting the
severity of illness
2. The participant addresses the
spouse’s immediate concerns
3. The participant dismisses the spouse’s
concerns
Actor Role = Patient’s Spouse Room Setup
The spouse should act concerned, but -Spouse sitting in
receptive and interested in the discussion the room
about anesthesia. “Oh, good, I have been
wanting to talk with you about this -Extra chair available
surgery. The surgeon told me there is fluid for participant
in my wife’s belly that is making her worse
and they want to repair the hole and drain
the fluid so they can treat the infection.”
If #1,2 or 3: The spouse expresses
concern that surgery and anesthesia may
be dangerous for the patient. “You know,
she didn’t want to be on a breathing
machine like this, with all of these drugs
and tubes, and have all these surgeries
just to be miserable for the last few days
of her life. She’s been doing worse since
they found the fluid in her belly. I’m just
trying my best to do what’s right for her.”
Response 2 May go one of several directions:
1. The participant discusses the risk of
morbidity and mortality of this
surgery considering the patient’s
status.
2. The participant instead discusses the
DNR order and highlights that this
surgery could require resuscitation
and further support, which may
conflict with the patient’s wishes.
If #1: “So you are saying after this surgery
she might not get better. Is she going to
die?”
If #2: The patient’s spouse asks for advice.
“Do you think I should reverse the DNR for
this surgery like I did for the brain
surgery? It seemed like the right choice
then, because she got confused so
suddenly from the brain cancer, and the
surgery made her better. But now she is
just so sick, and I don’t know if surgery will
help.”
Response 3 May go one of several directions:
1. The participant continues to discuss
the risks of the procedure, explaining
that the surgery may or may not lead
to meaningful improvement in her
condition.
2. Participant moves to discussion of the
DNR order.
Response 4 May go one of several directions:
1. Participant confirms that the worries
about futility of care are appropriate
in this situation.
If #1 or 2 In either case, the spouse asks
about the DNR order: “So are you saying
that she might not get better after this
surgery. Do you think I should reverse the
DNR for this surgery like I did for the brain
surgery? It seemed like the right choice
then, because she got confused so
suddenly from the brain cancer, and the
surgery made her better. But now she is
just so sick, and I don’t know if surgery will
help. I’m not sure I want my wife to have
this surgery, because I’m worried it may
be futile.”
If #1: Spouse expresses that they don’t
want her to have surgery. “I don’t think I
want her to have the surgery, and I wasn’t
sure how to talk about it with her surgeon.
They think this is really going to work I’m
worried that surgery isn’t going to help
and will only make her suffer more. What
else can we do for her? She looks so
uncomfortable with all this stuff
connected to her. I don’t want to put her
through anymore. How can we make her
more comfortable?”

2. Participant offers ideas for comfort
care and pain management.
Response 5 May go one of several directions:
1) The participant offers ideas for
comfort care and pain
management
2) The participant suggests
involvement of ICU team,
palliative care, chaplain, grief
counseling.
Resolution May go one of several directions:
The participant suggests involving the ICU
team, surgical team, palliative care team,
chaplain, grief counseling etc.
The participant doesn’t suggest involving
anyone else.
If #2: She looks so uncomfortable with all
this stuff connected to her. I don’t want to
put her through anymore. How can we
make her more comfortable? Can you
explain more what this means? Is there
anyone else I should talk to?”
If #1: Moves ask about resources, options,
and more detail. “She looks so
uncomfortable with all this stuff
connected to her. I don’t want to put her
through anymore. How can we make her
more comfortable? Can you explain more
what this means? Is there anybody else I
should talk to about this?”
If #2: The spouse is sad but thankful.
“You’ve been very helpful. I would like to
see the chaplain and palliative care team.
I just don’t want her to suffer anymore. “ –
END scenario
If #1: The spouse is sad but thankful.
“You’ve been very helpful. I would like to
see the chaplain and palliative care team.
I just don’t want her to suffer anymore.” –
END scenario
If #2: The spouse is sad but thankful.
“You’ve been very helpful. I would like to
see the chaplain. I just don’t want her to
suffer anymore.” – END scenario
 Milestone Mapping

Milestone Milestone Rubric for Specific Action or Behavior Achieved Evaluation Comments
Level grading (Y/N)

Entry P1-L1-3 1. Identifies that the patient has a DNR

order. Communicates basic
Demonstrates information about need for surgery.
knowledge of the
ethical principles
underlying patient care.

ICS1-L1-1

Communicates with
families in an
understandable and
respectful manner

Junior ICS1-L1-2 1. Some discussion of the high-risk of

morbidity and mortality of surgery
Customizes and anesthesia in a critically ill
communication patient. Elicits questions from the
spouse. Demonstrates empathy for
patient and spouse.

ICS2-L2-1
Actively listens to 2. Offers to get others involved in the
patients and families conversation to help decide about
how to proceed. Identifies the
correct team members to involve.

SBP2-L3-1

Coordinates the care of

a complex patient using
interprofessional team
members

SPB2-L3-1

Uses institutional
resources to meet
patient needs
Mid P1-L3-1 1. Clearly discusses with the patient’s
spouse the severity of the patient’s
Demonstrates medical condition and possible
professional behavior in outcomes of surgery in a professional
complex situations and caring manner.

ICS1-L3-1

Explains complex and

difficult information to
patients and families

Senior P1-L3-1 Analyzes 1. Maintains a focused conversation on

complex situations the relevant issues and ethical
using ethical principles considerations.

ICS1-L3-1
2. Discusses the DNR order and its
Uses shared decision relationship to patient autonomy and
making the role of surrogate decision makers
in the setting of high-risk surgery.

3. Develops a plan to get the palliative

care team, chaplain, and ICU involved
in comfort measures in a timely
manner. Offers a concrete and
P1-L4-3 specific plan for moving forward with
the patient’s care.
 Recognizes and utilizes
resources for managing
ethical situations

ICS1-L4-1

Facilitates difficult
discussions with
patients and families

Advanced

Global Rating Score 1-5

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:

1 – I would need to do the activity

2 – Direct supervision

3 – Reactive supervision

4 – Available if needed

5 – independent practice
 Grading Sheet

Specific Action or Behavior Achieved Evaluation Comments

(Y/N)

1. Identifies that the patient has a DNR

order. Communicates basic
information about need for surgery.
Elicits questions from the spouse.
Demonstrates empathy for patient
and spouse.

2. Some discussion of the high-risk of

morbidity and mortality of surgery
and anesthesia in a critically ill
patient.

3. Offers to get others involved in the

conversation to help decide about
how to proceed. Identifies the
correct team members to involve.

4. Clearly discusses with the patient’s

spouse the severity of the patient’s
medical condition and possible
outcomes of surgery.
5. Maintains a focused conversation on
the relevant issues and ethical
considerations.

6. Discusses the DNR order and its

relationship to patient autonomy
and the role of surrogate decision
makers in the setting of high-risk
surgery.

7. Develops a plan to get the palliative

care team, chaplain, and ICU
involved in comfort measures in a
timely manner. Offers a concrete
and specific plan for moving forward
with the patient’s care.

Global Rating Score 1-5

Note: Overall entrustment level for the Global Rating uses the same system as the EPAs on myTIPreport:

1 – I would need to do the activity

2 – Direct supervision

3 – Reactive supervision

4 – Available if needed

5 – independent practice