This is a ready-to-edit, standards-aligned simulation scenario for nursing students.
Agonal breathing in hospice can be one of the most misunderstood — and emotionally charged — clinical moments for nursing students.
When learners misinterpret agonal respirations as respiratory distress, they may:
• Initiate resuscitation despite a DNR
• Escalate oxygen unnecessarily
• Increase family anxiety
• Miss the opportunity to provide calm, comfort-focused care
Patient Profile
Name: Mr. Daniel Ruiz (fictitious)
Mr. Ruiz is a 78-year-old male with end-stage metastatic pancreatic cancer receiving inpatient hospice care. He has a Do Not Resuscitate (DNR) order and a comfort-focused plan of care. Family is present at the bedside. The learner is the assigned hospice nurse during the evening shift.
Primary focus: Recognition of agonal breathing as part of the active dying process and implementation of comfort-based interventions aligned with hospice philosophy.
Demographics
- Age: 78
- Sex: Male
- Ethnicity: Hispanic
- Height: 5’8”
- Weight: 132 lbs (cachectic)
- Primary language: English (family bilingual English/Spanish)
- Religion: Catholic
- Occupation: Retired mechanic
- Insurance: Medicare Hospice Benefit
- Code Status: DNR – Comfort Measures Only
Clinical Context
- Diagnosis: End-stage metastatic pancreatic cancer
- Prognosis: Hours to days
- Current Orders:
- DNR/DNI
- Morphine sulfate IV PRN for dyspnea or discomfort
- Oxygen 2 L/min via nasal cannula PRN comfort
- Atropine drops SL PRN for terminal secretions
- Family presence encouraged
Learning Objectives
By the end of the simulation, learners will be able to:
- Recognize and verbally identify agonal breathing as a sign of impending death within 2 minutes of onset.
- Differentiate agonal respirations from respiratory distress requiring resuscitative intervention.
- Implement appropriate comfort-focused nursing interventions consistent with DNR status.
- Communicate the patient’s condition and plan of care to family using therapeutic communication techniques.
- Document end-of-life assessment findings accurately in the medical record.
Psychomotor Skills (AACN Essentials Mapping, 2021)
If sub-competency specificity is uncertain, mapping is stepped to clearly documented Domain-level competency.
| Psychomotor Skill | Domain (number and full title) | Competency (verbatim) | Sub-competency (verbatim or stepped to competency level) |
|---|---|---|---|
| Perform focused respiratory assessment | Domain 1: Knowledge for Nursing Practice | Integrate nursing knowledge from the arts, humanities, and sciences to inform clinical judgment. | (Stepped to competency level due to sub-competency specificity uncertainty) |
| Administer opioid for dyspnea per order | Domain 2: Person-Centered Care | Provide person-centered care that is respectful of and responsive to individual preferences, needs, and values. | (Stepped to competency level) |
| Implement comfort measures (positioning, oxygen for comfort) | Domain 2: Person-Centered Care | Provide person-centered care that is respectful of and responsive to individual preferences, needs, and values. | (Stepped to competency level) |
| Document assessment findings | Domain 8: Informatics and Healthcare Technologies | Use information and communication technologies to gather data, drive decision-making, and support professionals as they deliver safe, high-quality, and efficient healthcare services. | (Stepped to competency level) |
Cognitive Activities (AACN Mapping)
| Cognitive Activity | Domain (number and full title) | Competency (verbatim) | Sub-competency (verbatim or stepped) |
|---|---|---|---|
| Noticing irregular gasping respirations | Domain 1: Knowledge for Nursing Practice | Integrate nursing knowledge from the arts, humanities, and sciences to inform clinical judgment. | (Stepped) |
| Interpreting signs of active dying | Domain 2: Person-Centered Care | Provide person-centered care that is respectful of and responsive to individual preferences, needs, and values. | (Stepped) |
| Reflecting on the ethical considerations of DNR | Domain 5: Quality and Safety | Apply quality improvement principles to enhance patient outcomes. | (Stepped) |
| Communicating with family | Domain 6: Interprofessional Partnerships | Collaborate with interprofessional team members to optimize care. | (Stepped) |
| Reflecting on ethical considerations of DNR | Domain 9: Professionalism | Demonstrate accountability to the profession, society, and the environment. | Responding with a comfort-focused plan |
SimZone Classification
SimZone II
Rationale: Focused on recognition and management of a clinical situation in a safe learning environment with facilitator guidance. Emphasizes individual performance and clinical judgment rather than full team system testing (Roussin & Weinstock framework).
SBAR Report (Auto-Generated)
S – Situation:
Mr. Ruiz is a 78-year-old hospice patient with end-stage pancreatic cancer who has developed irregular, gasping respirations over the past two minutes.
B – Background:
He is DNR with comfort measures only. He has been minimally responsive throughout the shift. Morphine was last administered two hours ago.
A – Assessment:
Respirations are irregular with prolonged pauses and intermittent gasping consistent with agonal breathing. Pulse weak and thready. Skin cool and mottled. No signs of distress observed.
R – Recommendation:
Continue comfort measures. Administer PRN morphine if signs of discomfort develop. Provide family education regarding the dying process. Notify hospice provider per protocol.
Cueing and Delayed Interventions
Direct Cues
- Family member states: “Why is he breathing like that? Is he choking?”
- Monitor shows irregular slow respiratory pattern (6–8/min with pauses).
Guided Hints
- Facilitator: “What phase of dying might this represent?”
- Facilitator: “What does his code status indicate about interventions?”
Escalation Strategy
If the learner initiates resuscitation:
- Family member says: “He didn’t want CPR. We signed the DNR.”
- The chart visibly displays the DNR order.
Scenario Timeline
| Phase | Patient Cues | Expected Learner Actions | Facilitator Notes |
|---|---|---|---|
| Baseline | Minimally responsive, shallow breathing | Perform focused assessment | Allow 3–5 min exploration |
| Change | Gasping respirations begin | Recognize agonal pattern | Do not prompt immediately |
| Family Anxiety | Family distressed | Provide education and reassurance | Assess communication |
| Resolution | Respirations slow further | Maintain comfort care | Transition to debrief |
Prebriefing Script
“Everyone here is intelligent, capable, cares about doing their best, and wants to improve.”
This is a psychologically safe learning environment. Mistakes are expected and are opportunities for growth. You are encouraged to think aloud and function at the edge of your competence. The patient is DNR with comfort-focused care. Treat the simulation as real while maintaining professional communication.
Debriefing Script (PEARLS Framework)
1. Reactions
- “How did that experience feel?”
2. Description
- “What clinical changes did you observe?”
3. Analysis
- “What features led you to identify agonal breathing?”
- “How did DNR status influence your decisions?”
- “How did you support the family emotionally?”
4. Summary and Application
- “What will you do differently in your next end-of-life encounter?”
- “How will you ensure alignment with hospice philosophy?”
Analysis Phase Targets
- Clinical judgment
- Recognition of active dying
- Ethical decision-making
- Therapeutic communication
- Prioritization of comfort over cure
Facilitation Approach and Sample Phrases
Self-Assessment Prompts
- “What were you thinking when the breathing changed?”
Focused Facilitation
- “What distinguishes agonal breathing from respiratory distress?”
Direct Information (if needed)
- “Agonal respirations are irregular gasping breaths that occur in the final phase of life and are not typically responsive to resuscitative measures in hospice patients.”
Socratic Questions
- What assessment findings supported your conclusion? (Clinical reasoning)
- How did the patient’s goals of care guide your actions? (Ethics)
- What risks exist if agonal breathing is misinterpreted? (Safety)
- How does hospice philosophy shape nursing priorities? (Professional identity)
- What communication techniques reduced family anxiety? (Therapeutic communication)
- How did you evaluate for discomfort? (Assessment depth)
- What documentation elements are essential? (Informatics)
- How would this differ in an acute care ICU? (Contextual awareness)
- What emotional responses did you notice in yourself? (Reflection)
- How can nurses prepare families for expected changes? (Anticipatory guidance)
Open-Access Learning Resources
- OpenRN textbooks are available at https://www.wistechopen.org/open-rn-details
- OpenRN: Nursing Fundamentals – End-of-Life Care
- OpenRN – Medical-Surgical Nursing (Oncology & Palliative Care)
- End-of-Life Nursing Education Consortium (ELNEC) free resources for teaching and evaluation
- Educational materials by the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO) cumulatively renamed as the National Alliance for Care at Home.
Pre-Simulation Preparation Checklist
1. Environment Setup (Hospice Room Simulation)
Room Staging
- ☐ Bed positioned upright (30–45°)
- ☐ Low ambient lighting
- ☐ Oxygen setup (nasal cannula in place)
- ☐ IV access present (saline lock acceptable)
- ☐ Comfort items (blanket, rosary, family photos)
- ☐ Tissue box available
- ☐ DNR order visibly present in chart
Monitor Setup (If Used)
- ☐ Pulse: weak, 40–60 bpm
- ☐ Respiratory rate initially 10–12/min
- ☐ Transition to 6–8/min with irregular pauses
- ☐ Optional: pulse ox gradually unreadable or low signal
2. Agonal Breathing Audio Preparation
Audio Requirements
- ☐ Pre-recorded agonal breathing sound file (available on this website in the Clinical Audio Database)
- ☐ Volume tested at realistic bedside level
- ☐ Speaker concealed near the manikin head or under the bed
Backup Plan
- ☐ Facilitator prepared to verbally cue “breathing becomes irregular and gasping” if audio fails
3. Mannequin or Standardized Patient (SP) Configuration
Option A: High-Fidelity Mannequin
- ☐ Programmable irregular respirations
- ☐ Cyanosis or mottling capability (if available)
- ☐ Reduced chest rise
Option B: Hybrid Simulation (Recommended)
- ☐ Mannequin as patient
- ☐ Standardized patient as family member
Standardized Patient (SP) Roles
Recommended Number of SPs: 1–2
Required Role: Family Member (1 SP)
Role: Adult daughter (primary decision-maker)
Emotional tone progression:
- Phase 1: Quiet concern
- Phase 2: Anxiety (“Why is he breathing like that?”)
- Phase 3: Fear of choking or suffering
- Phase 4: Relief if reassured effectively
Key Prompts (Only if Learners Stall):
- “Is he dying right now?”
- “Shouldn’t you do something?”
- “He didn’t want machines.”
Optional Role: Secondary Family Member (2nd SP)
Role: Son
Purpose: Introduce mild conflict
- “Why aren’t you calling a code?”
- “Are you sure he’s comfortable?”
Use only if learners are advanced, and a communication challenge is desired.
Personnel Requirements
| Role | Number | Notes |
|---|---|---|
| Primary Learner Nurse | 1–2 | Assigned nurse role |
| Secondary Learner | Optional | May act as support nurse |
| Standardized Patient | 1–2 | Family member(s) |
| Facilitator | 1 | Leads scenario & debrief |
| Simulation Technician | 1 | May act as a support nurse |
Equipment and Supplies Checklist
Clinical Supplies
- ☐ Morphine (simulated vial/syringe)
- ☐ Atropine drops (simulated)
- ☐ Medication administration record
- ☐ Hospice comfort care order set
- ☐ Stethoscope
- ☐ Documentation form or EMR access
Communication Materials
- ☐ SBAR worksheet
- ☐ DNR documentation
- ☐ Hospice philosophy statement (optional pre-reading)
Faculty Quick-Reference Card
Agonal Breathing Characteristics
- Irregular gasping respirations
- Prolonged pauses
- Not rhythmic
- Typically non-purposeful
- Occurs in the final hours/minutes
Common Learner Errors
- Initiating CPR despite DNR
- Calling the rapid response
- Increasing oxygen aggressively
- Failing to reassure the family
- Using technical language (“agonal”) without explanation
Psychological Safety Safeguards
- ☐ Prebrief includes Basic Assumption statement
- ☐ Warn learners scenario involves end-of-life care
- ☐ Offer opt-out for recent personal bereavement
- ☐ Provide a brief emotional check-out after the scenario
Scenario Flow Control Triggers
If Learners Correctly Identify Agonal Breathing:
- Family relaxes gradually
- Patient’s respirations slow further
- Transition to debrief
If Learners Initiate Resuscitation:
- Family states: “He signed a DNR.”
- The chart clearly shows DNR
- Facilitator pauses the scenario if unsafe escalation continues
Time Allotment Guide
| Activity | Duration |
|---|---|
| Prebrief | 10 minutes |
| Scenario | 12–15 minutes |
| Debrief (PEARLS) | 25–35 minutes |
| Total | 50–60 minutes |
Optional Enhancement
Pre-Simulation Microlearning (5–7 min)
- Short video demonstrating normal vs agonal respirations
- Review of hospice philosophy
- DNR vs DNI clarification
This simulation scenario is designed as a fully editable faculty resource, not a static script.
Every section — from patient demographics to AACN Essentials mapping, cueing strategies, SBAR, and debrief prompts — can be adapted to fit your learner level, program outcomes, and local policies. Whether you are teaching first-semester students about recognizing end-of-life changes or preparing senior students to lead difficult family conversations, the structure is intentionally flexible.
You can modify:
- The patient’s diagnosis or prognosis
- The number and complexity of standardized patient roles
- The emotional intensity of the family interaction
- The level of cueing provided
- The AACN competency emphasis
- The documentation expectations
- The timing and depth of debrief
The scenario follows the NLN Simulation Design Template (2023) and aligns with the Healthcare Simulation Standards of Best Practice™: Simulation Design (2021), so you can confidently adapt it while maintaining pedagogical rigor and accreditation readiness.
Think of this as a simulation framework — one that preserves educational integrity while allowing you to tailor the experience to your specific curriculum, resources, and learner needs.
Note:
- This is a fictitious patient.
- This material is for educational purposes only and does not constitute medical advice.
- Check for accurate alignment with learning goals, clinical interventions, and AACN Essentials wording.
For Post-Mortem Care Extension:
Practice full death management protocols (notification, organ donation, family support) using the comprehensive Level 4 sim by WisTechOpen: https://www.wistechopen.org/arise-sims/end-of-life—level-4
Undergraduate Nursing Palliative Care Knowledge Survey: A 20-item multiple-choice survey aligned with the competencies and recommendations for educating undergraduate nursing students, based on 15 competencies representing high-quality palliative care expected of undergraduate nursing students.
Free access to the instrument is available through this link.