The finding challenges a long-standing “no-death paradigm” in medical simulation, under which scenario designers have generally avoided allowing a simulated patient to die because fatal outcomes are thought to distract learners or undermine psychological safety. The authors noted that this approach rests largely on expert opinion and evidence involving novice learners, leaving little empirical information about students approaching independent clinical practice. In the sessions examined for this study, however, patient death was possible but not scripted: whether it occurred depended on the simulated clinical course and the decisions made by participants. The researchers did not record whether any respondent actually witnessed a death, so the results demonstrate acceptance of the possibility rather than students’ reactions to an experienced death.

Agreement remained above 90% in every academic year, including the cohorts recruited during the COVID-19 pandemic, and the study found no evidence of differences by sex: 91.5% of female participants and 93.8% of male participants agreed. There were also no detected differences across age groups. Cohort and sex comparisons were evaluated with non-parametric tests, and the researchers reported agreement proportions with 95% Wilson confidence intervals. These results indicate a consistently positive attitude toward potentially fatal simulation scenarios among the students surveyed, although the repeated cross-sectional design means that each cohort was measured at one point rather than tracking changes within individual students over time.

For simulation educators, the findings suggest that the possibility of death may be considered for final-year students nearing independent practice, provided that scenarios are carefully designed and accompanied by structured debriefing. The authors were explicit that their evidence concerns attitudes, not educational outcomes: a single attitudinal item cannot establish whether an experienced simulated death improves learning, clinical judgment, psychological safety or performance. Nor does the observational design show that exposure to fatal scenarios causes better or worse training outcomes. Further study would need to distinguish acceptance in advance from students’ responses after witnessing a death and to test whether the educational effects justify including such scenarios. The evidence nevertheless offers an empirical counterpoint to the assumption that all medical students reject simulated death, showing broad acceptance across eight years at one Spanish faculty.

Subject of Research: Medical students’ attitudes toward the possibility of patient death in high-fidelity clinical simulation.

Article Title: Acceptance of the possibility of simulated patient death among final-year medical students: a repeated cross-sectional study across eight consecutive cohorts

Article References: Dueñas-Ruiz, J., Rodrigues, L., Castro-Portillo, E., Sanz-García, A., Martín-Conty, J. L., Polonio-López, B., Castro-Villamor, M. Á., & Martín-Rodríguez, F. (2026). Acceptance of the possibility of simulated patient death among final-year medical students: a repeated cross-sectional study across eight consecutive cohorts. BMC Medical Education. https://doi.org/10.1186/s12909-026-10104-1

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10104-1

Keywords: medical simulation, patient death, medical education, high-fidelity simulation, final-year students, clinical training, attitudes, COVID-19 cohorts, debriefing, Spain, Acceptance, possibility