‘In their shoes now’—immersive video gameplay and design thinking for building grief literacy

Despite significant progress in palliative care education, ‘paediatric palliative care’ remains infrequently addressed across undergraduate medical curricula worldwide. As a result, medical graduates reported feeling unprepared to engage in difficult conversations with parents of paediatric cancer patients. Anticipatory grief (AG), referring to the emotional upheaval that families face upon realising impending, irrevocable death of their loved ones, are particularly daunting to family caregivers of terminally ill children. Most recently, ‘grief literacy’ has been increasingly recognised globally as a new competence referring to healthcare practitioners' responsiveness in identifying signs of grief and in supporting bereaved families. In this connection, I embedded a novel grief literacy training into a medical humanities curriculum.

‘That Dragon, Cancer’(2016) is an award-winning, point-and-click, immersive video game created by two bereaved parents Ryan and Amy Green in real life, using visual metaphors, autobiographical voice-over, archival recordings to vividly re-tell their lived experience of losing their 5-year-old son to Atypical Teratoid Rhabdoid Tumor (AT/RT), a horribly aggressive brain cancer. Vignettes from this game have been appraised by medical journals such as JAMA for ringing true to complexities of families' emotions in clinical realities. Although nothing replaces true-life clinical exposure and role modelling in shaping students' professional attitudes and moral values, I sought to harness the potential of this novel modality for enhancing medical students' grief literacy of anticipatory grief in end-of-life care, by pairing the immersive experience with a tool adapted from design thinking.

In 2022–2024, 51 year-2 MBBS students participated in our 2.5-hour face-to-face workshop comprising a mini-lecture introducing AG in end-of-life settings, followed by a 50-minute, five-part, in-class immersive experience for students to synchronously walk through our carefully selected vignettes from ‘That Dragon, Cancer’. I focused on two critical junctures, namely (i) ‘relocation to hospice’ and (ii) ‘cessation of eating and drinking’, turning points in caring for a terminally ill where literature showed family caregivers would experience the most intense psychological pain. My pedagogical decision for students to collectively go through the immersive video game, as a group and in the same classroom, was informed by Mitchell et al.'s¹ experimental studies which found that collectively attending to others' narratives of pain in virtual contexts could promote cohesion and interpersonal closeness among participants through perceived emotional synchrony. Debriefing approach was guided by the P.O.E.M.S. observation framework (‘People, Objects, Environments, Messages, Services’) from design thinking. Akin to how product designers made use of P.O.E.M.S. for understanding ‘pain points’ of product users, I adapted this tool for facilitating students to discover and to relate to the ‘pain points’ of AG experienced by family caregivers as ‘users’ of palliative care.

Among 46/51 students who completed post-class surveys on 7-point Likert scale, 87% (n = 40/46) strongly agreed or agreed the instructional method to be effective for learning grief literacy, and 89.1% (n = 41/46) strongly agreed or agreed the workshop's relevance to their development as a doctor. Reflective writings and peer-sharing sessions suggested the workshop left an indelible mark on forging students' positive personal dispositions towards caring for grieving families.

Emotional realism from being exposed to a dying human being, though virtually, must not be understated. Several students recalled the urge to tear up in class. Nuances must be made in replicating this workshop design. For instance, instead of using VR headsets in experiencing the poignant video game, it is best to use laptops and headphones, so for learners to retain a safe psychological distance from the potentially traumatising stimuli.