Objective: To increase the frequency of ACP conversations during acute illness by targeting hospitalists’ willingness to raise the topic with all patients over the age of 65 Duration: 3 h of gameplay possible Theory of behavior: self-determination theory Framework of design: narrative engagement theory

Didactic principles: ACP conversations—(a) help to ensure goal-concordant treatment decisions when or if medical decompensation occurs; (b) represent an opportunity to discuss hospice eligibility: (c) allow older adults to think generally about “life completion” tasks; (d) reduce emotional distress and decisional conflict experienced by surrogates and patients. Race should not influence physician decisions to engage in ACP conversations because individual goals and values, not race, affect patient preferences for end-of-life treatment

Game concept: The player takes on the role of Andy Jordan, a young emergency medicine physician, who moves home after his grandfather’s disappearance and accepts a job at a local community hospital covering night shifts

Game content

Medical: Physicians interview patients who present to Hopewell Hospital, and have the option of investigating further, having an ACP conversation with the patient/surrogate, or entering a code status order. The patients include: • 5 “teaching” cases of older patients with serious illness (e.g., heart failure), adapted from clinical practice. If players engage in ACP conversations, they later receive updates on the positive outcomes experienced by these patients. If players do not engage in ACP conversations, these patients return with complications of their initial complaint. Players also receive feedback from in-game characters (e.g., their supervisor, consultants, family members) about the impact that timely advanced care plans can have on the trajectories of patients’ care • 5 “non-teaching” cases of patients with diagnostically challenging problems, adapted from the clinical case records of the Massachusetts General Hospital as presented in the New England Journal of Medicine. These patients are designed to facilitate player engagement in the clinical task • 2 “non-teaching” cases of patients with life-threatening illnesses, adapted from clinical practice. These patients serve as a management challenge to facilitate player engagement in the clinical task

Non-medical: Robert Jordan, Andy’s estranged grandfather, has disappeared. The prologue hints that his disappearance may or may not have occurred voluntarily. The player must solve the mystery by uncovering clues revealed through conversation with in-game characters and by exploring the environment. The non-medical content is designed to increase player engagement with the game by increasing realism, interest, and identification

Game mechanics

1. Connect the dots: clues (medical and non-medical) appear on a notepad on the screen. The player can draw connections between clues to uncover information and to unlock additional dialogue options 2. Tap to act: the player can tap on the screen to move through the world and interact with other characters. This mechanic also allows the player to perform key patient-care actions, including procedures like lumbar punctures and intubations 3. Points: players receive points for uncovering non-medical clues, which unlock in-game lore. Specifically, they can access letters written by Andy and his grandfather, which should provide additional insight into their characters and motivations