To the Editor,

Crnjak et al. (Reference Crnjak, Kerns and Stevens2026) provide a timely demonstration that simulation can strengthen psychosocial end-of-life care. Their program, delivered to 43 child life specialists, combined didactic teaching with simulation and produced significant improvements in self-reported knowledge and comfort. The study is particularly valuable because it recognizes a core ethical advantage of simulation: clinicians can rehearse emotionally complex care without placing additional educational burden on dying patients and their families.

The next challenge is transferability. The intervention was developed within a large metropolitan children’s hospital with an established simulation program and a specialized child life workforce. In many resource-limited health systems, neither simulation centers nor child life services are routinely available. Yet the educational principles underpinning the intervention – rehearsal, feedback, reflection, and psychologically safe debriefing – do not depend on expensive technology.

A key adaptation principle is that the transferable unit should be the competency, not the profession or the equipment. Where child life specialists are unavailable, psychosocial functions such as preparing families for dying, supporting anticipatory grief, facilitating developmentally appropriate communication, recognizing spiritual or cultural concerns, and supporting memory-making can be distributed across nurses, physicians, social workers, community health workers, spiritual-care providers, or other locally available personnel. Simulation can then be designed around what the team must accomplish rather than around reproducing a high-resource staffing model.

A resource-adapted model could use facilitated role-play, peer actors, simple clinical rooms, or trained volunteers. Experience from an interdisciplinary pediatric and neonatal palliative-care simulation program in India suggests that meaningful gains in knowledge and perceived capacity are achievable in lower-resource environments (Flippo et al. Reference Flippo, Garner and Peck2024). More broadly, simulation-based palliative-care literature supports benefits for communication, teamwork, and professional development, while evidence for transfer into routine clinical practice remains limited (Skedsmo et al. Reference Skedsmo, Nes and Stenseth2023).

Adaptation must also be cultural rather than merely technical. How families understand disclosure, parental authority, spirituality, grief, and memory-making varies across settings. Local clinicians, families, community representatives, and spiritual-care stakeholders should therefore help shape scenario language, family roles, available treatments, referral pathways, and acceptable forms of bereavement support.

Finally, future programs should move beyond confidence as the principal outcome. Observed communication performance, interprofessional teamwork, retention of skills, changes in clinical practice, and family-reported experience would provide stronger evidence that simulation improves care rather than only perceived preparedness.

The lesson from Crnjak et al. should therefore be extended, not simply replicated. Global scalability will depend less on exporting simulation infrastructure than on preserving the pedagogical core of simulation while adapting competencies, workforce roles, culture, and evaluation to local realities.