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Should the manikin die in a simulated resuscitation?

Should the manikin die in a simulated resuscitation?
There's an interesting article and accompanying editorial blog in the current edition of Pediatrics
Anyone who attends, or teaches on, resuscitation courses will know how they usually pan out. The student is faced with a manikin and led through a scenario, where the manikin is critically ill. If a predetermined algorithm is followed, the scenario inevitably ends with the "patient" making a good recovery.
It is almost unheard of for the scenario to result in death, unless the student makes a catastrophic error. Even in those cases, the scenario is usually stopped before things get too far out of control.
The reality is that, in real life, depending on the environment, a high proportion of these patients will not survive, even if they receive high quality care. Yet this fact is not commonly reflected in resuscitation training scenarios.
It could be reasonably argued that none of us needs more practice in watching patients die. That's a fair point. But the candidates in the study that is referred to in the editorial felt that the death of their manikin was a useful outcome, albeit a more stressful outcome than the more traditional scenario where the patient always survives.
I integrated this type of "negative" outcome into my neonatal resuscitation training while working with healthcare workers in Sierra Leone. In a country where 1 in 20 newborns dies, it would be unrealistic not to address this issue during a newborn resuscitation course. What I feel about this type of training is that it should be reserved for those students with high levels of competence and confidence. It is very difficult to stop students equating manikin death with poor technique. Therefore, the less confident students may feel that a patient death is related to their own inadequacies as a resuscitator. Bringing some reality into the training room shouldn't come at the cost of a student's confidence and their willingness to resuscitate a baby. For the confident and competent student, I think it's reasonable to conclude some scenarios with patient death, even when high-quality resuscitation has been carried out. In Sierra Leone, where birth asphyxia and sepsis are very common in newborns, death is an unfortunate reality of life in the delivery room. Are we just brushing this reality under the carpet if we don't embrace it during scenario-based training?
I'd love to hear about your thoughts and experiences on this type of training, for both high- and low-income countries, as well as the different types of resuscitation courses (adult Vs child Vs Baby, In-hospital Vs Pre-hospital etc).
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