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Breaking bad news transition to Palliative Care for an Unconscious Stroke Patient: PLAB 2 Mock Attempt 2

Updated: Jun 24

Summary:

This case involves delivering bad news to a relative of a patient who has suffered a severe stroke with no hope of recovery. The objective is to communicate this sensitive information compassionately while managing time effectively and covering all critical aspects of care planning, including palliative management.


Key Points:


Communication and Empathy

  • Avoid starting management discussion too late; time management is essential.

  • Refrain from repeating questions, especially when the diagnosis is known.

  • Use pauses strategically after delivering the worst part of the news (e.g., "He won’t recover").

  • Employ the SPIKES protocol effectively, particularly the Knowledge and Emotions steps.

  • Utilize the EVE protocol for emotional validation:

    • E: Identify the emotion

    • V: Validate the feeling

    • E: Express empathy


Data Gathering

  • Do not repeat questions unnecessarily (e.g., asking about medication or family history multiple times).

  • Focus questioning based on what will influence management or enhance understanding of the condition.


Management

  • Shift focus from curative to palliative care promptly once prognosis is established.

  • Explain palliative care succinctly and clearly.

  • Offer leaflets and pamphlets as part of routine NHS practice.

  • Always include safety netting, e.g., offer further consultation and contact details.


Important Considerations:

  • Always analyze what the worst part of the news is and time your pause accordingly.

  • Avoid overloading the consultation with irrelevant questions in known diagnosis scenarios.

  • Ensure completion of ICE (Ideas, Concerns, Expectations)—use the actual terms clearly during history-taking.

  • Avoid statements that sound rehearsed; adapt language to suit the situation and individual patient.


Diagnostic Approach:

  1. Confirm understanding of patient’s clinical course and recent CT findings.

  2. Highlight non-responsiveness and severity of stroke.

  3. Deliver news of irrecoverable condition using SPIKES.

  4. Anticipate and respond to emotional reactions using EVE.

  5. Transition to discussing next steps in care (palliative focus).


Management:

  • Announce transition to palliative care early if time is short.

  • Explain what palliative care entails, and reinforce that it’s focused on comfort.

  • Offer written materials (leaflets) and encourage questions or follow-up consultations.

  • Use time efficiently: combine multiple management elements in one breath if needed.

  • Include follow-up plan and safety netting.


Communication Skills:

  • Identify and verbalize emotions and non-verbal cues.

  • Avoid mock empathy or overuse of phrases like “bear with me” or “is that okay?”

  • Maintain a structured, natural flow in conversation.

  • Use open body language and maintain appropriate distance.


Ethical Considerations:

  • Respect patient confidentiality and dignity.

  • Communicate truthfully but sensitively about prognosis.

  • Avoid making unrealistic promises or unnecessary referrals.


Additional Resources:

  • GMC Guidance on Good Medical Practice

  • GMC’s Treatment and care towards the end of life

  • SPIKES and EVE protocols

  • Examiner Top Tips for PLAB 2 (PDFs provided)

  • PLAB 2 Result Understanding (Feedback Guidelines)

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