Delivering Bad News and Initiating Palliative Care – A PLAB 2 Mock Scenario

examiner mla
Jun 15
2 min read

Summary:

This scenario involves a junior doctor in the palliative care team delivering difficult news to the daughter of a 70-year-old male patient who has suffered a major ischemic stroke. Despite treatment, the patient has shown no clinical improvement, and a CT scan reveals extensive brain damage. The case emphasizes delivering compassionate end-of-life care discussions and explaining the transition to palliative care.

Key Points:

Neurology – Ischemic Stroke

CT scan confirms a large territory infarction.
No recovery noted after 7 days of hospital care.
Extensive brain damage has rendered recovery unlikely.

Palliative Care Transition

Decision made by MDT to discontinue active treatment.
Plans to remove the nasogastric tube and stop non-essential medications (e.g., for hypertension or cholesterol).
Patient remains unconscious; oral intake is unsafe.

Family Discussion Content

Daughter was unaware of the lack of progress and scan results.
Clear, structured explanation needed using layman's terms (avoid terms like "ischemic").
Essential to convey that palliative care does not mean abandonment but prioritizes comfort and dignity.

Important Considerations:

Avoid medical jargon; use simple language.
Never assume the family’s understanding—always ask first.
Recognize and respond empathetically to emotional reactions.
Clarify that palliative care focuses on symptom relief, not curative intent.

Diagnostic Approach:

History Verification:
- Confirm previous medical conditions (e.g., hypertension, hyperlipidemia).
- Confirm medication history and previous strokes.
Functional and Social Background:
- Explore social setup, caregiver availability, and support systems.
Advance Care Planning:
- Inquire about advanced directives or lasting power of attorney.
- Clarify any prior patient wishes on resuscitation or end-of-life care.

Management:

Transition to Palliative Care:
- Discontinue medications that do not enhance comfort.
- Remove NG tube due to futility and risk of aspiration.
- Implement measures such as:
  - Morphine for pain or breathlessness.
  - Midazolam for agitation.
  - Laxatives for constipation.
  - Antiemetics and antipsychotics as needed.
Emotional and Family Support:
- Offer psychological support and family counseling.
- Provide contact for further queries and follow-up.

Communication Skills:

SPIKES Protocol:
- Setting: Calm, private space with tissues and water.
- Perception: Assess what the family understands.
- Invitation: Ask if they are ready to hear updates.
- Knowledge: Share findings gradually; end with prognosis.
- Emotion: Use the EVE method – Empathize, Validate, Explore.
- Strategy & Summary: Clearly explain next steps and focus of care.

Ethical Considerations:

Document full name and relationship of family members.
Ensure clarity on patient consent, wishes, and legal authorizations.
Discuss realistic expectations; do not provide false hope.
Respect cultural and religious considerations in end-of-life care.

Additional Resources:

GMC Guidance: Communication and End-of-Life Ethics
NICE Guidelines on Palliative and End-of-Life Care
SPIKES and EVE communication models