PLAB 2 Mock Scenario: Breaking Bad News in Terminal Dementia – A Guide to Compassionate and Ethical Communication

Summary:

This PLAB 2 station focuses on a consultation with a daughter concerned about her elderly mother’s weight loss, later revealed to be due to advanced dementia. The scenario tests the candidate's ability to gather history, explain complex medical outcomes, introduce palliative care, and manage carer expectations compassionately.

Key Points:

Neurology / Geriatrics – Dementia:

• Patient is a 78-year-old female diagnosed with dementia.

• Progressive cognitive decline is impacting eating behavior – refusal to eat, aggression, lack of recognition.

• Carer reports erratic behavior, refusal to communicate, and emotional detachment.

Red Flags and Clinical Assessment:

• Significant recent weight loss over a few weeks.

• Complete lack of oral intake except minimal sips.

• Rule out reversible causes – test results (ECG, X-ray, ultrasound, CT scan) all reported normal.

Psychosocial and Functional Assessment:

• Daughter is the sole carer and is overwhelmed with the care burden.

• No alternative caregiver or support system in place.

• Carer’s emotional and psychological distress is evident.

Important Considerations:

• Recognize terminal phase of dementia with inability to eat or drink meaningfully.

• Understand that NG tube feeding is not appropriate in advanced dementia due to risks like aspiration, discomfort, and no improvement in prognosis.

• Emphasize palliative approach over curative interventions.

Diagnostic Approach:

1. Confirm advanced dementia through history and lack of improvement despite investigations.

2. Exclude other reversible causes via full tests – all normal.

3. Assess functional decline and impact on ADLs.

4. Evaluate carer’s understanding and expectations of the illness.

Management:

• Clearly explain that dementia has progressed to a terminal stage.

• Introduce and explain the concept of palliative care: comfort-focused, pain management, quality of life.

• Educate about risks of NG tube feeding (aspiration, distress).

• Offer support services: social work referral, community palliative team, respite care.

• Provide educational leaflets and arrange follow-up with GP.

Communication Skills:

• Use simple, clear language without medical jargon.

• Acknowledge and validate carer’s emotions (shock, grief, disbelief).

• Explore ICE: Ideas, Concerns, Expectations of the daughter.

• Avoid stock phrases – maintain authenticity.

• Provide realistic reassurance without overpromising.

Ethical Considerations:

• Breaking bad news: use SPIKES protocol where possible.

• Respect patient dignity and autonomy.

• Avoid futile medical interventions.

• Offer emotional and practical support to family.

• Ensure decisions align with best interest principles and GMC guidance.

Additional Resources:

• GMC Guidance: Good Medical Practice

• NICE Guidelines on dementia care

• NHS End-of-Life Care Pathways

• Royal College of Psychiatrists – Management of Advanced Dementia