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PUID: 42 || PLAB 2 Mock 1 :: BBN1: Dementia Mother

Summary:

This scenario involves a consultation with a carer regarding an elderly patient with advanced dementia who has significantly declined and is now in the terminal phase. The candidate must sensitively deliver this prognosis and discuss the role of palliative care, adhering to the SPIKES protocol for breaking bad news.


Key Points:


Neurology / Dementia

  • Dementia is a progressive and irreversible neurodegenerative condition.

  • End-stage dementia includes refusal to eat, cognitive decline, disorientation, and progressive weight loss.

  • The patient is conscious but not cooperating, indicating a significant cognitive and functional decline.


Palliative Care

  • Emphasize comfort-focused care rather than curative intent.

  • Active interventions (e.g., NG tube feeding) may cause more harm than benefit:

    • Discomfort

    • Risk of aspiration

    • Potential for infections


SPIKES Protocol Breakdown

  • S – Setting: Ensure privacy and minimal interruptions.

  • P – Perception: Explore carer's understanding of the condition and recent changes.

  • I – Invitation: Gain consent to share difficult news.

  • K – Knowledge:

    • Deliver information from what the carer knows to the unknown.

    • Pause after delivering the worst part: “She is not going to recover.”

  • E – Emotion:

    • Use the EVE protocol: Empathize, Validate, Explore.

  • S – Strategy & Summary:

    • Introduce palliative care.

    • Explain what to expect and offer support resources.


Important Considerations:

  • The worst part of the news is that the patient is in terminal dementia with no recovery expected.

  • Language must be empathetic yet truthful; avoid direct terms like "dying" unless prompted.

  • NG tube feeding in conscious dementia patients is often not indicated.

  • Explore and acknowledge the carer’s burden and mental health.

  • Clarify palliative care is not giving up, but maximizing comfort.


Diagnostic Approach:

  1. Review history and caregiver's narrative.

  2. Confirm with investigations (e.g., CT scan, blood tests) that show no reversible cause.

  3. Correlate findings with the trajectory of dementia progression.

  4. Rule out differential diagnoses already done per hospital workup.


Management:

  • No aggressive feeding or invasive interventions.

  • Initiate palliative care plan:

    • Comfort measures

    • Symptom control

    • Hydration as tolerated

  • Offer hospice support, either hospital-based or home-based.

  • Refer to social services for caregiver support.

  • Provide educational leaflets, discuss follow-up, and safety-net for signs of further deterioration.


Communication Skills:

  • Use clear and compassionate language.

  • Avoid jargon.

  • Allow pauses for emotional processing.

  • Show empathy and validate carer's emotions.

  • Reinforce support is ongoing despite prognosis.


Ethical Considerations:

  • Discuss advance care planning if appropriate.

  • Respect patient's autonomy and dignity.

  • Ensure informed consent for palliative transition.

  • Be culturally sensitive in end-of-life conversations.


Additional Resources:

  • GMC Good Medical Practice Guidelines on end-of-life care.

  • NICE Dementia Management Guidelines.

  • GMC SPIKES & EVE protocols reference.

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