Breaking bad news transition to Palliative Care for an Unconscious Stroke Patient: PLAB 2 Mock Attempt 1

Practice a case with the AI patient 🤖

Summary:

This station involves breaking the news to a patient's relative about a significant deterioration in the patient’s condition following a major stroke. The primary objective is to communicate that the care focus is shifting from curative to palliative, managing concerns around stopping active treatment, and addressing questions regarding medications like antibiotics or antihypertensives.

Key Points:

Neurological System (Stroke)

• The patient suffered a major ischemic stroke with irreversible brain damage.

• Prognosis: Unlikely recovery; unconscious for 7 days.

• CT scan showed extensive ischemia.

General Medical Background

• History of hypertension and hyperlipidemia.

• Past medical history and medication review are essential for context.

Palliative Care

• Shift from curative to palliative care: focus is on comfort and dignity.

• Clarify the rationale for stopping medications like antihypertensives or statins.

• Avoid unnecessary treatments like antibiotics unless for symptom control.

Important Considerations:

• Avoid colloquial phrases like “he won’t make it” – use medically appropriate language.

• Always check understanding and summarize key points at the end.

• Clarify that stopping medications does not hasten death but avoids unnecessary harm.

• Be clear that this is not euthanasia or assisted dying.

Diagnostic Approach:

1. Confirm unconscious status and duration (7 days).

2. Review imaging (CT showing major stroke).

3. Assess for recovery potential (prognosis discussion with senior team).

4. Identify comorbidities (hypertension, hyperlipidemia).

5. Evaluate current interventions (e.g., NG tube, IV fluids, medications).

Management:

• Immediate: Transition to palliative care.

  • Withdraw NG tube.

  • Discontinue non-beneficial medications.

  • Start symptom-control meds via SC route (e.g., morphine, midazolam).

• Supportive:

  • Ensure patient comfort and dignity.

  • Provide emotional support and bereavement resources to family.

• Documentation and Multidisciplinary Involvement:

  • Discuss care plan with senior.

  • Record discussions and decisions.

  • Involve palliative team and nursing staff.

Communication Skills:

• Use SPIKES protocol:

  • Setting: Private, quiet room.

  • Perception: Ask what they understand so far.

  • Invitation: Ask if they are ready to discuss.

  • Knowledge: Deliver news clearly and in plain language.

  • Emotions: Respond empathetically.

  • Strategy and Summary: Outline next steps.

• Avoid stock phrases; be empathetic but authentic.

• Avoid over-explaining or giving speculative information about future treatments.

• Safety-net for emotional distress in the relative.

🌱 Additional Domain-Wise Remarks:

🧠 Data Gathering:You were empathetic and explored some key history but missed out on important points like comorbidities, medications, social setup, and cultural concerns. Try grouping your questions into categories: medical history, social support, and patient’s wishes. This will make it more structured.

🛠 Management:You did deliver the bad news and addressed some aspects of palliative care, but missed specifics such as medication names, supportive resources, and safety netting. Use clearer signposting and summarise before you end the conversation. These can help convey confidence and compassion.

💬 Interpersonal Skills:You showed good empathy and explained things in simple terms, but you relied on repeated apologetic phrases and didn’t fully explore her emotional or cultural background. Try to personalize support more and check if the daughter understood everything before concluding.

Ethical Considerations:

• Respect patient autonomy (advance directives, if known).

• Ensure non-maleficence (avoiding harm with futile treatment).

• Clarify that decisions are in line with best clinical practice, not abandonment.

• If unsure, defer complex decisions to a senior clinician.

Additional Resources:

• GMC Good Medical Practice Guidelines

• NICE Palliative and End of Life Care Guidance

• GMC PLAB 2 Feedback Framework

• Examiner top tips for effective consultation skills