When Emotions Run High: Mastering the Angry Relative Scenario: A PLAB 2 Mock Scenario

Summary:

This scenario involves a phone consultation with a concerned daughter regarding the unsanctioned change in her mother’s levothyroxine dosage. The daughter, who holds lasting power of attorney (LPA), expresses frustration over not being informed, linking the situation to a previous tragic incident involving her father. The doctor must address the relative’s concerns, explain clinical decisions, and manage the situation empathetically while upholding professional and ethical standards.

Key Points:

Endocrine System (Thyroid)

• The patient has hypothyroidism managed with levothyroxine.

• Thyroid function tests showed normalized TSH/T4, indicating overtreatment.

• The dosage of levothyroxine was adjusted to prevent iatrogenic hyperthyroidism and associated complications.

Geriatrics and Comorbidities

• The patient is 65 years old and resides in a nursing home.

• Likely has multiple comorbidities including possible dementia (justifying LPA).

• Ongoing medication and clinical monitoring are crucial.

Important Considerations:

• Always verify the patient's capacity before engaging with relatives.

• Recognize and document LPA status before disclosing medical information.

• Medication changes should be communicated, especially when relatives are legal decision-makers.

• Acknowledge emotional distress empathetically and validate concerns.

Diagnostic Approach:

1. Confirm the identity of the caller and their relationship to the patient.

2. Verify if the caller holds LPA for health and welfare decisions.

3. Review recent thyroid function test results.

4. Reassess for any clinical symptoms of hypo- or hyperthyroidism.

5. Evaluate potential medication side effects or interactions.

Management:

• Explain rationale for medication dose adjustment (T4 levels elevated).

• Offer to arrange follow-up for physical review and blood test reassessment.

• Provide written patient information leaflets regarding thyroid management.

• Escalate and document the incident:

  • Submit an incident form.

  • Discuss in the root cause analysis meeting.

  • Arrange for senior colleague consultation and apology if necessary.

• Outline a clear plan to prevent recurrence (e.g., improving communication protocols).

Communication Skills:

• Begin with clear identification and consent.

• Use empathetic statements and actively listen to concerns.

• Avoid defensive language; apologize sincerely.

• Provide reassurance and discuss actionable steps to rebuild trust.

• Ensure patient/relative is aware of complaint procedures and support services.

Ethical Considerations:

• Maintain patient confidentiality unless LPA is legally confirmed.

• Be transparent about medical errors (GMC's duty of candour).

• Respect autonomy and involve legal surrogates appropriately.

• Avoid over-promising; focus on feasible, realistic outcomes.

Additional Resources:

• GMC Guidance on Consent and Decision-Making

• BNF – Levothyroxine Monograph

• NICE Guidelines on Hypothyroidism

• GMC's “Good Medical Practice” and “Openness and Honesty When Things Go Wrong”