Personal Details:
Name: Mrs Green
Age: 70
Medical Record:
Past medical history: Admitted several weeks ago with progressive dementia.
Notes:
A 70-year-old woman with end-stage dementia is deteriorating. She is no longer able to eat or drink. The multi-disciplinary team (MDT) has decided that she is now for palliative, end-of-life care. Her nasogastric (NG) tube has been removed as it was causing distress and providing no clinical benefit.
Task:
1. Talk to the daughter and explain the change in focus to palliative care, and address her concerns.
3. Explain the MDT management plan.
Opening Sentence: “Doctor, I’ve just seen the nurse taking the tube out of my mum’s nose. What’s going on? Are you stopping her food?”
Open History (to give freely): “She’s been getting worse, I know that. But she needs food and water to live. If you stop the tube, you’re just starving her to death. I don’t understand.”
Cues to give: “I was thinking of taking her home. Maybe she would get better there.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I think you are giving up on her.”
Concerns: “Why did you remove the NG tube? Can she improve if I take her home? What can I do for her?”
Expectation: “I expect you to keep feeding her and keep her alive.”
How to Act: You are distressed, emotional, and feel that the medical team is giving up on your mother. You are torn between wanting her to live and seeing her suffer.
More History (only if asked): You have been caring for your mother for years, and it has been heartbreaking to watch her decline. You feel guilty and helpless.
Social History: You are her sole carer and next of kin.
Questions to ask:
“Are you saying she’s dying?”
“Isn’t it cruel to stop her food and water?”
Opening & Acknowledging Distress:
Hello, I’m Dr. [Name]. I can see you are very upset about the feeding tube. Please, let’s sit down and talk about what’s happening with your mum.
Exploring Her Understanding & Feelings:
Before we go any further, what have the doctors and nurses told you about your mum’s condition over the last few weeks?
How have you seen her change during this admission?
You said you feel we are giving up on her. Can you tell me more about that feeling?
ICE (Ideas, Concerns, Expectations):
What were your thoughts about the feeding tube? What did you think it was achieving for her?
What is your biggest fear about what is happening now?
In your heart, what were you hoping for your mum?
Exploring Patients' Wishes:
Have you and your mother ever talked about what she would want at the end of her life? Did she ever write anything down?
Explain the situation:
Thank you for talking with me. I want to explain what is happening. Your mother’s dementia has been gradually worse, and unfortunately, it is now severe and has reached what we can call a final stage.
Addressing and answering the patient’s ICE:
You are worried that by removing the feeding tube, we are starving her. This is a very common and understandable fear. At the very end of life, the body can no longer digest or process food and fluid. Continuing to feed at this stage doesn’t help; in fact, it can cause more harm and discomfort, leading to bloating, fluid in the lungs, and distress. The decision to remove the tube was made by the whole team because it was causing her discomfort and was no longer providing any benefit.
Next Steps:
You mentioned taking her home. I understand that desire completely, and we can facilitate that. Our focus now has completely shifted to making sure she is comfortable, peaceful, and has a dignified death. We call this palliative care.
What you can do for her, which is the most important thing in the world, is just be with her. You can hold her hand, talk to her, and play her favourite music. The nurses will keep her comfortable. They will keep her mouth moist with special sponges, and we will give her small doses of medication to ensure she is not in any pain or agitated.
This is a natural end to a long illness. We are here to support you as well as her. Please let us know if there is anything at all we can do for you.
Addressing ideas, concerns, and expectations: Gently but clearly state that her mother is deteriorating. Address the difficult issue of stopping feeding, explaining that it is to prevent suffering, not to hasten death.
The management is about explaining the principles of end-of-life care. 1. Explain the focus on comfort, peace, and dignity. 2. Describe the practical steps (mouth care, pain relief). 3. Empower the daughter by explaining her vital role in providing comfort and presence.
What is scenario testing? This is a very difficult communication station about end-of-life care. It tests the candidate’s ability to explain the transition to palliative care and to address the emotive issue of withdrawing artificial nutrition and hydration. The key is to be compassionate, honest, and clear, reframing the situation from ‘giving up’ to a positive act of providing comfort and dignity.