You are an FY2 in AMU

Personal Details:

Name: Mary Smith

Age: 85

Medical Record:

Past medical history: Advanced dementia (diagnosed 4 years ago), significant weight loss.

Regular medication: None relevant.

Allergies: None known.

Notes:

Mary was admitted to the Acute Medical Unit (AMU) a week ago due to a decline in oral intake and weight loss. She is now unable to eat or drink. All investigations for a reversible cause have come back normal. A CT scan shows changes consistent with advanced dementia. Mary no longer recognises her family and is non-verbal. The consultant has reviewed her and made the decision that active treatment would be burdensome and not in her best interests. The plan is to focus on palliative, comfort-based care. Her son, who is her primary carer, is very unhappy with this decision.

Task:

1. Talk to the son, explain the current situation and the rationale behind the consultant’s decision.

2. Address his concerns

Opening Sentence: “Doctor, I am worried about my mum. What is going on. I feel like you are giving up?

Open History (to give freely): “She’s not eating or drinking. We have to keep fighting. I’m her son, I’m responsible for her.”

Cues to give: “I have the money. I have a full-time carer for her at home. We can afford to do whatever it takes.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think you’re just writing her off because she’s old and has dementia.”

Concerns: “worried about taking the nasogastric tube out. How will my mum eat? Are you just going to let her starve?”

Expectation: “I expect you to start feeding her through a tube and continue to treat her.

How to Act: You are distressed, angry, and feeling guilty. You are confrontational initially because you feel you are fighting for your mother’s life.

More History (only if asked): Your mother has been deteriorating for months. You know she doesn’t recognise you anymore, which is heartbreaking. You have dedicated your life to caring for her. You feel that agreeing to stop treatment is like letting her down.

Social History: You are her only child and next of kin. You have organised and paid for a comprehensive care package for her at home.

Questions to ask:

“What does palliative care even mean? Is it just about waiting for her to die?”

“Why can’t you just put a tube in? It’s a simple thing.”

Opening & Establishing Rapport:

Hello, I’m Dr. [Name], one of the doctors looking after your mother, Mary. Thank you for coming in. How are you doing? This must be a very difficult time.

Breaking the News (Warning Shot): “I wanted to talk to you about your mother’s condition. I’m afraid the news is not what we were hoping for. Despite our best efforts, she is not getting better. We believe she is now approaching the end of her life. (Pause, allow for reaction)

Exploring the Daughter’s Understanding & Wishes: What were your thoughts about your mother’s health before this admission? Has she ever talked to you about what she would want in a situation like this? Did she ever express any wishes about her end-of-life care? You mentioned she was scared of being a burden. Can you tell me more about that?

ICE (Ideas, Concerns, Expectations): What are your thoughts on what you would like us to do for her now? What is your biggest fear or worry about what happens next? Are you worried she is in pain? You mentioned a drip. What were you hoping that would achieve for her?

Explain the situation:

Thank you for talking with me. I can see how incredibly upsetting and distressing this is for you. I want to assure you we are not giving up on your mother. Our focus is changing, but it’s changing to make sure she is as comfortable and dignified as possible. Your mother’s dementia has now reached a very advanced stage. This is not a new illness, but the final stage of the disease she has been living with for years. At this point, her brain is no longer able to coordinate the basic functions of eating and drinking.

Addressing and answering the patient’s ICE:

You’re asking us to put in a feeding tube, and your biggest concern is that she will starve. This is a very difficult concept, but in the final stages of dementia, the body starts to shut down. Forcing food and fluid into her stomach with a tube can actually cause more harm than good. It can cause pain, bloating, and a high risk of fluid going into her lungs, causing a serious pneumonia. It would not prolong her life in a meaningful way and would likely just prolong her dying process, causing her discomfort.

Next Possible Steps:

Our plan is to start what we call palliative care. You asked what this means. It’s not about waiting for her to die; it’s about making the time she has left as comfortable, peaceful, and dignified as possible. We will stop doing invasive tests and treatments. Instead, our nurses will focus on keeping her mouth moist, keeping her skin comfortable, and giving her small doses of medication to ensure she is not in any pain or distress.

“You asked about taking her home. That is absolutely something we can support if it is your wish. We can arrange for our palliative care team to work with the community team and the carers you have to ensure she can be cared for in her own familiar environment, with the same focus on her comfort and dignity.

I know this is a huge amount to take in, and it feels like you are losing the fight. But in fact, you are doing the most loving thing possible by shifting the focus from fighting the disease to caring for the person. It’s about ensuring her final days are peaceful, not filled with tubes and medical interventions that are causing her distress.

I hope I explained myself well. Do you have any questions? How do you see that?

Addressing ideas, concerns, and expectations: Gently but clearly reframe the situation from “giving up” to “changing focus”. Directly address his request for a feeding tube, explaining why it would be burdensome and not beneficial (non-maleficence). Redefine palliative care as active, comfort-focused care.

The management is purely communicative. Offer referral to the palliative care team for more specialist support for him and his mother. Offer practical support for discharge home if desired.

What is scenario testing? This is a very challenging breaking bad news and ethics station. It tests the candidate’s ability to communicate a complex and emotionally charged end-of-life decision to a distressed and resistant relative. It requires a deep understanding of the principles of palliative care and the ability to explain the concept of burdensome treatment. Key skills are empathy, communication, and ethical reasoning.