Ethics · Advanced · Ethics

Breaking Bad News: A Dementia Diagnosis

Practise this PLAB 2 ethics station on Alzheimer's Disease. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the outpatient memory clinic. Mrs Nia Adebayo, a 72-year-old woman, has attended with her husband following referral from her GP for memory concerns. Cognitive testing and MRI have confirmed Alzheimer's disease. She is alert, oriented, and has capacity. You need to discuss the diagnosis, prognosis, management options, support services, driving safety, and lasting power of attorney. Please handle this sensitively and address her and her husband's concerns.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Hypothyroidism, T2DM, Normal gynae history

What this station tests

  • Delivering dementia diagnosis to the patient directly: she has the right to know
  • Cholinesterase inhibitors (donepezil) as treatment: slows progression, does not cure
  • Advance care planning while capacity is present: LPA for health and finances
  • DVLA notification: mandatory for dementia diagnosis
  • Alzheimer's Society and Admiral Nurses: key support resources

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Delivering a dementia diagnosis to the patient (not just the family) requires honesty, sensitivity, and practical next steps. Mrs Adebayo is 72, attending the memory clinic with her husband Thomas. Formal assessment has confirmed Alzheimer's disease. Open with: 'Mrs Adebayo, Thomas, I have the results of all the assessments. Before I explain them, can you tell me what you have been expecting?'

Core approach

Check her perception. She may suspect, deny, or be prepared. Deliver the diagnosis: 'The assessments show that the memory changes you have been experiencing are caused by a condition called Alzheimer's disease. This is the most common type of dementia.' Pause. Allow the response.

Explain what it means practically. 'Alzheimer's is a condition where the brain changes gradually over time, affecting memory and thinking. It progresses slowly, and there are medications that can help slow the progression.' Cholinesterase inhibitors (donepezil) can be started.

Address their immediate concerns. 'Will I lose my mind completely?' Not immediately: progression is slow. 'Can I still live at home?' Yes, with support, for a considerable time. 'What about driving?' DVLA must be notified, and a driving assessment may be needed. Advance care planning while capacity is present: LPA for health and finances.

Closing and safety netting

Immediate next steps: start donepezil (or alternative cholinesterase inhibitor). DVLA notification. Advance care planning discussion (LPA, preferred place of care). Alzheimer's Society for support, local memory cafe, Admiral Nurses. Support for Thomas as carer. Follow-up in 6 weeks to assess medication response and provide ongoing support. 'You are not alone in this. There is a lot of support available.'

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Supporting)

Scores well: Perception checked. Formal assessment results interpreted. Current function assessed.

Costs marks: Not checking perception.

Domain 2 (Primary focus)

Scores well: Diagnosis delivered to patient. Donepezil started. DVLA discussed. ACP initiated. Support resources. Carer support.

Costs marks: Not telling patient. No medication. No DVLA. No ACP.

Domain 3 (Primary focus)

Scores well: Honest but hopeful. Allowing emotional response. Practical information. Supporting both patient and carer.

Costs marks: Blunt delivery. Not allowing emotion. Ignoring carer. No hope.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Telling only the husband: she has the right to know her own diagnosis
  2. Not starting medication: cholinesterase inhibitors should be offered
  3. Not discussing advance care planning: capacity may decline, so planning now is essential

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

How should I approach this alzheimer's disease ethics station in PLAB 2?

Delivering a dementia diagnosis to the patient (not just the family) requires honesty, sensitivity, and practical next steps. Mrs Adebayo is 72, attending the memory clinic with her husband Thomas.

What are examiners marking in this alzheimer's disease station?

Marks are won for: Perception checked. Formal assessment results interpreted. Current function assessed. Marks are lost for: Not checking perception.

What is the most common mistake candidates make in this alzheimer's disease station?

Telling only the husband: she has the right to know her own diagnosis. Another frequent error: Not starting medication: cholinesterase inhibitors should be offered.

How do I prepare for this station if I have not managed alzheimer's disease in clinical practice?

This station rewards process over personal experience. The skill being assessed: Cholinesterase inhibitors (donepezil) as treatment: slows progression, does not cure. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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