Ethics · Advanced · Ethics

Bruises and Silence in an Elderly Patient

Practise this PLAB 2 ethics station on Elder Abuse. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the emergency department. Mr Benjamin Meadows, a 78-year-old man, has attended with a fall and shoulder pain. On examination, you discover multiple bruises at various healing stages and other concerns that suggest possible elder abuse. His son, who is his main carer, is present but remains in the room during examination. Please sensitively explore what has happened, assess capacity and safeguarding concerns, and discuss appropriate management and reporting.

Background notes: PMH: Hypertension, T2DM, Osteoarthritis (multiple joints), Mild cognitive impairment, Penicillin allergy (rash)

What this station tests

  • Separating the patient from the suspected abuser: essential for honest disclosure
  • Recognising elder abuse types: physical, financial, psychological, neglect
  • Safeguarding referral to adult social care: mandatory when abuse is suspected
  • Not confronting the suspected abuser: this jeopardises the investigation
  • Fear of institutionalisation as a barrier to disclosure: reassure that disclosure does not automatically mean leaving home

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

Suspected elder abuse requires the same safeguarding vigilance as child protection. Mr Meadows is 78, widower, attending A&E after a fall with unexplained bruising. He seems withdrawn and fearful. His son Rajesh (who is his carer) brought him but seems impatient. Open with: 'Mr Meadows, I would like to examine your injuries. Could I speak to you on your own for a moment?'

Core approach

Separate him from the son. As with suspected NAI in children and trafficking, assessment requires privacy. Use a clinical reason: 'I need to examine you privately.' Assess the injuries: bruising in unusual locations (upper arms, trunk), different ages, inconsistent with the fall history. Signs of neglect: poor hygiene, weight loss, unkempt appearance.

Assess for abuse types. Physical: unexplained bruising, grip marks. Financial: is Rajesh managing his finances? Has money gone missing? Psychological: is he afraid of Rajesh? Does he seem controlled? Neglect: is he receiving adequate care, nutrition, medication?

He may be reluctant to disclose because Rajesh is his only carer and he fears institutionalisation. 'If you are being hurt or feel unsafe, I can help. Telling me will not automatically mean you have to leave your home.'

Closing and safety netting

If abuse is suspected: safeguarding referral to adult social care. Document injuries with body maps. Do not confront Rajesh directly (as with child NAI, confrontation jeopardises the investigation). Ensure Mr Meadows is safe before discharge: if immediate risk, he should not be sent home with the suspected abuser.

Offer support: domestic abuse services are not just for women. Age UK. Independent Mental Capacity Advocate if capacity is in question. Safety net: 'If you feel unsafe at any time, call 999 or come back here.' Follow-up: adult safeguarding team will coordinate.

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 (Primary focus)

Scores well: Patient separated. Injuries documented. Abuse types screened. Disclosure encouraged safely. Capacity assessed.

Costs marks: Not separating. Not documenting injuries. Not screening for abuse.

Domain 2 (Primary focus)

Scores well: Safeguarding referral. Body maps. Not discharging with abuser. Support resources. Safety plan.

Costs marks: Not referring. Discharging with abuser. Confronting son.

Domain 3 (Primary focus)

Scores well: Creating safe space for disclosure. Reassuring about home. Not confronting. Gentle questioning.

Costs marks: Confronting. Making him feel he will be institutionalised. Not creating safety.

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. Not separating from the son: assessment is impossible with the suspected abuser present
  2. Confronting the son: this is dangerous and jeopardises the safeguarding process
  3. Discharging home with the suspected abuser without safeguarding involvement

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

What is the right way to handle the elder abuse scenario in this station?

Suspected elder abuse requires the same safeguarding vigilance as child protection. Mr Meadows is 78, widower, attending A&E after a fall with unexplained bruising. He seems withdrawn and fearful.

Where are marks won and lost in this elder abuse station?

Examiners reward: Patient separated. Injuries documented. Abuse types screened. Disclosure encouraged safely. Capacity assessed. Candidates are penalised for: Not separating. Not documenting injuries. Not screening for abuse.

Where do candidates most often go wrong in this station?

Not separating from the son: assessment is impossible with the suspected abuser present. Another frequent error: Confronting the son: this is dangerous and jeopardises the safeguarding process.

Can I do well in this station without real-world experience of elder abuse?

Structure beats experience here. Focus on recognising elder abuse types: physical, financial, psychological, neglect. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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