Ethics · Advanced · Ethics

Declining Further Treatment: A Question of Autonomy

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

Clinical scenario

You are an FY2 doctor on an acute medical ward. Mr Clifton Jennings, a 47-year-old man, has been diagnosed with infective endocarditis and has been on antibiotics for two weeks. Despite your team's recommendations for prolonged IV antibiotics and possible valve surgery, he is now adamant he wants to stop treatment and go home. Please discuss his wishes, explore his concerns, and address the serious implications.

Background notes: PMH: Hepatitis C (cured 5 yrs ago), History of IV drug use (clean 10 yrs), Depression and anxiety (off medications 3 yrs)

What this station tests

  • Exploring barriers to treatment before accepting refusal: needle phobia and claustrophobia are addressable
  • OPAT as a compromise: outpatient IV antibiotics may address the hospital aversion
  • Informed refusal documentation: capacity, information given, alternatives offered, and final decision
  • Not simply accepting refusal at face value: explore why and offer solutions first
  • Oral antibiotics as a safety net compromise: less effective but better than nothing

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

A patient declining life-saving treatment for a potentially curable condition is ethically challenging. Mr Jennings is 47, diagnosed with infective endocarditis needing IV antibiotics and possible surgery. He wants to self-discharge. Open with: 'Mr Jennings, I understand you want to leave. Before you go, I need to make sure you understand what that would mean.'

Core approach

Assess capacity. Is he making this decision with full understanding? He is not confused, intoxicated, or in pain affecting judgment. He has a needle phobia that is contributing (he cannot tolerate the IV cannula). He also feels claustrophobic in hospital. These are real barriers, not irrational refusal.

Ensure informed refusal. 'Without IV antibiotics, infective endocarditis can damage your heart valves, cause stroke, and can be fatal. This is a serious condition that needs hospital treatment.' He must understand the consequences before you can accept his decision.

Explore and address barriers. Needle phobia: 'We can involve the psychology team or use anaesthetic cream to make cannulation easier.' Claustrophobia: 'Would a side room with a window help? Can you have visitors to make it more bearable?' OPAT (outpatient parenteral antibiotic therapy): could some of his treatment be delivered at home? Explore all options before accepting refusal.

Closing and safety netting

If barriers can be addressed: negotiate continued treatment. If he still refuses after all options explored: document informed refusal. 'I respect your decision, but I want to be clear that leaving without treatment puts your life at risk.' Offer oral antibiotics as a compromise (less effective but better than nothing). Arrange GP follow-up. Leave the door open: 'If you change your mind, come back immediately.' Document everything including capacity, information given, alternatives offered, and his final decision.

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: Capacity assessed. Barriers identified (needle phobia, claustrophobia). Severity of condition communicated. Alternatives explored.

Costs marks: Not identifying barriers. Not assessing capacity.

Domain 2 (Primary focus)

Scores well: Barriers addressed (psychology, EMLA, side room). OPAT offered. Oral antibiotics as compromise. Informed refusal documented. GP follow-up.

Costs marks: Simply accepting refusal. No alternatives. No documentation.

Domain 3 (Primary focus)

Scores well: Respecting autonomy while exploring solutions. Not being paternalistic. Acknowledging his fears as real. Leaving the door open.

Costs marks: Being coercive. Dismissing his fears. Not offering alternatives.

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. Accepting refusal without exploring barriers: his needle phobia and claustrophobia are treatable
  2. Detaining him against his will: if he has capacity, he can leave (unless Mental Health Act applies, which it does not here)
  3. Not offering any alternative: oral antibiotics or OPAT may keep him in some form of treatment

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 do I structure my approach to this infective endocarditis consultation?

A patient declining life-saving treatment for a potentially curable condition is ethically challenging. Mr Jennings is 47, diagnosed with infective endocarditis needing IV antibiotics and possible surgery. He wants to self-discharge.

What does a strong performance look like to the examiner in this station?

Strong performances show: Capacity assessed. Barriers identified (needle phobia, claustrophobia). Severity of condition communicated. Alternatives explored. Weak performances: Not identifying barriers. Not assessing capacity.

What is the biggest pitfall in this infective endocarditis station?

Accepting refusal without exploring barriers: his needle phobia and claustrophobia are treatable. Another frequent error: Detaining him against his will: if he has capacity, he can leave (unless Mental Health Act applies, which it does not here).

How should I prepare for infective endocarditis if I have never seen it in practice?

Structure beats experience here. Focus on oPAT as a compromise: outpatient IV antibiotics may address the hospital aversion. 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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