Ethics · Advanced · Ethics

Difficult Conversation: Breaking Dementia News to Adult Child

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

Clinical scenario

You are an FY2 doctor in the memory clinic. Mrs Claire Moss has been diagnosed with vascular dementia following cognitive testing and imaging. She has capacity to understand her diagnosis. Her adult daughter Sarah, age 38, has attended the appointment and is now sitting with her mother. Claire has asked that you discuss the diagnosis, prognosis, and management with her daughter present. Please deliver the diagnosis, discuss the impact on Claire's and Sarah's lives, address Sarah's questions and concerns, and discuss care planning and support.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Stroke/TIA

What this station tests

  • Vascular dementia management: cardiovascular risk factor optimisation can stabilise progression
  • No cholinesterase inhibitors for pure vascular dementia: different from Alzheimer's treatment
  • Advance care planning while capacity is present: LPA for health and finances
  • Supporting the adult child as carer: separate needs and separate support
  • DVLA notification: mandatory for any dementia diagnosis

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 an adult child alongside the patient requires balancing both their emotional responses. Mrs Moss (74) has vascular dementia. Her daughter Sarah (45) is present. Open with: 'Mrs Moss, Sarah, I have the results of the assessments. Would you both like to hear them together?'

Core approach

Deliver to both, directed at the patient. 'Mrs Moss, the tests show that the memory and thinking changes you have been experiencing are caused by vascular dementia. This is related to the blood supply to your brain, connected to your blood pressure and the small strokes you have had.' Pause.

Sarah may react strongly (her mother is her closest person since her father died). She may become protective, tearful, or angry. Allow her response. Then provide information: vascular dementia can be stabilised by managing cardiovascular risk factors (BP, cholesterol, diabetes, smoking). This is different from Alzheimer's where decline is more inevitable.

Practical concerns: driving (DVLA notification), safety at home (she lives alone), financial management, lasting power of attorney while capacity is present.

Closing and safety netting

Treatment: optimise cardiovascular risk factors (aspirin, statin, antihypertensive). No cholinesterase inhibitors for vascular dementia (these are for Alzheimer's) unless mixed dementia. Support: social care assessment, Alzheimer's Society, carers' support for Sarah. Advance care planning while capacity is present.

Address Sarah specifically: 'This will affect you too. There is support available for carers.' Offer a separate appointment for Sarah to discuss her concerns. Follow-up in 4 weeks.

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: Diagnosis explained clearly. Vascular cause connected to cardiovascular history. Current function assessed.

Costs marks: Not connecting to cardiovascular history.

Domain 2 (Primary focus)

Scores well: Cardiovascular optimisation. No inappropriate cholinesterase inhibitors. ACP. DVLA. Social care referral. Carers support.

Costs marks: Wrong medication. No ACP. No DVLA.

Domain 3 (Primary focus)

Scores well: Directing at patient not just daughter. Allowing emotion from both. Supporting Sarah separately. Honest but hopeful about stabilisation.

Costs marks: Only telling daughter. Ignoring patient. Not supporting daughter.

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. Prescribing donepezil for vascular dementia: cholinesterase inhibitors are for Alzheimer's not vascular
  2. Directing all communication at the daughter: the patient has the right to be told directly
  3. Not supporting the daughter: she is the future carer and needs her own support

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 vascular dementia consultation?

Delivering a dementia diagnosis to an adult child alongside the patient requires balancing both their emotional responses. Mrs Moss (74) has vascular dementia. Her daughter Sarah (45) is present.

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

Strong performances show: Diagnosis explained clearly. Vascular cause connected to cardiovascular history. Current function assessed. Weak performances: Not connecting to cardiovascular history.

What is the biggest pitfall in this vascular dementia station?

Prescribing donepezil for vascular dementia: cholinesterase inhibitors are for Alzheimer's not vascular. Another frequent error: Directing all communication at the daughter: the patient has the right to be told directly.

How should I prepare for vascular dementia if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: No cholinesterase inhibitors for pure vascular dementia: different from Alzheimer's treatment. 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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