Ethics · Advanced · Ethics

Family Request to Withhold Diagnosis

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

Clinical scenario

You are an FY2 doctor in a general medical ward. Mrs Joyce Marshall, a 72-year-old woman, has been admitted for investigation of abdominal pain and weight loss over the past four months. Her imaging and histology results confirm advanced pancreatic cancer. Her two adult sons have asked to speak with you urgently before you tell their mother. They are requesting that you do not disclose the diagnosis to her, as they believe she would lose hope and deteriorate. Please discuss this request with the family.

Background notes: PMH: Type 2 diabetes, Hypertension, Hypothyroidism, Widow, Retired teacher

What this station tests

  • Patient autonomy: the right to know one's diagnosis belongs to the patient, not the family
  • Not colluding with the family to withhold information: regardless of good intentions
  • Assessing information preferences: 'how much would you like to know?' gives the patient control
  • Conspiracy of silence: withholding often isolates the patient rather than protecting them
  • Acknowledging the family's love while maintaining ethical principles

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 family requesting that a terminal diagnosis be withheld from the patient creates an ethical tension between family wishes and patient autonomy. Mrs Marshall (72) has advanced pancreatic cancer. Her sons want to protect her by not telling her. Open with: 'I understand your concern for your mother. Can you tell me why you feel she should not be told?'

Core approach

Listen to the family's reasoning. They love her. They think the diagnosis will destroy her. They want to protect her remaining time. These are understandable, well-intentioned motivations. Acknowledge them: 'I can see this comes from a place of deep love for your mother.'

Then explain the ethical and legal position. 'Your mother has the right to know her diagnosis if she wants to. Without this information, she cannot make informed decisions about her treatment, her finances, her relationships, and how she wants to spend her remaining time. Withholding information removes her autonomy.'

Explore what she might already suspect. Most patients know they are seriously ill. Withholding the diagnosis often creates a conspiracy of silence that isolates the patient. She may be protecting them by not asking. Offer: 'Would it help if I asked your mother how much she wants to know? Some patients want full details, others prefer broad strokes.'

Closing and safety netting

Propose a compromise: assess her information preferences. 'I will ask your mother whether she wants to know her diagnosis and how much detail she wants. If she says she does not want to know, I will respect that. But the decision must be hers, not ours.' This respects both the family's concern and the patient's autonomy.

If she wants to know: deliver the diagnosis with the family present if she wishes. If she does not want to know: document this and provide care without forcing information. Either way, the patient's autonomy is preserved. Follow-up: ongoing support for both patient and family.

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: Family's reasoning explored. Patient's capacity confirmed. Cultural context understood.

Costs marks: Not exploring reasons. Not confirming capacity.

Domain 2 (Primary focus)

Scores well: Patient autonomy upheld. Information preferences to be assessed. Compromise offered (ask the patient). Documentation plan.

Costs marks: Agreeing to withhold. Not offering compromise. Not documenting.

Domain 3 (Primary focus)

Scores well: Acknowledging family's love. Not being confrontational. Explaining autonomy gently. Offering assessment of patient's wishes.

Costs marks: Being confrontational. Dismissing family concerns. Not offering compromise.

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. Agreeing to withhold the diagnosis: this violates patient autonomy regardless of family wishes
  2. Being confrontational with the family: they are acting out of love, not malice
  3. Not offering to assess the patient's own information preferences: this is the ethical compromise

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 advanced pancreatic cancer ethics station in PLAB 2?

A family requesting that a terminal diagnosis be withheld from the patient creates an ethical tension between family wishes and patient autonomy. Mrs Marshall (72) has advanced pancreatic cancer. Her sons want to protect her by not telling her.

What are examiners marking in this advanced pancreatic cancer station?

Marks are won for: Family's reasoning explored. Patient's capacity confirmed. Cultural context understood. Marks are lost for: Not exploring reasons. Not confirming capacity.

What is the most common mistake candidates make in this advanced pancreatic cancer station?

Agreeing to withhold the diagnosis: this violates patient autonomy regardless of family wishes. Another frequent error: Being confrontational with the family: they are acting out of love, not malice.

How do I prepare for this station if I have not managed advanced pancreatic cancer in clinical practice?

This station rewards process over personal experience. The skill being assessed: Not colluding with the family to withhold information: regardless of good intentions. 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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