Ethics · Advanced · Ethics

Multiple Sclerosis Patient Requesting DNAR

Practise this PLAB 2 ethics station on Secondary Progressive Multiple Sclerosis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on a neurology ward. Mr Emeka Okeke, a 62-year-old man with progressive multiple sclerosis (SPMS, wheelchair-bound, progressive neurological decline, recurrent infections), has asked to speak with you about a Do Not Attempt Cardiopulmonary Resuscitation decision and advance planning. He is concerned about his future and wants to discuss his preferences for end-of-life care. He is asking about lasting power of attorney and advance decision documentation. Please discuss his wishes, explore his concerns, and help him plan for his future.

Background notes: PMH: Progressive multiple sclerosis (SPMS for 15 yrs), Secondary progressive MS since age 47, Wheelchair-bound past 10 yrs, Recurrent UTIs

What this station tests

  • DNAR does not mean withdrawing treatment: all other care continues
  • Patient autonomy overrides family disagreement when capacity is confirmed
  • Capacity assessment: all four elements documented
  • ReSPECT form completion: the correct documentation for DNAR decisions
  • Supporting the spouse who disagrees: her distress is valid even though his decision stands

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 with progressive neurological disease requesting DNAR is exercising legitimate autonomy about end-of-life care. Mr Okeke is 62, secondary progressive MS, wheelchair-dependent, requesting DNAR. His wife disagrees. Open with: 'Mr Okeke, I understand this is something you have been thinking about. Tell me what has brought you to this decision.'

Core approach

Assess capacity (all four elements). He is cognitively intact despite physical disability. He has been thinking about this for months. He has discussed it with his MS nurse. He understands what DNAR means: 'If my heart stops, I do not want to be resuscitated.' He can articulate his reasoning: progressive disability, loss of independence, watching the disease worsen, wanting control over how his life ends.

His wife Susan is distressed and disagrees. She sees DNAR as 'giving up.' Address both: the patient's decision is legally binding if he has capacity, but Susan's distress is real and deserves support.

Clarify what DNAR does and does not mean. 'A DNAR order means that if your heart stops, we would not attempt CPR. It does NOT mean we stop treating you. You will still receive all other treatments for infections, pain, and symptoms.' This distinction often resolves the family's concern.

Closing and safety netting

Complete the DNACPR/ReSPECT form with his informed consent. Document capacity assessment, his reasoning, and that Susan was present. Support Susan: 'This is not giving up. This is your husband making a considered decision about one specific intervention. All other care continues.' Offer palliative care team involvement for advance care planning. MS Society for ongoing support. Follow-up: review the decision at subsequent appointments (it can be changed at any time).

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 formally assessed. Reasoning explored. Wife's perspective heard. MS progression documented.

Costs marks: Not assessing capacity. Not hearing wife.

Domain 2 (Primary focus)

Scores well: DNACPR completed. DNAR vs treatment withdrawal explained. Palliative care referral. ReSPECT form. Decision reviewable.

Costs marks: Refusing DNAR. Conflating with treatment withdrawal. No documentation.

Domain 3 (Primary focus)

Scores well: Respecting his autonomy. Supporting Susan. Clarifying DNAR meaning for both. Not taking sides.

Costs marks: Siding with wife. Dismissing his decision. Not supporting Susan.

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. Refusing DNAR because the wife disagrees: patient autonomy takes precedence
  2. Conflating DNAR with treatment withdrawal: they are different concepts
  3. Not supporting the wife: her distress is legitimate and needs addressing

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 secondary progressive multiple sclerosis scenario in this station?

A patient with progressive neurological disease requesting DNAR is exercising legitimate autonomy about end-of-life care. Mr Okeke is 62, secondary progressive MS, wheelchair-dependent, requesting DNAR. His wife disagrees.

Where are marks won and lost in this secondary progressive multiple sclerosis station?

Examiners reward: Capacity formally assessed. Reasoning explored. Wife's perspective heard. MS progression documented. Candidates are penalised for: Not assessing capacity. Not hearing wife.

Where do candidates most often go wrong in this station?

Refusing DNAR because the wife disagrees: patient autonomy takes precedence. Another frequent error: Conflating DNAR with treatment withdrawal: they are different concepts.

Can I do well in this station without real-world experience of secondary progressive multiple sclerosis?

This station rewards process over personal experience. The skill being assessed: Patient autonomy overrides family disagreement when capacity is confirmed. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

Related cases