Breaking Bad News · Advanced · Ethics

Progressive Cognitive Decline and Headaches

Practise this PLAB 2 breaking bad news station on Glioblastoma. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on the neurology ward. Mr Geoffrey Gill, a 56-year-old man, has presented with progressive headaches and memory problems. Imaging and biopsy have confirmed a high-grade glioma (grade 4 glioblastoma) in the frontal lobe with significant midline shift. The tumour is inoperable and has very poor prognosis. The consultant neuro-oncologist has reviewed the results and asked you to break this news to Mr Gill and discuss treatment options and prognosis, as you have been involved in his investigations and admission. Mr Geoffrey Gill, a 56-year-old man, has presented with progressive headaches and memory problems. Imaging and biopsy have confirmed a high-grade glioma (grade 4 glioblastoma) in the frontal lobe with significant midline shift. The tumour is inoperable and has very poor prognosis. You must break this news to Mr Gill and discuss treatment options and prognosis.

Background notes: PMH: Nil significant

What this station tests

  • SPIKES framework for delivering terminal diagnosis directly to patient
  • Glioblastoma prognosis: median 12-18 months with treatment, honest without removing hope
  • Advance care planning while capacity is present: LPA, will, preferred place of death
  • Dexamethasone for cerebral oedema: immediate symptom relief while awaiting definitive treatment
  • Offering to tell the family together or separately: patient's choice

How to use your 8 minutes

  • 0-1 min — Setting: Introduce yourself. Ensure privacy. Ask what they already know (SPIKES: Perception).
  • 1-2 min — Warning Shot: Give a warning shot. 'I'm afraid I have some difficult news.' Pause and allow reaction.
  • 2-4 min — Deliver Information: Give information in small chunks. Use clear, simple language. Avoid euphemisms. Pause after key information.
  • 4-6 min — Respond to Emotion: Acknowledge and validate emotions. Allow silence. Empathic statements. Address immediate concerns.
  • 6-8 min — Plan and Support: Discuss next steps when patient is ready. Offer support resources. Arrange follow-up. Written information.

Consultation approach

The opening

Delivering a terminal brain tumour diagnosis directly to the patient requires SPIKES, honesty about prognosis, and addressing his immediate concerns about his family. Mr Gill is 56, married with two adult children, presenting with progressive headaches and cognitive decline. MRI confirms glioblastoma. Open with: 'Mr Gill, I have the results of your brain scan. Before I explain them, can you tell me what you have been expecting?'

Core approach

Check his perception. He suspects something serious (the cognitive decline frightened him). Warning shot: 'I am afraid the scan has shown something serious.' Deliver: 'The scan shows a tumour in your brain called a glioblastoma. This is a type of brain cancer.' Pause. Allow silence.

When ready: prognosis. Glioblastoma has a median survival of 12 to 18 months with treatment. Be honest when asked: 'The average is about 12 to 18 months, but some people live longer.' Treatment: surgery (debulking, not cure), radiotherapy, temozolomide chemotherapy (Stupp protocol). Treatment extends life and maintains quality of life but is not curative.

His concerns will be about his family (wife Fatima, children at university), his capacity to make decisions while he still can (LPA, will), and whether his cognitive symptoms will worsen.

Closing and safety netting

Immediate next steps: MDT discussion, neurosurgical review, oncology appointment. Dexamethasone for cerebral oedema (reduces headache and may improve cognition temporarily). Advance care planning while capacity is present. Macmillan, Brain Tumour Charity. Offer to tell his wife with him or separately. Safety net: 'If your headaches worsen significantly, you develop seizures, or sudden weakness, come to A&E.' Follow-up within days.

How examiners mark this station

Examiners will focus heavily on Domain 3 (Interpersonal Skills): how sensitively you deliver the news, whether you give a warning shot, allow silence, and respond to emotion. Domain 2 (Clinical Management) assesses the accuracy and clarity of information provided and the appropriateness of the plan discussed. Domain 1 (Data Gathering) assesses whether you established prior knowledge and readiness.

Domain 1 (Supporting)

Scores well: Perception checked. Information preferences established. Family context understood.

Costs marks: Not checking perception.

Domain 2 (Primary focus)

Scores well: Honest prognosis. Treatment options outlined. Dexamethasone started. ACP discussed. MDT referral. Brain Tumour Charity.

Costs marks: Evasive prognosis. No treatment plan. No ACP.

Domain 3 (Primary focus)

Scores well: SPIKES applied. Silence allowed. Empathic. Offering family involvement. Genuine compassion.

Costs marks: Rushing. No warning shot. Clinical detachment.

Common examiner feedback (and how to fix it)

Did not demonstrate sensitivity when delivering difficult information

Fix: Always give a warning shot. Deliver the key information in one clear sentence, then stop. Allow silence. Respond to emotion before giving more detail.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: After delivering bad news, your primary role shifts to emotional support. Use the NURSE mnemonic (Name, Understand, Respect, Support, Explore) to respond to the patient's reaction.

Common mistakes in this station

  1. Being evasive about prognosis: he deserves honest information to make decisions
  2. Not discussing advance care planning: cognitive decline may affect capacity, so planning now is essential
  3. Not starting dexamethasone: provides immediate symptom relief and may improve cognition temporarily

Resitting PLAB 2?

If breaking bad news stations have been a weakness, practise the SPIKES framework until the structure is automatic. The most common resitter mistake is rushing past the emotional response. Allow genuine silence after delivering the news, and resist the urge to fill pauses with more information.

Example opening

Hello, my name is Dr [Name]. Thank you for coming in today. Before we start, can I ask if you have anyone with you, or would you like to have someone here? I have the results from your recent tests, and I'd like to go through them with you.

Frequently asked questions

What is the best way to structure breaking bad news about glioblastoma?

Delivering a terminal brain tumour diagnosis directly to the patient requires SPIKES, honesty about prognosis, and addressing his immediate concerns about his family. Mr Gill is 56, married with two adult children, presenting with progressive headaches and cognitive decline. MRI confirms glioblastoma.

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

Strong performances show: Perception checked. Information preferences established. Family context understood. Weak performances: Not checking perception.

What is the biggest pitfall in this glioblastoma station?

Being evasive about prognosis: he deserves honest information to make decisions. Another frequent error: Not discussing advance care planning: cognitive decline may affect capacity, so planning now is essential.

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

Structure beats experience here. Focus on glioblastoma prognosis: median 12-18 months with treatment, honest without removing hope. 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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