Breaking Bad News · Advanced · Ethics

Sudden Onset Severe Headache with Altered Consciousness

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

Clinical scenario

You are an FY2 doctor in A&E, working under the neurology team. The consultant neurologist has reviewed the imaging and confirmed the diagnosis, and has asked you to speak with the patient's son to break the news, as you have been involved in Mrs Price's care since admission. Mrs Tracy Price son has brought her in following a sudden severe headache whilst at home. Imaging has confirmed a subarachnoid haemorrhage. The prognosis is poor. You must break this news sensitively to her son using a structured approach and discuss what happens next.

Background notes: PMH: Hypertension (well-controlled on amlodipine)

What this station tests

  • SPIKES framework for breaking bad news: Setting, Perception, Invitation, Knowledge, Empathy, Summary
  • Warning shot before delivering devastating news: 'I am afraid the news is very serious'
  • Allowing silence: do not fill emotional space with information
  • Asking about the patient's wishes: advance care planning, what would she have wanted
  • Comfort-focused care: transitioning from active treatment to dignity and pain management

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

Breaking bad news about a life-threatening condition to a family member requires SPIKES framework, honesty, and compassion. Winston is the son of Mrs Tracy Kerr (58), who collapsed with a massive SAH and is now critically ill with poor prognosis. Open with: 'Mr Kerr, thank you for coming. I need to update you about your mother. Can we sit down somewhere private?'

Core approach

Set up the conversation. Private room. Ensure he is sitting. Ask if anyone else should be present. Check his understanding: 'Can you tell me what you have been told so far?' This establishes his baseline.

Deliver the news using SPIKES. Warning shot: 'I am afraid the news is very serious.' Knowledge: 'Your mother had a large bleed around her brain called a subarachnoid haemorrhage. The bleeding was extensive and has caused significant damage. Despite our best treatment, she has not improved.' Pause. Allow silence.

Empathic response. He may cry, become angry, go silent, or ask questions. Respond to the emotion: 'I am so sorry. I know this is devastating.' Do not rush. Do not fill the silence with information.

When he is ready: explain prognosis honestly. 'The team's assessment is that your mother is unlikely to recover. We need to discuss what the best care for her looks like from here.' This opens the conversation about ceiling of treatment, palliative care, and what she would have wanted.

Closing and safety netting

Discuss next steps sensitively. 'We want to make sure your mother is comfortable and not in pain. The most important thing now is her dignity and comfort.' If appropriate: discuss withdrawal of active treatment, organ donation (only if he raises it or if clearly appropriate). Ask about her wishes: 'Did your mother ever talk about what she would want in a situation like this?'

Practical support: chaplaincy, bereavement services, PALS. Allow him to stay with her. Offer to update other family members. 'Take all the time you need.' Follow-up: named consultant for ongoing communication.

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: Understanding checked. Family dynamics assessed. Patient's prior wishes explored.

Costs marks: Not checking understanding. Not asking about wishes.

Domain 2 (Primary focus)

Scores well: SPIKES applied. Prognosis communicated honestly. Ceiling of treatment discussed. Comfort care prioritised. Support services offered.

Costs marks: Not being honest about prognosis. Not discussing care goals. No support offered.

Domain 3 (Primary focus)

Scores well: Warning shot. Silence allowed. Empathic response to emotion. Not rushing. Genuine compassion. Offering time and space.

Costs marks: Rushing. No warning shot. Filling silence. Clinical detachment. Not allowing emotion.

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. Rushing through the news: silence after delivering bad news is therapeutic, not awkward
  2. Not checking his understanding first: he may already know, or may have been told different information
  3. Not asking about her wishes: the family's perspective on what she would have wanted is essential for care planning

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

How should I break the news in this subarachnoid haemorrhage station?

Breaking bad news about a life-threatening condition to a family member requires SPIKES framework, honesty, and compassion. Winston is the son of Mrs Tracy Kerr (58), who collapsed with a massive SAH and is now critically ill with poor prognosis.

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

Strong performances show: Understanding checked. Family dynamics assessed. Patient's prior wishes explored. Weak performances: Not checking understanding. Not asking about wishes.

What is the biggest pitfall in this subarachnoid haemorrhage station?

Rushing through the news: silence after delivering bad news is therapeutic, not awkward. Another frequent error: Not checking his understanding first: he may already know, or may have been told different information.

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

This station rewards process over personal experience. The skill being assessed: Warning shot before delivering devastating news: 'I am afraid the news is very serious'. 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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