Ethics · Advanced · Ethics

Treatment Refusal and DNAR Request

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

Clinical scenario

You are an FY2 doctor on an elderly care ward. Mr Tobias Sanderson, a 78-year-old man with advanced COPD (GOLD stage 4), recurrent respiratory failures requiring NIV, and multiple comorbidities, has asked to speak with you. He tells you he does not want to be resuscitated if his heart stops, and he wants to stop all medical treatment and be allowed to die peacefully at home with his family. He is adamant about this decision. Please discuss his wishes, assess his capacity, and develop an appropriate management plan.

Background notes: PMH: COPD GOLD stage 4, Hypertension, Atrial fibrillation, CKD stage 3b, Osteoporosis with vertebral compression fracture

What this station tests

  • Capacity assessment: understand, retain, weigh, communicate (all four elements)
  • Patient autonomy: a capacitous patient's refusal of treatment must be respected
  • DNACPR/ReSPECT form: correct documentation of the decision
  • Supporting the family who disagrees: acknowledging distress while upholding patient autonomy
  • Palliative care referral: symptom management for comfort, not treatment withdrawal without support

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 capacity requesting DNAR and treatment withdrawal must have their autonomy respected, even when the decision is distressing for the medical team. Mr Sanderson is 78, advanced COPD GOLD 4, frequent admissions, requesting no further active treatment and a DNAR order. Open with: 'Mr Sanderson, I understand you have been thinking about your treatment. Tell me what you have been considering.'

Core approach

Assess capacity first. Does he understand the information (what DNAR means, what treatment withdrawal means)? Can he retain it? Can he weigh it up? Can he communicate his decision? He is a retired factory manager, cognitively intact, and has been thinking about this for months. He has capacity.

Explore his reasoning. He has had 6 admissions in 12 months. He is on home oxygen. He cannot walk 10 metres without stopping. His quality of life is poor. He has watched friends die on ventilators and does not want that for himself. He wants to die comfortably at home. These are rational, considered reasons.

Address the family dimension. His wife Margaret disagrees and wants everything done. His son understands. The patient's decision takes precedence over the family's wishes if he has capacity. But the family's distress must be acknowledged and supported.

Closing and safety netting

If capacity is confirmed: respect his decision. Complete the DNACPR form (ReSPECT form in many trusts). Document the conversation, his reasoning, and that capacity was assessed. Arrange palliative care referral for symptom management (breathlessness, anxiety, pain). Advance care planning: preferred place of death (home), what interventions he does and does not want.

Support Margaret: 'I understand this is incredibly difficult for you. His decision does not mean we are giving up on him. It means we are focusing on his comfort and quality of life.' Offer family meeting with palliative care team. Safety net: palliative care team for ongoing support. 'We will make sure he is comfortable.' Follow-up: palliative care, GP, community nursing.

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 (all four elements). Reasoning explored. Family views documented. Current functional status assessed.

Costs marks: Not assessing capacity. Not exploring reasoning.

Domain 2 (Primary focus)

Scores well: DNACPR completed correctly. Advance care planning. Palliative care referral. Symptom management plan. ReSPECT documentation.

Costs marks: Not completing DNACPR. No palliative referral. No ACP.

Domain 3 (Primary focus)

Scores well: Respecting his autonomy genuinely. Supporting Margaret's distress. Not being paternalistic. Framing palliative care as active comfort, not giving up.

Costs marks: Overriding his decision. Dismissing Margaret. Being paternalistic. Making him feel he is being abandoned.

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. Overriding his decision because the wife disagrees: patient autonomy takes precedence if he has capacity
  2. Not assessing capacity formally: the decision must be documented as capacitous
  3. Not involving palliative care: treatment withdrawal without symptom management is neglect, not respect

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 advanced COPD consultation?

A patient with capacity requesting DNAR and treatment withdrawal must have their autonomy respected, even when the decision is distressing for the medical team. Mr Sanderson is 78, advanced COPD GOLD 4, frequent admissions, requesting no further active treatment and a DNAR order.

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

Strong performances show: Capacity formally assessed (all four elements). Reasoning explored. Family views documented. Current functional status assessed. Weak performances: Not assessing capacity. Not exploring reasoning.

What is the biggest pitfall in this advanced COPD station?

Overriding his decision because the wife disagrees: patient autonomy takes precedence if he has capacity.

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

This station rewards process over personal experience. The skill being assessed: Patient autonomy: a capacitous patient's refusal of treatment must be respected. 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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