Breaking Bad News · Advanced · Ethics

Weight Loss and Abdominal Pain in Elderly Patient

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

Clinical scenario

You are an FY2 doctor on the oncology ward. The consultant oncologist has confirmed the diagnosis following imaging and histology, and has asked you to meet with the patient's daughter Emma to discuss the results, as you have been closely involved in Mr Amaechi's care during his admission. Mr Musa Amaechi daughter, Emma, has requested a meeting with you to discuss her father's recent investigations. Imaging and histology have confirmed metastatic pancreatic cancer with significant hepatic involvement. Palliative chemotherapy may extend survival by weeks to months but with considerable side effects. You must break this news sensitively and discuss options.

Background notes: PMH: Nil significant

What this station tests

  • Information sharing consent: checking who the patient has nominated to receive information
  • Honest prognosis communication: 'months rather than years, typically 3 to 6 months'
  • Preparing the family to tell the patient: discussing how and when to share the diagnosis with Mr Okafor
  • Advance care planning while capacity is present: lasting power of attorney, preferred place of death
  • Not colluding with information withholding: the patient has the right to know if he wishes

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 cancer diagnosis to a family member (daughter) while the patient is not present requires navigating who has the right to know what, and preparing the daughter for a conversation with her father. Emma is the daughter of Mr Musa Okafor (74), diagnosed with metastatic pancreatic cancer. Open with: 'Emma, thank you for coming. I have the results of your father's tests and I want to go through them with you.'

Core approach

Check who should be told. 'Has your father said who he would like to receive information about his diagnosis?' If he has nominated his daughter: proceed. If not: discuss with him first if possible. Patient autonomy regarding information sharing must be respected.

Deliver the diagnosis. Warning shot: 'I am afraid the results are not what we were hoping for.' Diagnosis: 'The scans and biopsy have confirmed that your father has pancreatic cancer. Unfortunately, it has spread to his liver, which means it is not curable with surgery.' Pause. Allow the response.

She will ask about prognosis. Be honest but compassionate. Metastatic pancreatic cancer has a median survival of 3 to 6 months. She may ask 'how long?' Answer: 'Months rather than years, typically 3 to 6 months, but every person is different.' She may ask about treatment: palliative chemotherapy (gemcitabine-based) may extend life modestly but has side effects. This is a discussion for her father and the oncologist.

Closing and safety netting

Discuss how to tell her father. 'Your father has the right to know his diagnosis if he wants to. Would you like us to tell him together, or would you prefer to be there when the consultant speaks to him?' Some families want to 'protect' the patient by withholding information: gently explain that honesty allows the patient to make informed decisions about his remaining time.

Palliative care referral. Macmillan Cancer Support. Symptom management (pain, appetite, weight loss). Practical support: advance care planning, lasting power of attorney while he has capacity. Safety net: 'We are here for your father and for you. The palliative care team will provide ongoing support.'

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: Information sharing consent checked. Family dynamics understood. Patient's capacity and wishes explored.

Costs marks: Not checking consent. Not exploring wishes.

Domain 2 (Primary focus)

Scores well: Honest prognosis. Palliative care referral. Advance care planning discussed. Macmillan signposted. Treatment options outlined for oncologist discussion.

Costs marks: Evasive prognosis. No palliative referral. No advance planning.

Domain 3 (Primary focus)

Scores well: SPIKES applied. Honest without brutal. Guiding her through telling her father. Offering joint disclosure. Genuine compassion.

Costs marks: Being brutal. Colluding to withhold. Not offering support for the conversation with her father.

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. Sharing information without checking patient consent: the patient may not want his daughter to know details
  2. Colluding with the family to withhold the diagnosis from the patient: the patient has the right to know
  3. Being evasive about prognosis: 'we cannot say' is less helpful than 'months rather than years'

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 metastatic pancreatic cancer?

Delivering a terminal cancer diagnosis to a family member (daughter) while the patient is not present requires navigating who has the right to know what, and preparing the daughter for a conversation with her father. Emma is the daughter of Mr Musa Okafor (74), diagnosed with metastatic pancreatic cancer.

What are examiners marking in this metastatic pancreatic cancer station?

Marks are won for: Information sharing consent checked. Family dynamics understood. Patient's capacity and wishes explored. Marks are lost for: Not checking consent. Not exploring wishes.

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

Sharing information without checking patient consent: the patient may not want his daughter to know details.

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

Structure beats experience here. Focus on honest prognosis communication: 'months rather than years, typically 3 to 6 months'. 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