Delivering Difficult News in PLAB 2: Mesothelioma Disclosure with Compassion and Skill

Summary:

This scenario involves a patient diagnosed with mesothelioma, where the candidate must break the bad news empathetically while assessing the patient's understanding, current health status, and support systems. Proper management and communication skills are critical for providing holistic care and emotional support.

Key Points:

Main Topic: Data Gathering

• Assess the history of presenting illness, including work history (asbestos exposure).

• Screen for red flags and symptoms related to the diagnosis (e.g., coughing up blood).

• Quickly gather essential background information: medical history, occupation, and potential asbestos exposure.

• Always ask questions that will directly inform your management decisions.

Main Topic: Psychosocial Inquiry

• Ask about the patient's support system, including living situation and emotional support, especially after delivering the diagnosis.

• Clarify work history and the potential link to asbestos exposure in this case.

• Investigate social factors, such as who the patient lives with or if they live alone.

Main Topic: Communication with the Patient

• Use structured communication methods like the SPIKES protocol for breaking bad news:

  • Setting: Ensure the patient is comfortable.

  • Perception: Ask what the patient already knows about their condition.

  • Invitation: Prepare the patient for bad news without overwhelming them.

  • Knowledge: Present the diagnosis gradually, allowing the patient to process the information.

  • Emotion: Address their emotions and concerns.

  • Summarize and Strategize: Discuss further steps or management options.

Important Considerations:

• Time management: Divide the station equally between data gathering and management, allowing 4 minutes each.

• Interpersonal skills should be displayed throughout the consultation, especially when addressing the patient’s concerns, beliefs, and feelings.

• Use empathy appropriately without overextending time on stock phrases or unnecessary questions.

• Focus on patient-centered care by understanding how the diagnosis impacts their life (e.g., work, home life).

Diagnostic Approach:

1. Work History and Risk Factors: Investigate any history of asbestos exposure given the diagnosis of mesothelioma.

2. Symptom Inquiry: Ask about red flags such as unexplained weight loss, persistent cough, or blood in sputum.

3. Past Medical History: Briefly review other significant conditions that might impact the diagnosis or management.

4. Social and Occupational History: Understand the patient’s current living and working conditions, as it might influence management decisions.

Management:

1. Breaking the News:

   • Gradually reveal the diagnosis using the SPIKES protocol.

   • Be mindful of the patient's emotional state and readiness to absorb the information.

   • Offer support, such as counseling or Macmillan Cancer Support services.

2. Medical Management:

   • Discuss treatment options (if any) or palliative care for mesothelioma.

   • Arrange follow-up appointments, further imaging, or oncologist referral.

   • Provide clear safety netting instructions regarding symptoms that require urgent medical attention.

3. Social Support:

   • Ensure the patient has access to social services if they lack home support.

   • Discuss potential work accommodations or sick leave.

Communication Skills:

• Maintain clarity and empathy throughout the conversation.

• Always check the patient’s understanding by summarizing information and asking for feedback.

• Use language that is free of medical jargon and appropriate for the patient’s level of understanding.

• Invite the patient to ask questions and express their concerns about the diagnosis and future steps.

Ethical Considerations:

• Ensure confidentiality and respect the patient’s right to autonomy, allowing them to make informed decisions about their care.

• Always offer emotional support and guidance when delivering difficult news, ensuring no harm to the patient's dignity.

Additional Resources:

• NICE guidelines for the management of mesothelioma.

• Macmillan Cancer Support for patient education and counseling services.

• GMC's Good Medical Practice on patient communication and emotional care​ .