Ethics, law and professionalism · Hard
This case is fictional and exists for study. It describes no real patient.
62 years · female
A 62-year-old female presents to the outpatient oncology clinic accompanied by her adult son to receive the results of her recent liver lesion biopsy. Before the doctor enters the room, the son approaches the clinician privately in the corridor, urgently requesting that any cancer diagnosis be withheld from his mother. He states that she is extremely anxious and 'would not be able to cope mentally' with bad news. The histology report confirms metastatic pancreatic adenocarcinoma. In the consultation room, the patient is alert, oriented, fully competent, and tells the doctor she is eager to find out what her scan and biopsy showed.
Vital signs
- HR
- 76 bpm
- BP
- 128/82 mmHg
- RR
- 14/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Mild scleral icterus observed
- Abdomen soft, mild right upper quadrant tenderness without guarding
Investigations
| Total Bilirubin | 58 µmol/L | reference: 3-21 |
| Alkaline Phosphatase | 310 IU/L | reference: 30-130 |
Question 1 of 3
Which of the following is the single most appropriate initial action regarding the son's request to withhold the diagnosis?
Option C is correct. Under GMC guidance and medical law, competent adult patients have a fundamental right to be informed about their diagnosis. When relatives ask doctors to withhold information ('collusion'), the doctor should sensitively explore the relative's underlying fears and explain that the patient has a right to know unless doing so would cause severe physical or mental harm (which is extremely rare). Option D violates patient autonomy and confidentiality. Option A is insensitive and aggressive, missing the opportunity to address family distress. Option B is inappropriate as feeling anxious about biopsy results does not indicate a psychiatric emergency or incapacity.
Teaching point: When family members request that bad news be withheld, clinicians should explore their fears while explaining that competent patients generally have a right to know their diagnosis.
Question 2 of 3
When beginning the discussion with the patient regarding her biopsy results using the SPIKES protocol, which of the following is the most appropriate next step?
Option D is correct. In the SPIKES protocol (Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary), 'P' stands for assessing the patient's Perception. Before giving information, the clinician must determine what the patient already knows or suspects about her condition. Option B skips the 'Perception' and 'Invitation' steps, which can cause severe distress. Option A jumps prematurely to 'Strategy/Summary' and overloads the patient with details before establishing understanding. Option C creates unnecessary conflict between the patient and her son.
Teaching point: According to the SPIKES protocol, establishing the patient's baseline perception of their illness must precede the disclosure of new medical information.
Question 3 of 3
During the consultation, before any results are disclosed, the patient states: 'Doctor, I am terrified of bad news. If this is cancer, I really do not want to know the details—please just explain everything to my son.' What is the next best management step?
Option D is correct. Patients with decision-making capacity have the right to decline information ('right not to know'). If a patient explicitly requests not to receive detailed bad news and asks for a family member to be informed instead, the doctor should respect this autonomous choice. The doctor should clarify what specific information she wishes to avoid or receive, and obtain her consent to disclose her medical details to her designated representative (her son). Option B wrongly assumes autonomy means forcing unwanted information onto a patient. Option A is unethical abandonment. Option C involves active deception, which violates professional codes.
Teaching point: Competent patients have a recognized right 'not to know' their diagnosis; clinicians must respect this preference and clarify consent for disclosing information to a designated family member.
Key learning points
- Competent adult patients generally have the legal and ethical right to be informed of their diagnostic findings.
- Requests by family to withhold information ('collusion') should be managed by empathetically exploring the relative's concerns while upholding patient autonomy.
- The SPIKES framework structures breaking bad news, emphasizing assessment of patient perception (P) and invitation (I) prior to sharing knowledge (K).
- Patients have a right 'not to know' specific medical information; if chosen, clinicians should establish boundaries and obtain explicit consent to communicate with a nominated surrogate.
This is one of 158 free cases
AskPreceptor is a study tool for medical students: answer first, then see the reasoning — including why each wrong option is wrong. Free, no sign-up required.