Ethics, law and professionalism · Hard
This case is fictional and exists for study. It describes no real patient.
62 years · male
A 62-year-old male attends the outpatient respiratory clinic with his wife to receive the results of a lung biopsy performed two weeks ago for a persistent pulmonary mass. Before entering the consultation room, the patient's wife privately approaches the doctor. She tearfully requests that the doctor withhold any diagnosis of cancer if the results are positive, explaining that her husband's brother recently died from lung cancer and that knowing this diagnosis would cause him severe depression and loss of hope. The patient is currently sitting calmly in the waiting area, unaware of this interaction.
Vital signs
- HR
- 74 bpm
- BP
- 126/80 mmHg
- RR
- 14/min
- Temp
- 36.7 °C
- SpO₂
- 98%
Examination findings
- Alert and oriented
- Eupnoeic on room air
- Vesicular breath sounds bilaterally with fine bibasilar crackles
Investigations
| Haemoglobin | 13.8 g/dL | reference: 13.0-17.0 |
| Histopathology (Lung Biopsy) | Invasive Non-Small Cell Lung Adenocarcinoma N/A | reference: Normal tissue |
Question 1 of 3
Before calling the patient into the consultation room, which of the following is the single most appropriate response to the wife's request?
According to GMC guidance, competent adult patients have a right to be fully informed about their health condition and prognosis. Clinicians must not withhold information simply because relatives ask them to, or because they fear it will cause distress. The correct approach is to acknowledge and explore the family member's fears sympathetically, while gently explaining the ethical obligation to respect the patient's autonomy and right to information unless the patient himself asks not to know.
Teaching point: Patients have an autonomous right to information about their health, which cannot be overridden by requests from relatives unless the patient explicitly declines information.
Question 2 of 3
The patient and his wife enter the consultation room. Which of the following is the next best management step in delivering the biopsy results using a structured breaking bad news framework?
When breaking bad news using structured tools like the SPIKES protocol, assessing Perception (P) and Invitation (I) precedes giving Information/Knowledge (K). Before breaking bad news, the doctor must gauge what the patient already knows or suspects about their health and ask how much detail they want to receive today. Immediately blurting out the diagnosis skips these crucial steps, while forcing the wife out without the patient's request damages rapport.
Teaching point: Before disclosing a serious diagnosis, assess the patient's current understanding and desired level of detail using structured communication principles.
Question 3 of 3
After the clinician delivers the diagnosis of lung adenocarcinoma, the patient becomes visibly tearful and asks, 'Am I going to die soon?' What is the single most appropriate response by the clinician?
When responding to strong emotional reactions and difficult questions about dying, clinicians should use the Empathy step of the SPIKES protocol, in which empathic responses may be structured with the NURSE mnemonic (Naming, Understanding, Respecting, Supporting, Exploring). False reassurance ('cancer is no longer terminal') is misleading and unethical. Giving rigid statistical timelines can be misleading and overwhelming. Deflecting entirely is unhelpful. The clinician should validate the patient's distress, explore what specific fears he has, and provide clear, honest information tailored to his needs while explaining that exact timelines are difficult to predict.
Teaching point: Respond to patient distress with empathy, explore their underlying concerns, and avoid giving false reassurance or overly rigid statistical prognostic timeframes.
Key learning points
- Relatives cannot demand that information be withheld from a competent patient (collusion request); clinicians must explore the relative's concern while upholding patient autonomy.
- The SPIKES framework guides breaking bad news: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary.
- Prognostic questions require empathetic validation, exploration of patient fears, and realistic, nuanced discussion rather than false reassurance or rigid statistical predictions.
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