Ethical Decision Making and Palliative Communication — WACS Viva & Clinical Scenarios (Geriatric Medicine and Palliative Care)

Exam-style ethical decision making and palliative communication viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: Objective Structured Clinical Examination (OSCE) Station: Breaking Bad News and Navigating Family Collusion — A 68-year-old retired civil servant is admitted with worsening jaundice, cachexia, and right upper quadrant abdominal pain. Diagnostic imaging reveals locally advanced, inoperable pancreatic adenocarcinoma with extensive hepatic metastases. His eldest son privately approaches you outside the ward, demanding that the diagnosis and poor prognosis be withheld from his father, stating that revealing the truth will cause his father to lose hope and die prematurely. You have 10 minutes to co
• SCENARIO 2: Clinical Single Best Answer (SBA): Assessment of Decision-Making Capacity — An 82-year-old woman with mild vascular dementia is admitted with severe community-acquired pneumonia and type 1 respiratory failure. Her arterial blood gas shows pH 7.31, PaO₂ 52 mmHg on room air, and PaCO₂ 34 mmHg. High-flow oxygen and intravenous antibiotics are initiated. When invasive mechanical ventilation in the intensive care unit is considered due to clinical fatigue, the patient calmly states, I do not want to be put on a breathing machine; I want to stay here with medicine and oxygen, even if I do not surviv
• SCENARIO 3: Oral Examination (Viva Voce): Treatment Limitation and the Principle of Double Effect — A 74-year-old man with end-stage chronic obstructive pulmonary disease and severe congestive cardiac failure is experiencing intractable dyspnoea and acute distress despite maximal non-invasive ventilatory support and medical optimization. The multidisciplinary team recommends instituting continuous subcutaneous morphine and midazolam for symptom palliation and documenting a formal Do Not Attempt Resuscitation (DNAR) order. How do you ethically justify symptom control with sedating analgesics, distinguish w
• SCENARIO 4: Extended Matching Questions (EMQ): Bioethical Principles in Geriatric and Palliative Practice — Theme: Ethical and Legal Frameworks in End-of-Life Decision-Making
• SCENARIO 5: Objective Structured Clinical Examination (OSCE) Station: Conducting a Goals-of-Care Family Conference — A 79-year-old male with severe ischaemic cardiomyopathy and acute-on-chronic renal failure is deteriorating despite maximum inotropic support and continuous renal replacement therapy. His prognosis is poor, with death anticipated within days. You are tasked with leading a formal family conference involving the spouse, children, and key community elders to transition the clinical goals from disease-directed restorative treatment to end-of-life comfort care, ensuring clear consensus and compa