Best-interests decisions and treatment limitation — OSCE

Objectives

1. Apply the best-interests balance of benefits against burdens to a treatment-limitation recommendation. [1]
2. Run an honest, structured goals-of-care conversation using a recognised framework. [10]
3. Avoid the error of an isolated resuscitation decision and build an overall limitation and comfort plan. [4]
4. Identify the escalation pathway to ethics and the courts for a genuine value dispute. [1] [12]

Candidate brief

A 12-minute station. An 8-year-old with a known progressive neurodegenerative disease is admitted with respiratory failure that has not reversed over 72 hours despite maximal non-invasive support. The treating team, including a second consultant, agrees that intensive care can no longer achieve its goal and that the burdens of escalation now outweigh any benefit. The candidate must meet the parents, who have not yet heard this assessment, and lead the goals-of-care conversation. The nurse asks what the plan is. The child is comfortable but tiring. [1]

Expected actions

• Set the scene: a private room, no interruptions, both parents present, and confirm who else the family would like included. [10]
• Give a warning shot before sharing the assessment, then share the prognosis honestly in plain language. [10]
• Ask what the parents understand about the condition and what matters most to them and to their child. [10]
• Explain the best-interests balance: the team has weighed the chance of recovery against the burden the child is now bearing, and concluded escalation would add suffering without benefit. [1]
• Clarify that stopping disease-directed escalation is not abandoning their child; comfort care is intensified, and the family stays central. [9] [4]
• Build an overall limitation plan covering escalation, ventilation, resuscitation and comfort — not an isolated resuscitation order. [4]
• Explore fears and hope honestly; do not treat 'do everything' as a binding instruction. [10]
• Agree a plan you and the family own, and name the review point or time-limited trial if uncertainty remains. [1]
• Document the benefits and burdens analysis, who agreed, what will and will not be offered, and the comfort plan. [1]
• If genuine disagreement remains, name the ethics-consultation and court pathway rather than overriding or capitulating. [1] [12]

Examiner prompts

• "Are you saying we should just let her go?" → Reframe limitation as redirecting to comfort and what matters, not giving up. [9] [4]
• "We want you to do everything." → Explore the fear underneath the phrase before treating it as a treatment directive. [10]
• "Isn't stopping worse than never starting?" → Explain that withholding and withdrawing are morally equivalent. [4]

Marking foci

• Applies the best-interests balance of benefits against burdens, not personal quality-of-life judgement. [1]
• Runs a structured, honest goals-of-care conversation that elicits family values. [10]
• Builds an overall limitation and comfort plan, not an isolated resuscitation order. [4]
• Frames withdrawal as active comfort care, not abandonment. [9]
• Identifies the ethics and court escalation pathway for a genuine value dispute. [1] [12]