Explain paediatric delirium and the ABCDEF plan to parents — OSCE

Candidate instructions

You are the paediatric registrar in the cardiac ICU. The parents of a four-year-old boy who is delirious on day three after cardiac surgery have ten minutes with you. They are frightened because he does not recognise them and keeps pulling at his lines, and they wonder whether he has brain damage. Explain, in plain language: (1) what delirium is and that it is usually reversible; (2) what the team is doing to find and treat the cause; (3) why his sedation is being changed from midazolam to a different medicine; and (4) what the ABCDEF care bundle is and how they can help. Invite their questions and check understanding throughout. Do not use jargon; do not lecture. [4]

Encounter

Parent: "He doesn't even know who we are. Has the surgery damaged his brain?" [4]

Registrar: "I can see how frightening this is, and I am glad you asked. What he is experiencing is called delirium — it is a temporary confusion that happens when a child is very ill, in intensive care, and on strong medicines. It is not brain damage from the surgery. His brain is reacting to the stress of the operation, the medicines he has needed, and the intensive care environment. The good news is that it is usually reversible once we find and treat what is driving it." [4]

Parent: "So what is driving it?" [2]

Registrar: "We are working through a checklist to find that out. We use a quick screening tool called the CAPD — it takes about a minute and tells us whether this is delirium. Then we look for the cause: is there an infection we need to treat? Are his salts and blood tests normal? Is he in pain? Is he getting enough oxygen? And we look at his medicines, because some of the strong sedatives we use in intensive care can themselves contribute to this confusion." [2]

Parent: "You mentioned his medicines. The nurse said something about changing his sedation." [3]

Registrar: "Yes. He has been on a medicine called midazolam to keep him comfortable, and we know from research that this family of medicines — benzodiazepines — can actually contribute to delirium in children in intensive care. So we are carefully bringing that down and switching to a different medicine called dexmedetomidine, which does the same job of keeping him comfortable but is less likely to cause the confusion. This is based on the latest international guideline from 2022." [3]

Parent: "What else are you doing to help him?" [3]

Registrar: "We use a structured approach called the ABCDEF bundle — it sounds like a mouthful, but it is a checklist that covers everything that matters. We Assess and manage his pain properly, we use the right Choice of sedation, we screen for Delirium regularly, we get him moving Early even in the bed, and — this is where you come in — we want Family engagement. Your presence, your voice, familiar objects from home, helping us keep a day and night rhythm for him: all of that is part of the treatment. You know him better than anyone." [3]

Parent: "Will he need tablets for the confusion?" [1]

Registrar: "Probably not. We focus first on finding and treating the cause and using the bundle I described. In most children, that is enough and the confusion settles over days to weeks. We would only consider a medicine — and it would be a very low dose of a specific type — if he was so agitated that he was at risk of pulling out a life-saving line and we could not keep him safe any other way. That is a last resort, not the first step." [1]

Parent: "And he will get better?" [4]

Registrar: "In most children, yes — the confusion resolves as they recover from the underlying illness. We will keep screening him twice daily, keep you involved, and plan to follow up after he goes home to make sure he is back to his usual self. Before we finish, what questions do you still have, and is there anything you want me to go over again?" [4]

Marking domains

• Communication (25%): plain language, empathy, checks understanding, invites questions, avoids jargon and does not lecture.
• Clinical content (30%): explains delirium as acute brain dysfunction that is usually reversible; describes the cause-finding approach and CAPD screening; explains the benzodiazepine link and the switch to dexmedetomidine; describes the ABCDEF bundle accurately; gives an honest account of antipsychotics as last resort. [1]
• Shared decision-making (20%): presents the plan collaboratively, acknowledges the family's fear, explains how they can help, and agrees a shared approach.
• Safety and accuracy (15%): does not over-reassure about outcome, names the structured follow-up, confirms that cause-finding is ongoing.
• Professionalism and global (10%): maintains a calm, non-judgemental, collaborative stance; appropriate use of the nurse and family as partners in care.