Medical neglect and refusal of care — OSCE

Candidate information (2 minutes reading, 12 minutes station)

You are the general paediatric registrar in the oncology day unit. Liam, aged four, has been newly diagnosed with standard-risk acute lymphoblastic leukaemia. His parents, Sarah and David, have refused the standard chemotherapy protocol and plan to treat the cancer with herbal remedies and dietary changes. Read the presentation, then conduct the assessment and counselling. The examiner will role-play Sarah. [2] [9]

Candidate tasks

1. Explore the refusal non-judgementally — understand the family's specific fears, their understanding of the diagnosis and prognosis, and their reasons for declining chemotherapy without dismissing their beliefs. [1]
2. Provide clear, accurate information about the cure rate with chemotherapy, the natural history without treatment, the side-effect profile, and the narrowness of the induction window. [9]
3. Apply the Diekema harm-principle threshold to this child and explain to the family, with empathy, why the threshold for intervention is met. [1]
4. Outline the stepped plan — negotiate now, involve the ethics committee and oncology team, offer time, and explain that if the refusal persists the treating team will seek a court order — while maintaining rapport and supporting the family throughout. [12]

Marking anchors

Distinction (PASS)

• Defines refusal of care as active rejection rather than passive omission, and separates it from access-based neglect using the mechanism and the caregiving response. [2] [3]
• Names and applies the four-condition Diekema harm-principle threshold — significant harm, imminent, effective treatment, proportionate burden — to this child. [1]
• Explores the family's fears non-judgementally, provides accurate information about cure rates and side effects, and involves the ethics committee and oncology team. [9]
• Articulates the stepped plan — negotiate first, offer time, escalate to a court order if the refusal persists and the threshold is met — while maintaining rapport and supporting the family. [12]

Borderline

• Names the harm threshold but cannot apply all four conditions, or provides information but does not negotiate, or escalates to a court order without first attempting respectful conversation, or focuses on the legal pathway without maintaining rapport. [1]

Fail

• Dismisses the family's beliefs, blames the parents, or fails to negotiate before escalating. [3]
• Waits for the child to deteriorate before acting, or fails to recognise that the treatment window is closing, or does not seek a court order when the threshold is clearly met and negotiation has failed. [1] [9]
• Fails to document the refusal, the information given, and the harm assessment, or loses the child to follow-up after a single conversation. [2]

Examiner prompt sequence

1. Opening (the mother): "Doctor, we've decided. We're not doing the chemo. We've read what it does to children, and we believe the herbs and the diet will heal him — God willing." — Candidate must explore the fears without judgement, map the understanding, and provide accurate information. [9]
2. Escalation prompt: "But the side effects — you doctors always minimise them. His cousin had chemo and he was never the same." — Candidate must acknowledge the fear, provide honest information about the side-effect profile, and contrast it with the natural history of untreated leukaemia. [9]
3. Threshold prompt: "So what happens if we just say no and take him home?" — Candidate must explain, with empathy, that the Diekema threshold is met, that the team has a duty to seek a court order, and that the court will likely authorise treatment — while emphasising that the team will continue to support the family throughout. [1] [12]
4. Closing prompt: "We need time to think." — Candidate must offer time within the narrowing window, involve the ethicist, set a same-day or next-day follow-up, and document the refusal, the information given, and the harm assessment verbatim. [2]