End-of-Life Care and Advance Care Planning — Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mr Robert Whitlam is an 82-year-old retired engineer with ischaemic heart failure — NYHA IV, ejection fraction 20 per cent — chronic kidney disease with an eGFR of 25, and type 2 diabetes, who is admitted with his third decompensation in six months and who, after a response to intravenous diuretics, is now stable on the ward and presents the team with the question of how to manage his end-of-life trajectory prospectively, while he has capacity. [1]

His main problems are:

1. End-stage heart failure with a one-year mortality in excess of 30 per cent — the trajectory that drives the end-of-life question.
2. Chronic kidney disease compounding the heart failure and limiting the disease-directed therapy.
3. The absence of any advance care planning — no directive, no documented goals of care, no identified substitute decision-maker.
4. His preserved capacity, which is the window in which the advance care planning conversation must be held.
5. The family — a wife and adult daughter — who are present and who must be part of the goals-of-care discussion. [1]

My approach is to recognise that he triggers a "no" answer to the Surprise Question and to initiate advance care planning now, while he has capacity; to hold a structured goals-of-care conversation using the SPIKES protocol and the Serious Illness Conversation Guide, exploring his values, his treatment preferences and his preferred place of death; to document an advance care plan and, if he wishes, an advance care directive with a formal refusal of the treatments he would not want; to propose a ceiling of ward-based active treatment with no escalation to intensive care and no cardiopulmonary resuscitation, while continuing optimal guideline-directed medical therapy and active symptom control — the principle being do not resuscitate, but do not abandon; to discuss prognosis honestly using the hope-for-the-best, prepare-for-the-worst frame; and to involve the palliative care team for symptom control and family support. The overarching principle is that the advance care planning conversation is the intervention — the form is the record — and the evidence (Detering, Wright, Brinkman-Stoppelenburg) is that it reduces non-beneficial treatment at the end of life, increases concordance with patient preferences, and lowers family distress." [1]

Examiner probing questions and model answers

Q1: "Why have you decided to initiate advance care planning now, rather than waiting until he is more unwell?" [1]

"Because the Surprise Question is the trigger, and he answers it with a clear no — I would not be surprised if he died in the next 12 months. The Surprise Question came from the Gold Standards Framework and is the simplest, most widely taught screening tool for end-of-life need; a no answer is the trigger to start. The reason not to wait is that the conversation must be held while he has capacity — once he loses capacity in a crisis, the decision about escalation is forced at three in the morning, by the team and the family, without his voice, and that is exactly the failure mode advance care planning is designed to prevent. [1]

The evidence that acting on the trigger improves outcomes is strong. Detering's randomised trial of facilitated advance care planning in medical inpatients aged 80 and over showed that end-of-life wishes were far more likely to be known and respected in the intervention group (86 per cent versus 30 per cent), with reduced stress, anxiety and depression in bereaved relatives and higher family satisfaction [2]. Wright's cohort study in advanced cancer showed that end-of-life discussions were associated with less aggressive care in the final week and no increase in depression, and that more aggressive care near death was associated with worse quality of life and more major depressive disorder in bereaved caregivers [3]. The Brinkman-Stoppelenburg systematic review confirmed that advance care planning reduces life-sustaining treatment at the end of life and improves concordance between preferences and care, with complex facilitated planning outperforming a directive alone [1]. So the trigger is the Surprise Question, and the evidence supports acting on it."

Q2: "How would you actually run the goals-of-care conversation with this man and his family?" [1]

"I would use a structured conversation combining the goals-of-care framework with the SPIKES protocol for delivering bad news [6][7]. Setting: a quiet, private room, with the patient and the family he wishes present, the senior clinician and a nurse, enough time, no interruptions, and I sit down. Perception: I ask what he and the family understand about his heart failure and its trajectory — 'Tell me what you understand about your heart condition and how it has been going.' This establishes the baseline and surfaces misconceptions. Invitation: I ask how much detail he wants about the prognosis and the options, and I respect his right to defer to his family if he prefers. Knowledge: I give honest information in plain language — that his heart failure is advanced and progressive, that the repeated admissions indicate the disease is no longer responding well to treatment, and that this is the time to think together about what matters most and what he would want if he became more unwell. Empathy: I acknowledge the emotion, name it, and stay with it — I allow silence rather than rushing to a plan. Summarise and Strategise: I summarise, check understanding, and agree the next steps and a follow-up.

Within that frame I use the questions of the Serious Illness Conversation Guide to elicit his values and goals [7]: what matters most to him now; what he is willing and not willing to go through; what he would consider an acceptable outcome; who he wants to make decisions if he cannot. I would specifically address the guilt that families feel when a comfort-focused plan is proposed — I would say that choosing comfort is not giving up, it is an act of care consistent with what he would want."

Q3: "He asks you directly how long he has. How do you answer?" [1]

"I discuss prognosis honestly, using the hope-for-the-best, prepare-for-the-worst frame. I ask first how much detail he wants — some patients want a number, some a range, some only the gist. I give a range rather than a point estimate: with his NYHA IV heart failure and chronic kidney disease, the median survival is measured in months rather than years, and a realistic statement is 'weeks to a few months rather than years' if he continues to decompensate at this rate. I acknowledge uncertainty explicitly — I cannot give an exact number, and I will be honest with him as we learn more. I avoid the two common errors: false reassurance, which destroys trust when the prognosis declares itself, and brutal honesty without support, which abandons him to despair. And I connect the prognosis to goals — once he knows the trajectory, I ask what matters most with the time that remains, which is the bridge from prognosis to the advance care plan [7]."

Q4: "You propose a ceiling of ward-based care with no ICU and no resuscitation. What exactly will you do and what will you not do? And is this withdrawing care?" "The ceiling documents what will and will not be done in the event of deterioration. What I will do: continue optimal guideline-directed medical therapy for the heart failure — the disease-directed therapy is not stopped by a ceiling; treat a decompensation with intravenous diuretics; supplemental oxygen for symptomatic hypoxaemia; treat reversible precipitants (anaemia, infection, arrhythmia, ischaemia); symptom control; and full comfort measures. What the ceiling explicitly excludes is admission to intensive care, mechanical ventilation, inotropic support in cardiogenic shock without a reversible cause, and cardiopulmonary resuscitation in cardiac arrest. [1]

This is not withdrawing care. The phrase is do not resuscitate, but do not abandon. A ceiling is not a withdrawal — it sets the upper limit of escalation in deterioration, while active treatment within the limits and full symptom control continue. The separate ethical principle is that withholding and withdrawing life-sustaining treatment are ethically and legally equivalent — the Truog consensus statement [8] — and there is no obligation to provide futile treatment. Where there is genuine prognostic uncertainty I would start an intervention as a trial and review. The ceiling is documented as a medical order, communicated to the team, the ambulance service and the GP, and reviewed at each admission and each major functional decline. Not for resuscitation is a decision about CPR only — it is not the same as palliative care, and it does not mean withdrawing other active treatment. I would involve the palliative care team for symptom control and family support."

Q5: "Suppose he later loses capacity, and his wife and daughter disagree with the ceiling you documented — the daughter wants everything done. How do you handle the conflict?" [1]

"The wife is his appointed substitute decision-maker — the enduring guardian — and her role is to represent his prior values and wishes, not her own, under the substituted judgement standard. The daughter, however distressed, does not have the legal authority to override either the documented plan or the substitute decision-maker. My approach is, first, to acknowledge the daughter's grief and her love for her father — wanting everything is often an expression of love and a fear of letting go. Second, to reframe the comfort-focused plan as an act of care consistent with what he would have wanted, by reference to the advance care plan and the documented conversation. Third, to provide honest prognostic information about the likely outcome of intensive care in his end-stage heart failure — a very low chance of survival to discharge and a high chance of a prolonged, distressing death. The SUPPORT trial demonstrated the failure of aggressive end-of-life care in advanced disease to improve outcomes [9].

If the daughter remains distressed, I would offer time, a follow-up family meeting, and the involvement of the palliative care team and the social worker. The decision is not forced through against the family — it is worked through together. If we genuinely cannot agree, the escalation is a second senior medical opinion, the hospital clinical ethics service, and finally the guardianship tribunal. Throughout, the patient continues to receive active treatment within the current ceiling and full symptom control. I would not unilaterally impose intensive care against the team's clinical judgement, nor unilaterally withdraw all active treatment. The resolution is through the best-interests process and, where necessary, the tribunal." [1]

Short Case Discussion

A structured goals-of-care conversation at the bedside

Examiner instruction: "You are asked to conduct a goals-of-care discussion with a 75-year-old woman with advanced COPD on long-term oxygen who has just been admitted with a hypercapnic exacerbation requiring non-invasive ventilation. She has capacity. Describe how you would structure the conversation and what you would document." [1]

Candidate's model answer: [1]

"This is a patient with advanced COPD who has had a significant exacerbation requiring non-invasive ventilation, and the goals-of-care discussion is to align her treatment with her values and prognosis. I would use a structured conversation using the SPIKES protocol and the Serious Illness Conversation Guide [6][7].

Step 1 — Setting: A quiet space, the patient, a family member if she wishes, the senior clinician, enough time, no interruptions. I sit down. [1]

Step 2 — Perception: I ask what she understands about her COPD and this admission. 'Tell me what you understand about your lung condition and what has been happening.' I listen for her grasp of the trajectory and any misconceptions. [1]

Step 3 — Invitation: I ask how much detail she wants about the prognosis and the options, and I respect her right to defer to family. [1]

Step 4 — Knowledge: I give honest information in plain language. Her COPD is severe and progressive; this exacerbation needed non-invasive ventilation, and a future one may need invasive ventilation in intensive care; the trajectory is of gradual decline punctuated by exacerbations. I frame this as the time to think together about what matters most and what she would want. [1]

Step 5 — Elicit values and preferences: I ask: what matters most to you now; what are you willing and not willing to go through; what would you consider an acceptable outcome; if you could not speak for yourself, who would you want to make decisions. I listen for whether she would accept invasive ventilation and intensive care in a future exacerbation, whether she would want CPR if her heart stopped, and what her preferred place of care and death would be. [1]

Step 6 — Empathy: I acknowledge the emotion. This is a hard conversation. I stay with it. [1]

Step 7 — Summarise, agree a plan, document: I summarise what was said, agree a plan and a follow-up, and document the conversation — her values, her treatment preferences (specifically regarding invasive ventilation, ICU, CPR), her preferred place of care and death, her appointed substitute decision-maker, and the agreed ceiling of treatment. I document this on the goals-of-care form, communicate it to the ward team, the GP and the ambulance service, and review it at each admission. If she wishes, I support her to complete a formal advance care directive that legally documents her refusals. I would involve the palliative care team for symptom control, advance care planning support and family support.* [1]

The key communication principle throughout is that the conversation is the intervention — a documented, accessible conversation changes what happens to her; a form alone does not [1][2]."

Examiner follow-up: "She says she would want to be ventilated if it meant she could come off it and go home, but not if it meant staying in intensive care indefinitely. How do you capture that nuance?" [1]

"I would capture it precisely in the advance care plan and the goals-of-care form, as a time-limited trial. The agreed plan would be: in the event of a future exacerbation that requires ventilatory support, a trial of non-invasive ventilation first, and — if that fails and she still has a prospect of recovery to a quality of life she would value — a time-limited trial of invasive ventilation in intensive care, with a defined review point (for example 48 to 72 hours) at which the team and the substitute decision-maker assess whether the trial is working. If at the review the trial is failing — she is not recovering, she is developing complications, she is heading toward prolonged ventilator dependence — then the ventilation is withdrawn and the focus shifts to comfort. This captures her stated preference (a trial with a prospect of going home, but not indefinite intensive care), it respects the principle that withholding and withdrawing are ethically equivalent so a trial is appropriate, and it gives the team and the family a clear, documented framework for the decision in the crisis. The time-limited trial is the standard tool for exactly this kind of conditional preference." [1]