Psych CASC / OSCE · Emergency psychiatry
De-escalation and rapid tranquillisation explanation — CASC communication station
MRCPsych/FRANZCP-style station: de-escalate, offer oral RT with named options, explain IM pathway and combination ban if needed, discuss capacity and least-restrictive care with family, and describe monitoring.
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Target exams
Station brief
Format. Communication and clinical reasoning station, approximately 7–10 minutes after reading time. You are the psychiatry registrar on the acute ward. [1]
Candidate instructions. Engage the patient with de-escalation skills, offer oral medication with clear choices, explain what happens if IM medication is needed (including safety monitoring and that the goal is calm not unconsciousness), and answer the sister's questions about rights, capacity, and least-restrictive care without inventing statute section numbers. The examiner may play patient and/or relative. [2][3]
Candidate scenario
The patient is pacing but not currently swinging punches. He says: “I’m scared they’re poisoning me. Don’t inject me.” Sister says: “Just sedate him properly so we can all go home.” Observations are stable. [1]
Marking domains
- Empathic engagement, one calm communicator, respect personal space
- Clear oral offer with named options (for example lorazepam 1–2 mg oral or olanzapine 5–10 mg oral)
- Accurate explanation of IM RT only if danger and oral fails, single agent, monitoring
- Explicitly avoids or corrects the idea of “knocking him out” / banned combinations
- Capacity and least-restrictive principles without invented section codes
- Collaborative plan with review and documentation [1][2][3]
Reveal assessor key
Open. Introduce role, ensure safety and privacy, acknowledge fear, use short sentences, one primary speaker. [2]
De-escalate and offer oral. Validate distress, reduce stimulation, offer choices: quiet space, water, oral lorazepam 1–2 mg or oral olanzapine 5–10 mg (orodispersible if available) to help him feel safer so you can assess together. Explain this is treatment, not punishment.[1]
If he asks about injections. Explain IM medication is only if he or others are at serious risk and oral is not possible; usually a single medicine; staff will monitor breathing and blood pressure every 15 minutes for at least an hour; the aim is calm and able to talk, not unconsciousness. Do not describe combining IM olanzapine with an injection of a benzodiazepine.[1]
Sister's rights questions. Explain capacity is about this decision now; if he can understand, retain, weigh and communicate, his choices matter; if not and serious risk exists, the law may allow treatment under local mental health legislation using the least restrictive option, with review — you will involve seniors and will not invent legal codes. Home only if safe after assessment — not as a demand after forced deep sedation.[3]
Close. Summarise shared plan, check understanding, document, arrange review time. [1]
References
- [1]Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation J Psychopharmacol, 2018.PMID 29882463
- [2]Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup West J Emerg Med, 2012.PMID 22461917
- [3]Spencer BWJ, Gergel T, Hotopf M, et al. Unwell in hospital but not incapable: cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. Br J Psychiatry, 2018.PMID 29909778