Psych CASC / OSCE · Old age psychiatry — capacity, guardianship and end of life
Capacity for treatment refusal and goals of care — CASC communication station
MRCPsych/FRANZCP-style CASC: goals-of-care and capacity-sensitive communication with patient (and optionally brief spouse joining).
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes after reading. You are the psychiatry registrar jointly reviewing with oncology/palliative care. [1]
Candidate instructions. Explore the patient’s understanding of illness and treatment options. Assess capacity elements with teach-back without turning the station into a hostile cross-examination. Elicit values and fears. Screen briefly for depression, hopelessness, and desire for hastened death. Outline advance care planning (proxy appointment, documenting preferences) as a process. If the spouse joins, validate distress while centring the patient’s voice if capacious. Agree next steps. Do not invent statute section numbers or coerce treatment. [1][2][3]
Candidate scenario
Your patient is 78 with mild Alzheimer disease and metastatic cancer. Mid-session they say: "I know the chemo may shrink things for a while, but I am exhausted and I want time at home, not in hospital. My husband thinks I am giving up." They appear low in mood but make good eye contact and answer consistently. English is fluent. [1]
Marking domains
- Empathy; non-coercive stance; clear agenda setting
- Explores understanding of illness, treatment burdens/benefits, alternatives (including comfort-focused care)
- Teach-back style capacity probes without humiliation
- Values, what living well means, unacceptable states
- Brief mood/hopelessness/desire-for-death screen and safety if suicidal ideation emerges
- Introduces ACP: who should speak if they become unwell; written preferences; review over time
- Handles spouse distress without silencing the patient
- Clear agreed plan and follow-up; no invented legal sections [1][2][4]
Reveal assessor key
Open. Thank them for discussing difficult issues; normalise talking about goals of care; check comfort and privacy. [3]
Understanding and capacity. "Can you tell me in your own words what the team has said about the cancer and the chemotherapy?" Explore appreciation ("how does that apply to you?") and reasoning ("what leads you to prefer home comfort care?"). Confirm a clear choice. If gaps appear, re-explain simply and re-check; note mild dementia does not equal incapacity. [1]
Mood and desire for death. Screen depression vs appropriate grief; ask about hopelessness and whether they want help dying versus refusing burdensome treatment. If desire for hastened death, explore drivers (pain, burden, depression) and escalate appropriately; do not moralise. [4][5]
ACP. "If you became too unwell to speak, who should decide with the doctors? What should they know about what matters to you?" Frame ACP as preparation, not giving up. Offer to document preferences and involve palliative care. [2]
Spouse. If present: acknowledge love and fear; explain that if the patient understands and chooses, we support that choice; offer couple support and practical palliative resources. [3]
Close. Summarise: preference for comfort-focused care if capacity intact; mood plan if needed; ACP documents/proxy discussion; follow-up with oncology/palliative/psychiatry; safety net. [1][2]
Optional OSCE extension (2–3 minutes)
Explain to the spouse alone (with patient consent) that capacity is decision-specific, that mild dementia does not cancel autonomy, and that lawful substitute decision-making only applies if capacity for that decision is lost — still guided by the patient’s known values. [1][2]
References
- [1]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292
- [2]Sudore RL, Fried TR Redefining the "planning" in advance care planning: preparing for end-of-life decision making Ann Intern Med, 2010.PMID 20713793
- [3]Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment JAMA, 2008.PMID 18840840
- [4]Block SD Assessing and managing depression in the terminally ill patient Ann Intern Med, 2000.PMID 10651602
- [5]Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer JAMA, 2000.PMID 11147988