Psych CASC / OSCE · Consultation-liaison — hepatic encephalopathy and advanced transplant psychiatry
Covert HE, driving concern, and pre-listing depression — CASC communication station
MRCPsych/FRANZCP-style CASC: explain HE in accessible clinical language, screen depression and alcohol recovery, discuss capacity/driving as clinical risk communication, and collaborate on a plan that supports hepatology and possible listing work-up.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar embedded with hepatology / transplant assessment clinic. [1]
Candidate instructions. Explain that subtle cognitive change in cirrhosis may be covert hepatic encephalopathy, not a character flaw. Explore sleep–wake change, attention, mood, alcohol recovery, and medication adherence (especially lactulose). Address driving as a shared safety concern using clinical language and local process — do not invent statute numbers. Link depression and adherence to transplant evaluation constructively. Check suicide risk. Agree a collaborative plan with hepatology. [1][2][3]
Candidate scenario
Your patient is 58 with alcohol-associated cirrhosis, currently compensated after a recent HE admission. Family reports irritability and reversed sleep. The patient drove into a kerb last week but minimises this. PHQ-9 is in the moderate range; they fear transplant psychiatry will “fail” them. Partner is outside if the patient consents. [1][2]
Marking domains
- Empathic, non-stigmatising explanation of HE
- Screens covert cognitive symptoms, depression, suicide, alcohol recovery
- Explains lactulose/precipitant principles in plain language
- Discusses driving risk responsibly without invented legal sections
- Links mood/adherence to transplant psychosocial optimisation (not veto theatre)
- Collaborative plan and safety netting
- Optional partner involvement with consent [1][3][4][5]
Reveal assessor key
Open. Introduce role; purpose is to protect brain function and future transplant options together, not to judge character. Check preference for partner presence. [1]
Explain. Covert HE can impair attention and driving even when conversation seems OK; it is a medical complication of liver disease and often improvable with treatment of precipitants and lactulose (± other hepatology therapies such as rifaximin when indicated for recurrent overt HE).[1][2][3]
Explore. Sleep–wake inversion, concentration, mood, anhedonia, death wishes, last drink, recovery supports, lactulose taking, sedative use. Normalise fear of “psych clearance.” Frame evaluation domains (support, mood, substance, adherence) as optimisation, not automatic exclusion.[4][5]
Driving. State clinical concern after near-miss; advise not driving until reviewed with treating team and local fitness-to-drive process; document and involve hepatology — avoid invented legal section numbers.[2]
Plan. Confirm lactulose technique and bowel-motion targets with hepatology nursing education; treat depression; reinforce alcohol recovery; reduce DNA barriers; written summary; urgent contact if confusion worsens; follow-up before formal listing interview if planned. Safety plan for suicidal thoughts.[3][4]
Close. Check understanding with teach-back; agree next appointment; thank partner if involved.[1]
References
- [1]Patidar KR, Bajaj JS Covert and Overt Hepatic Encephalopathy: Diagnosis and Management Clin Gastroenterol Hepatol, 2015.PMID 26164219
- [2]Shaw J, Bajaj JS Covert Hepatic Encephalopathy: Can My Patient Drive? J Clin Gastroenterol, 2017.PMID 28027071
- [3]Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver Hepatology, 2014.PMID 25042402
- [4]Dew MA, Rosenberger EM, Myaskovsky L, et al. Depression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis Transplantation, 2015.PMID 26492128
- [5]Maldonado JR, Dubois HC, David EE, et al. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates Psychosomatics, 2012.PMID 22424160