Consent
Informed Consent Refusal
A 67-year-old patient refuses colonoscopy despite possible colorectal malignancy.
OSCE Steps
- Introduce yourself and clarify concerns.
- Assess understanding and decision-making capacity.
- Explain risks, benefits, alternatives, and consequences of refusal.
- Use simple language and check understanding.
- Respect capable refusal.
- Document informed refusal carefully.
“I respect your decision. My responsibility is to ensure you understand the possible risks of declining this investigation and answer any questions you may have.”
Confidentiality
Family Requests Information
The patient's daughter demands full medical information without patient permission.
Best Approach
- Acknowledge concern empathetically.
- Maintain patient confidentiality.
- Request patient permission before disclosure.
- Offer family meeting if patient agrees.
“I understand you are worried about your father. I need to respect his privacy, but with his permission I would be happy to discuss his care with you.”
Medical Error Disclosure
Wrong Medication Dose
A patient received the incorrect medication overnight but is currently clinically stable.
Expected NAC OSCE Response
- Disclose the error honestly.
- Apologize professionally.
- Explain known facts only.
- Assess for patient harm.
- Describe monitoring and management plan.
- Document disclosure.
“I’m sorry. A medication error occurred overnight. Right now you are stable, and we are monitoring closely to ensure there has been no harm.”
Boundary Issues
Inappropriate Gift
A patient gives you an expensive watch after treatment and asks to meet socially.
Professional Response
- Thank the patient respectfully.
- Decline expensive gifts professionally.
- Maintain therapeutic boundaries.
- Avoid social or romantic relationships with patients.
“I truly appreciate your kindness, but I must maintain professional boundaries and cannot accept this gift.”
Substitute Decision Maker
Capacity & SDM Conflict
An elderly delirious patient requires urgent treatment while family members disagree on management.
Safe OSCE Approach
- Assess and document incapacity.
- Identify appropriate substitute decision maker.
- Determine prior patient wishes if known.
- Use best-interest standard if wishes unknown.
- Escalate conflict appropriately.
“At this moment your mother cannot fully understand this treatment decision. We need to identify the appropriate substitute decision maker and act according to her known wishes and best interests.”
High-Yield NAC Rule
Core Ethics Formula
Listen → Empathize → Clarify Facts → Assess Capacity/Safety → Explain Clearly → Shared Plan → Document
Common NAC Traps
- Breaking confidentiality for family pressure.
- Forcing treatment on capable patients.
- Hiding medical errors.
- Crossing professional boundaries.
- Ignoring patient autonomy.