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Goals of Care: Fluctuating Capacity

Help the son of a delirious patient with a DNR honor his father's wishes, even when the patient is crying out for 'help'.

  1. 1
    Briefing
  2. 2
    Simulation
  3. 3
    Feedback

How This Works

This is an interactive phone call simulation. You'll speak with Michael in a realistic clinical communication scenario.

1. Start Call

Click "Start Call" when you're ready. Speak naturally as you would on a real call.

2. Have the Conversation

10 minutes to complete the call. The AI responds in real-time to what you say.

3. Get Feedback

End the call when finished. You'll receive AI-powered feedback on your communication.

💡 Tip: Speak clearly and at a natural pace. If you need a moment to think, it's okay to pause briefly - just as you would in a real conversation.

Briefing Details

1. Learning: Navigating Fluctuating Capacity

Purpose of this Scenario

This simulation explores the profound ethical challenge of honoring a patient's wishes when their ability to communicate those wishes fluctuates. Delirium, a state of acute confusion common in hospitalized patients, can cause patients to say or do things that seem to contradict their previously stated goals. Your task is to navigate the distress of the family, explain the medical reality of delirium, and remain anchored to the patient's true, underlying values.

Key skills include:

  • Explaining delirium in simple, non-technical terms.
  • Differentiating between a delirious utterance and a considered change of mind.
  • Re-centering the conversation on the patient's known, long-held values.
  • Reassuring the family that comfort measures are not "doing nothing," but are active, compassionate care.

2. Scenario Briefing: The Delirious Patient with a DNR

Your Objective

You are the hospital physician. Your goal is to speak with Michael, the distressed son and healthcare proxy of an 88-year-old patient with a valid DNR order. The patient is delirious and intermittently saying "help me," causing Michael to question the DNR. You must explain delirium, manage Michael's distress, and build consensus to continue honoring the patient's advance directive while treating his symptoms.

Patient Background

Your patient is an 88-year-old man with metastatic cancer and a poor prognosis, who has a well-established DNR/DNI order. He was admitted for a severe UTI and is now septic and delirious. His son, Michael, is his proxy and is at the bedside.

Crucial Information: The patient, in his delirium, is agitated and intermittently crying out "Help me, I can't breathe!" Michael is hearing this and is beginning to question the DNR order, asking you, "He's asking for help, shouldn't we be doing more?"

Key Medical Facts

  • The Condition: Sepsis from a UTI is causing delirium, a state of acute confusion and altered consciousness. This is a medical symptom, not a change of the patient's fundamental wishes.
  • The Plan: You are treating the underlying infection with antibiotics and providing oxygen. The patient's symptom of "air hunger" can and should be treated with medications like morphine, which is consistent with comfort care.
  • The Prognosis: The underlying cancer is terminal. Intubation would violate his DNR and would not change the ultimate outcome of his cancer.

Learning Objectives

Optional prep details

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Optional Pre-Call Knowledge Check

Optional self-check before you start

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After completing this scenario, you will be able to:

  • Differentiate between a patient's capacitated, established goals of care and utterances made during an episode of delirium.
  • Explain the pathophysiology and clinical presentation of delirium to a distressed family member in simple, empathetic terms.
  • Apply the ethical principle of patient autonomy in a situation where a patient's current behavior seems to contradict their advance directive.

A patient with a valid DNR order develops hyperactive delirium and repeatedly shouts 'Help me! Don't let me die!' What is the most ethically sound initial approach?

When a delirious patient's actions seem to contradict a pre-existing advance directive, which principle holds the most weight in guiding the clinical team's response?

What is the most effective initial communication technique when engaging a highly distressed family member?