o SPIKES model:
Set up the interview.
Perception — check patient’s understanding.
Invitation — how much do they want to know?
Knowledge — share information clearly and in small chunks.
Empathy — respond to emotions.
Strategy and summary — plan together.
o Important to avoid medical jargon and allow silence.
o Patients must understand, retain, weigh, and communicate a decision.
o Presumed to have capacity unless proven otherwise.
o Capacity is decision- and time-specific.
o Includes discussing:
Preferred place of care and death.
DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) orders.
Advance decisions to refuse treatment (ADRT).
Lasting power of attorney (LPA) for health and welfare.
Extra Revision Pearls
• Terminal agitation: may require benzodiazepines (e.g., midazolam SC).
• Anticipatory (just-in-case) medication: includes morphine, midazolam, glycopyrronium, haloperidol.
• Opioid-induced hyperalgesia: consider reducing dose or rotating opioid.
• When converting between opioids: reduce dose by 30% to account for incomplete cross-tolerance.
• Bowel regimens: always prescribe prophylactic laxatives with opioids.
• Family education: explain signs of imminent death (e.g., reduced intake, Cheyne-Stokes breathing, cool extremities).
• Doctrine of double effect: giving medication with the intention of symptom relief is ethically acceptable even if life-shortening.
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
