MRCP PACES Communication: Mastering Relative and Family Discussions

Communicating with patients' relatives is one of the most challenging yet essential skills you'll demonstrate in MRCP PACES. Whether you're explaining a new diagnosis, discussing treatment options for a patient lacking capacity, or managing a difficult family meeting, your ability to navigate these conversations can significantly impact your exam performance—and your clinical practice.

As someone who has examined countless PACES candidates, I've observed that many trainees excel at patient communication but stumble when faced with an anxious relative at the bedside. This guide will equip you with the frameworks, language, and confidence to handle these scenarios expertly.

Why Relative Communication Matters in PACES

The MRCP PACES exam explicitly tests your ability to communicate with patients and their relatives. In Stations 2 and 5, you may encounter:

• A concerned daughter asking about her mother's new dementia diagnosis

• An angry son demanding answers about his father's care

• A spouse requesting detailed information about treatment options

• A family member acting as a surrogate decision-maker

Examiners assess how you:

1. Build rapport with anxious relatives

2. Manage emotions including anger, grief, and denial

3. Deliver information appropriately without breaching confidentiality

4. Navigate capacity issues and best interest decisions

5. Demonstrate empathy whilst maintaining professional boundaries

The SPIKES Framework for Breaking Bad News to Relatives

The SPIKES protocol, widely used for breaking bad news, adapts beautifully for relative discussions:

S – Setting

Before speaking with relatives, ensure you have a private, quiet space. In PACES, this means acknowledging the environment and suggesting: "Perhaps we could find somewhere quieter to discuss this properly."

P – Perception

Assess what the relative already knows and understands:

"Before I explain what's happening, could you tell me what you've already been told about [patient's] condition?"

This prevents you from assuming too much or too little knowledge—a common PACES pitfall.

I – Invitation

Gain permission to share information:

"Would it be helpful if I explained what the tests have shown?"

This respects autonomy and prepares the relative for potentially difficult news.

K – Knowledge

Share information in small chunks, using plain language:

"The scan shows there's a growth in the lung. We call this a mass or tumour..."

Avoid jargon. Pause frequently. Watch for signs of distress.

E – Emotions

Acknowledge emotions before continuing. This is where many candidates falter:

"I can see this is very upsetting news..."
"It's completely natural to feel angry right now..."

Do not rush past emotions. Sit with them. Allow silence.

S – Strategy and Summary

Outline next steps and confirm understanding:

"Shall I explain what happens next? We'll need to take some further tests..."

Navigating Confidentiality Dilemmas

A classic PACES challenge: a relative asks for information about a patient who hasn't consented to disclosure.

Key Principles

1. Never disclose without consent unless legally mandated

2. Acknowledge the relative's concern without dismissing them

3. Explain your position clearly without being defensive

Exemplar Response

"I completely understand you're worried about your father, and I want to help. However, I need to respect his privacy, and he hasn't given permission for me to share details with others. Have you spoken with him about whether he'd like you involved in these discussions? Often, patients are happy for their family to be present when we talk, but I need him to agree first."

This response:

• Validates the relative's feelings

• Explains the ethical position

• Offers a practical solution

• Maintains professional boundaries

Managing Capacity and Best Interest Discussions

When patients lack capacity, relatives become crucial partners in decision-making. PACES scenarios frequently involve:

The Framework

1. Confirm capacity assessment: Demonstrate you've assessed capacity (two-stage test)

2. Explain best interest process: Involve the relative appropriately

3. Clarify their role: They're informing the decision, not necessarily making it (unless they hold lasting power of attorney)

Exemplar Language

"Because your mother is too unwell to understand the treatment options right now, I need to make a decision in her best interests. I'd really value your input—what do you think she would have wanted? What mattered most to her?"

Note: Ask about what the patient would have wanted, not what the relative wants. This subtle distinction demonstrates advanced communication skills.

Handling Angry Relatives

Anger is a natural response to fear, grief, or perceived injustice. In PACES, your response to an angry relative can distinguish you as a candidate.

The PEARLS Framework

• P – Partner: "Let's work together to understand what's happened..."

• E – Emotion: "I can see you're frustrated..."

• A – Acknowledge: "You're right to be concerned..."

• R – Respect: "You clearly care deeply about your father..."

• L – Legitimise: "Anyone in your position would feel the same..."

• S – Support: "How can I help you right now?"

Key Dos and Don'ts

Telephone Communication with Relatives

Post-pandemic, PACES increasingly tests telephone consultations. Key adaptations:

1. Identify yourself clearly: "Hello, this is Dr [Name] calling from [Hospital]..."

2. Confirm identity: "Can you confirm you're [Name], [Patient's] daughter?"

3. Check environment: "Are you somewhere private where we can talk?"

4. Use verbal cues: Since they can't see your nodding, use "Mmm, I see" and "Go on..."

5. Summarise frequently: "Let me just check I've understood correctly..."

Gathering Collateral History

Station 2 may require you to gather collateral history from a relative. Key principles:

Open Questions First

"Tell me about how your husband has been recently..."

Then Focus

"You mentioned his memory—can you give me an example of something that's happened?"

Functional Assessment

"How is he managing with dressing, bathing, cooking?"

Timeline Clarity

"When did you first notice this change? Was it sudden or gradual?"

Common PACES Pitfalls

As an examiner, I frequently observe these errors:

1. Dismissing Emotions

Weak: "I understand, but we need to focus on the medical aspects..."

Strong: "I hear how worried you are. These feelings are completely understandable. Let's take a moment..."

2. Information Overload

Weak: Launching into a detailed explanation of pathophysiology, treatment options, and prognosis in one breath.

Strong: Chunking information, pausing, checking understanding: "Shall I go on, or would you like to ask questions first?"

3. Defensive Responses to Complaints

Weak: "We did everything according to protocol..."

Strong: "I'm sorry you feel things haven't been explained well. Can you tell me what you would have wanted to know?"

4. Ignoring the Relative

Weak: Focusing entirely on the patient whilst the relative stands awkwardly.

Strong: "I can see you're very involved in your mother's care. Do you have any questions?"

Exam Day Tips

1. Introduce yourself to everyone present—patients AND relatives

2. Maintain appropriate eye contact with both patient and relative

3. Position yourself so both can see you if possible

4. Never contradict patient's account to relative without exploring sensitively

5. Document your discussions appropriately in station wrap-up

Practice Scenarios

Work through these with your study partner or mock circuit:

1. Breaking bad news: Explain a new cancer diagnosis to a patient's spouse

2. Capacity discussion: Discuss best interests with a daughter regarding her mother's DNACPR decision

3. Angry relative: Address complaints about delays in care

4. Confidentiality: Handle a request for information about an adult patient

5. Collateral history: Gather information from a partner about a patient's blackout

Final Thoughts

Communicating with relatives tests not just your knowledge but your humanity. Remember that behind every "angry relative" is someone's loved one, frightened and uncertain. Your ability to remain calm, compassionate, and clear under pressure is what makes you a physician—not just a medical graduate.

In PACES, examiners are asking: Would I want this doctor caring for my family? Your relative communication skills help answer that question decisively.

Further Reading:

• GMC: Good Medical Practice – Partnership principles

• SPIKES: A Six-Step Protocol for Delivering Bad News (Baile et al., 2000)

• NICE: Decision-making and mental capacity guidelines