OSCE: actor and procedure stations13 / 22
Refusing the recommended spinal for TURPActor: 74-year-old man, moderate COPD (FEV1 55% predicted), booked for elective TURP
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
- Spinal is the preferred technique for classic TURP; T10 is high enough.
- Awake, early TURP syndrome (confusion, restlessness) can be spotted.
- COPD: regional linked with fewer pneumonias, less prolonged ventilation, fewer reintubations.
- Permanent injury after spinal: about 0.15 per 10,000.
- Informed refusal needs the same disclosure as consent.
The patient
Actor: 74-year-old man, moderate COPD (FEV1 55% predicted), booked for elective TURP.
A spinal was recommended; he refuses and wants to be asleep.
Vitals: BP 142/84, HR 78, SpO2 94% on air, RR 18.
Task: explore his refusal and agree a plan.
The examiner asks
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Open
How do you start?
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- I'm seeing a 74-year-old with COPD before his prostate operation, who doesn't want a spinal. Patient
- I hear you'd rather be asleep. What is it about the spinal that bothers you? Communication
- Has something happened before, to you or someone you know?
Explain
Explain your recommendation and the alternatives.
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- I recommended a spinal because it's gentler on your lungs than being put to sleep. (Communication)
- With your COPD, a general anaesthetic raises the chance of a chest infection or breathing problems.
- Awake, you can tell us early if you feel confused, a warning sign in this operation.
- You'd be numb below the belly button for a few hours.
- Permanent nerve damage after a spinal is very rare, roughly 1 in 70,000.
- We can add light sedation, so you're relaxed and drowsy throughout.
Respond
He says: 'No needles in my back, thank you.'
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- That's a common worry. I numb the skin first, and you can be sedated before I start. (Communication)
- You won't see anything, and I'll tell you each step before I do it.
- Would sedation first help, so you're drowsy when I do it?
Respond
He says: 'I'll take the risk of being put to sleep.'
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- That's your right, and I'll respect it. I just wanted you to have the facts. (Communication)
- We'll make the general anaesthetic as kind to your lungs as we can.
- I'll be with you throughout, watching your breathing closely.
Close
How do you close?
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- Before surgery, we'll check your inhalers are working well and your chest is at its best. (Communication)
- I'd use a breathing device in the throat rather than a tube if suitable, and short-acting drugs.
- I'll record that you declined the spinal after hearing its risks and benefits.
Fatal mistakes
- Doing a spinal without consent.
- Coercing him.
- No discussion of risks.
Checked against: Miller 10e · Barash 9e
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