Palliative Care — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mr James Connolly, 67 years old, retired builder. [1]

Presenting complaint: Worsening breathlessness, right chest-wall pain, nausea, constipation, and new agitation, assessed on the oncology ward. [1]

History of the presenting complaint: Mr Connolly was diagnosed with metastatic non-small-cell lung cancer (stage IV, EGFR and ALK wild-type) 11 months ago. He completed first-line carboplatin-pemetrexed chemotherapy with a partial response, then began second-line pembrolizumab four months ago. Over the last three weeks his wife has noticed increasing breathlessness — initially on exertion, now at rest — a worsening right chest-wall pain, and a loss of appetite with an 8-kilogram weight loss over 3 months. Over the last 48 hours he has become intermittently confused and agitated on the ward, picking at the sheets and calling out. He has vomited twice today. [1]

Past history: Ischaemic heart disease (a drug-eluting stent 4 years ago), hypertension, and a 50 pack-year smoking history (ceased at diagnosis). No known metastases to bone or brain on the last staging scan, but the current CT shows new pulmonary progression. [1]

Current medications:

• Sustained-release morphine 30 mg orally twice daily
• Immediate-release morphine 10 mg orally as needed for breakthrough pain (uses 3 to 4 times daily)
• Senna 15 mg nocte
• Macrogol one sachet daily
• Dexamethasone 4 mg daily
• Aspirin 100 mg, atorvastatin 40 mg, perindopril 5 mg
• Pembrolizumab intravenously every 3 weeks [1]

Social history: Lives with his wife (64, in good health) in their own single-storey home. Two adult sons who live locally. He was a builder, retired at 65. He is the main financial provider; his wife works part-time. He hoped to attend his grandson's christening in 6 weeks. [1]

Examination findings (trainee elicits):

• Cachectic, in obvious discomfort, respiratory rate 26 per minute, oxygen saturation 88 per cent on room air.
• Dullness and reduced air entry at the right base; no wheeze.
• Abdomen soft but distended; bowel sounds present but reduced.
• Intermittently disoriented to place and time; picks at the sheets; grimaces periodically.
• Dry mucous membranes.
• His wife is at the bedside, tearful and exhausted. [1]

Investigations:

• Full blood count: haemoglobin 102 g/L (normocytic), white cell count 9.1, normal differential, platelets 280.
• Biochemistry: sodium 134, potassium 4.2, urea 9.1, creatinine 110 (baseline 85), corrected calcium 2.85 mmol per litre (albumin 28 g/L), ALT normal, ALP 220.
• C-reactive protein 85.
• CT chest (current admission): large right pleural effusion, progressive pulmonary metastases, no bone destruction visible on chest cuts, no brain involvement (no head CT done).
• Urinalysis: clear. [1]

Candidate's long-case presentation (SASPOP)

"Mr James Connolly is a 67-year-old retired builder with metastatic non-small-cell lung cancer on second-line immunotherapy, presenting with worsening breathlessness, chest-wall pain, nausea, constipation, and new agitation, and an 8-kilogram weight loss over 3 months. [1]

His past history includes ischaemic heart disease with a drug-eluting stent, hypertension, and a 50 pack-year smoking history. His medications are sustained-release and immediate-release morphine, senna, macrogol, dexamethasone, aspirin, atorvastatin, and perindopril. [1]

On examination he is cachectic, tachypnoeic with a respiratory rate of 26 and an oxygen saturation of 88 per cent on room air, has dullness and reduced air entry at the right base consistent with a pleural effusion, is intermittently disoriented and agitated, and has a distended abdomen with reduced bowel sounds. His corrected calcium is 2.85, his creatinine has risen from a baseline of 85 to 110, and his CT chest shows a large right pleural effusion and progressive pulmonary metastases. [1]

His main problems are:

1. Refractory breathlessness with a large right pleural effusion
2. Suboptimally controlled chest-wall pain on an under-dosed opioid regimen
3. Hypercalcaemia of malignancy contributing to confusion, nausea, and constipation
4. Acute delirium — multi-factorial (hypercalcaemia, hypoxia, opioids, dehydration)
5. Nausea and constipation
6. Cancer anorexia-cachexia syndrome
7. Acute kidney injury (pre-renal plus possible bisphosphonate nephrotoxicity)
8. Progressive disease refractory to second-line therapy — the overarching framework
9. Carer strain in his wife, and goals-of-care decisions [1]

My integrated plan is to drain the right pleural effusion immediately with an intercostal catheter (with pleurodesis or an indwelling pleural catheter if it recurs), give supplemental oxygen for his hypoxaemia, and treat the hypercalcaemia with intravenous normal saline and a bisphosphonate (zoledronic acid 4 mg, dose-reduced for his renal impairment). I will optimise his analgesia by increasing the sustained-release morphine to 60 mg twice daily and recalculating the breakthrough dose to 20 mg (one-sixth of the new 24-hour total), adding an NSAID for the bone pain and a gabapentinoid if there is a neuropathic component. I will start haloperidol for the chemical nausea, up-titrate the senna and macrogol for the constipation, and seek and treat the reversible precipitants of his delirium (the hypercalcaemia, the hypoxia, the opioids, the dehydration) before ascribing it to the disease. I will involve the specialist palliative care team alongside the oncology team from this admission, have a goals-of-care conversation using the SPIKES protocol with his wife present, discuss a ceiling of treatment and a not-for-resuscitation decision framed in the context of his illness, and support his wife with a carer assessment, respite, and a bereavement risk assessment." [1]

Discussion questions

Q1: "How would you manage his hypercalcaemia, and how quickly will it work?" [1]

"The management follows the sequence of aggressive intravenous rehydration first, then a bisphosphonate. I would give 3 to 6 litres of normal saline over the first 24 hours, guided by his volume status and his cardiac and renal function — the saline expands the intravascular volume, promotes a natriuresis (calcium is passively excreted with sodium in the proximal tubule), and corrects the dehydration that is contributing to his acute kidney injury and to the hypercalcaemia. After rehydration I would give zoledronic acid 4 mg intravenously over 15 minutes, dose-reduced for his renal impairment. The bisphosphonate takes 48 to 72 hours to lower the calcium; if he is symptomatic in the interim, calcitonin 4 to 8 IU per kilogram subcutaneously every 12 hours provides a faster but transient bridge. I would recheck the calcium at 24 and 48 hours. The underlying cause is humoral hypercalcaemia of malignancy or local osteolysis, and treating the cancer is the definitive solution, but the immediate priority is to lower the calcium because it is contributing to his confusion, his nausea, and his constipation, and it may be worsening his delirium independently of the other precipitants." [1]

Q2: "His wife is exhausted. How do you support her?" [1]

"Carer strain is a major driver of admission and of complicated bereavement, and supporting her is central to his community care. I would offer education about the illness and the symptoms (so she knows what to expect and is not blindsided), a formal carer assessment, referral to a palliative care support group and a carer advisory service, regular in-home respite and a day programme if available, a community palliative care package for assistance with personal care and medications, and active monitoring of her own health including a depression screen. I would involve the two adult sons to share the load, and I would name a single contact for questions. I would also do a bereavement risk assessment — anticipatory grief, social isolation, prior mental illness, a death perceived as preventable, and a dependent relationship all identify those at risk of complicated grief, who warrant specialist bereavement referral. Crucially, I would not wait until he dies to offer this support — carer strain in the active phase is itself a clinical problem." [1]

Q3: "He mentions his grandson's christening in 6 weeks. How does this affect your conversation?" [1]

"This is an example of a time-limited, values-based goal, and it is exactly the kind of information that the goals-of-care conversation should surface. It tells me what matters to him now, and it gives me a concrete anchor for the discussion of prognosis and treatment. I would be honest that his disease is progressing despite second-line therapy, that further disease-directed treatment is unlikely to control the cancer within 6 weeks, and that the realistic aim is to help him be well enough to attend the christening — which means focusing on symptom control and avoiding interventions that would keep him in hospital. I would discuss whether continuing the pembrolizumab is in his interest given the progression (the oncology team would advise), whether a brief palliative radiotherapy course to a painful site or to the effusion would help, and how to manage him at home with community palliative care support. I would frame the conversation around his values — being at home, being well enough for the christening, being with his family — and align the medical plan with those values. The SPIKES protocol emphasises assessing perception and invitation before delivering information, and the most important step is responding to the emotion with empathy and silence when the implications sink in." [1]

Q4: "How would you decide whether to continue the pembrolizumab?" [1]

"This is a decision for the oncology team in consultation with the patient, but the medical physician's contribution is the honest framing. The CT shows progression on second-line immunotherapy, which by the RECIST criteria suggests the treatment is not working. Continuing a treatment that is not working exposes him to the risk of immune-related adverse events (colitis, pneumonitis, hepatitis, endocrinopathy) without benefit, and it requires hospital visits that compete with his goal of being at home. I would ask the oncology team to assess whether there is a third-line option with a realistic chance of benefit, and I would help the patient and his wife weigh the likely benefit against the burden. The principle is that disease-directed therapy and palliative care run in parallel, but when the disease-directed therapy is no longer working and the goal shifts to comfort and specific time-limited events, the palliative care becomes the primary focus. I would not withdraw all support — I would intensify the palliative care." [1]

DCE Short Case — Symptom Assessment in a Palliative Patient

Examiner instruction: "This 72-year-old woman with metastatic breast cancer is on the ward. She reports pain and breathlessness. Please assess her symptoms and present your findings and plan." [1]

Systematic assessment routine

1. Prepare — confirm identity, introduce, ensure comfort, ensure glasses and hearing aids if used, note the time of day.
2. Symptom inventory — ask specifically about pain, breathlessness, nausea, constipation, appetite, sleep, mood, and her understanding and goals; palliative patients under-report unless asked directly.
3. Pain assessment (SOCRATES) — Site, Onset, Character (somatic, visceral, neuropathic), Radiation, Associations, Time course, Exacerbating and relieving factors, Severity on a 0 to 10 scale; functional impact (does it wake her, limit movement, prevent coughing); current analgesic regimen including background dose, breakthrough dose and frequency of use, and side effects.
4. Breathlessness assessment — intensity at rest and on exertion (0 to 10), pattern, impact on activities and mood, associated symptoms (cough, sputum, orthopnoea, chest pain); check oxygen saturation and examine for reversible contributors.
5. Focused examination — for reversible contributors to breathlessness (pleural effusion, consolidation, wheeze, ascites, anaemia) and for the source of the pain (focal tenderness, neurological deficit, signs of cord compression).
6. Collateral and goals — ask what matters most to her now, what she is hoping for, and what she is worried about. [1]

Key signs this patient demonstrates

• Alert, cooperative, in moderate distress; respiratory rate 22, oxygen saturation 94 per cent on room air.
• Reduced air entry and dullness at the right base — a pleural effusion.
• Focal tenderness over the lower thoracic spine.
• Cachectic; dry mucous membranes. [1]

Presentation template

"I assessed this 72-year-old woman with metastatic breast cancer. She has two main symptoms. [1]

Her pain is in the lower back and the right ribs, sharp and well-localised, worse on movement, present for two weeks, rated 7 out of 10 at rest and 9 out of 10 on movement, and it wakes her at night. She is on sustained-release morphine 30 mg twice daily with 10 mg immediate-release breakthrough, which she uses two to three times a day, and her pain is not fully controlled. The character is somatic, consistent with bone metastases. [1]

Her breathlessness is on exertion, rated 6 out of 10, present for a week, with no orthopnoea. Her oxygen saturation is 94 per cent on room air. Examination reveals reduced air entry and dullness at the right base — a pleural effusion. [1]

My assessment is of a patient with suboptimally controlled bone pain and a right pleural effusion. For the pain, I would increase the sustained-release morphine to 60 mg twice daily and recalculate the breakthrough dose to 20 mg — one-sixth of the total 24-hour dose. I would add an NSAID if not contraindicated, confirm the laxative regimen is titrated, and consider palliative radiotherapy to the painful bone metastases. For the breathlessness, I would arrange imaging to confirm the effusion and drain it if symptomatic; her saturation of 94 per cent means she is not hypoxaemic, so oxygen would not be my first step — I would rely on drainage and, if needed, low-dose morphine, with non-pharmacological measures (upright positioning, a fan to the face). I would discuss her goals of care and involve the palliative care team." [1]

Discussion

Q: "What is the WHO analgesic ladder, and where does this patient sit on it?" [1]

"The WHO three-step analgesic ladder is the framework for cancer pain. Step 1 is a non-opioid (paracetamol, NSAID) plus adjuvants for mild pain. Step 2 adds a weak opioid (codeine, tramadol) for moderate pain. Step 3 uses a strong opioid (morphine, oxycodone, fentanyl) plus adjuvants for severe pain. Adjuvants — gabapentinoids for neuropathic pain, NSAIDs or dexamethasone for bone pain, antispasmodics for colic — are added at every step. The five principles are by the mouth, by the clock, by the ladder, for the individual (titrated, no fixed maximum), and with attention to detail (always a laxative). This patient is on Step 3 — a strong opioid — but her dose is suboptimal and her pain is uncontrolled, so I would titrate the background dose up and recalculate the breakthrough dose to one-sixth of the new total." [1]

Q: "What single pharmacological intervention would most improve her breathlessness, and why is oxygen not the answer here?" [1]

"Low-dose oral morphine — she is already on morphine, so I would ensure the dose is adequate. The Abernethy randomised trial (BMJ 2003) showed that low-dose oral morphine relieves refractory breathlessness in advanced disease, and that in the non-hypoxaemic patient supplemental oxygen offers no benefit over room air. Her oxygen saturation of 94 per cent means she is not hypoxaemic, so oxygen would not help her breathlessness. Draining the pleural effusion is the most effective single intervention if it is the dominant cause, and non-pharmacological measures (upright positioning, a fan to the face, pursed-lip breathing) are the foundation. Oxygen is reserved for the hypoxaemic patient." [1]

Q: "How would the management differ if her oxygen saturation were 86 per cent rather than 94 per cent?" [1]

"At 86 per cent she would be hypoxaemic, and supplemental oxygen would be indicated and would help her breathlessness as well as her oxygenation. The threshold for oxygen in palliative care is the same as in any other setting — a saturation below 90 per cent or a PaO2 below 60 mmHg. The key point is that oxygen is a treatment for hypoxaemia, not a comfort measure for the non-hypoxaemic patient; the non-hypoxaemic patient with refractory breathlessness is best served by low-dose oral morphine, non-pharmacological measures, and treatment of any reversible cause (the effusion, an anaemia, a pulmonary embolism). The Abernethy trial specifically addressed the non-hypoxaemic patient, and the lesson is not to prescribe oxygen reflexively for breathlessness but to reserve it for the patient who is actually hypoxaemic." [1]