Palliative Care — Written Clinical Reasoning

SAQ 1 — Metastatic Lung Cancer with Multiple Uncontrolled Symptoms (20 marks, 30 minutes)

Prompt: Outline your integrated assessment and management plan for this patient, including the assessment of each symptom and its likely mechanism, the investigations and procedures you would arrange, the pharmacological management by symptom, the approach to his goals of care and his wife's distress, and the communication. Justify each decision with reference to evidence and guideline recommendations. [1]

Model Answer

Problem framing and the early-integration principle (2 marks): [1]

This man has metastatic non-small-cell lung cancer with multiple uncontrolled symptoms in the context of progressive disease. The Temel 2010 trial established that early integrated palliative care alongside oncology improves quality of life, reduces aggressive end-of-life care, and is associated with longer survival [1] — the principle is that palliative care is active and parallel to disease-directed therapy, not reserved for the end of life. I would involve the specialist palliative care team alongside the oncology team from this admission.

His prioritised problem list is: [1]

1. Refractory breathlessness with a large right pleural effusion — likely the most distressing and the most immediately reversible.
2. Chest-wall pain — partially controlled on morphine; reassess and optimise.
3. Nausea and constipation — likely opioid- and hypercalcaemia-related; the constipation may be exacerbating the nausea.
4. Acute delirium — multi-factorial; a reversible precipitant must be sought.
5. Cancer anorexia-cachexia — the 8 kg weight loss.
6. Progressive disease — the framework within which every decision is made.
7. Goals of care, communication, and carer strain. [1]

Breathlessness and the pleural effusion (4 marks): [1]

The breathlessness has a reversible component — the right pleural effusion. The first intervention is a therapeutic pleural aspiration or chest drain (intercostal catheter) to drain the effusion, which can relieve the breathlessness within hours. If the effusion recurs, a pleurodesis (talc, via medical thoracoscopy or chest tube) or an indwelling pleural catheter (for the patient with limited prognosis) is the definitive management. This is the most effective single intervention for his breathlessness. [1]

His oxygen saturation is 88 per cent on room air, so he is hypoxaemic, and supplemental oxygen is indicated and will help. The Abernethy trial of sustained-release morphine for refractory dyspnoea (BMJ 2003) showed that low-dose oral morphine relieves breathlessness in advanced disease [3], and he is already on morphine — I would ensure his background and breakthrough morphine are adequate. I would add non-pharmacological measures: sit him upright and leaning forward, a fan to the face, pursed-lip breathing, and carer education. The oxygen would be continued for the hypoxaemia; if the breathlessness persists after drainage and he becomes non-hypoxaemic, I would not expect additional oxygen to help and would rely on the morphine and the non-pharmacological measures.

Pain assessment and optimisation (3 marks): [1]

He is on sustained-release morphine 30 mg twice daily (60 mg per 24 hours) with 10 mg immediate-release breakthrough (which is one-sixth — correct). He uses 3 to 4 breakthrough doses a day, which means his total opioid use is around 90 to 100 mg per 24 hours — he is under-dosed for his background pain. I would increase the sustained-release morphine to 60 mg twice daily (covering the background plus breakthrough use) and recalculate the breakthrough dose to 20 mg (one-sixth of 120 mg). I would characterise the chest-wall pain — if it has a neuropathic component (burning, shooting, allodynia in a dermatomal distribution from chest-wall invasion), I would add a gabapentinoid (gabapentin, titrated) or dexamethasone for perineural oedema. I would confirm the laxative is adequate (senna 15 mg nocte plus macrogol may need up-titration) — opioid-induced constipation is universal and tolerance never develops, so the stimulant plus osmotic regimen must be titrated at every review. [1]

Nausea and constipation (3 marks): [1]

The nausea is most likely chemical (opioids, possible hypercalcaemia from bone metastases) compounded by constipation. I would check a corrected calcium and renal function, treat hypercalcaemia with intravenous fluids and a bisphosphonate if present, and review the opioid. The first-line antiemetic for chemical nausea is haloperidol 0.5 to 1.5 mg nocte (a D2 antagonist) or olanzapine 2.5 to 5 mg nocte. For the constipation, I would up-titrate the senna to two to three tablets nocte and add a second macrogol sachet, assess for faecal impaction with a plain abdominal film or rectal examination, and give a phosphate enema or suppository for impaction. A faecal regulator (as a stool-softener, not a stimulant) helps maintain a comfortable stool pattern once the impaction is cleared. [1]

Delirium — seek the reversible cause first (3 marks): [1]

His delirium is multi-factorial. I would systematically seek and treat the reversible precipitants: hypercalcaemia (check and treat), hypoxia (the saturation of 88 per cent is contributing — give oxygen), opioid neurotoxicity (consider rotation to oxycodone if myoclonus or vivid nightmares suggest morphine metabolite accumulation), infection (urinalysis, chest), urinary retention (bladder scan), constipation (already being managed), and metabolic disturbance. I would reorient him, ensure a quiet, well-lit environment with familiar objects and his wife present, and avoid sedating drugs where possible. If the agitation is distressing to him, haloperidol 0.5 mg subcutaneously is first-line; the Hui 2017 trial supports haloperidol as the foundation, with lorazepam added only for refractory agitation [4]. I would avoid a benzodiazepine first-line because benzodiazepines worsen delirium.

Anorexia-cachexia (1 mark): [1]

The 8 kg weight loss reflects the cancer anorexia-cachexia syndrome — a cytokine-mediated metabolic disorder, not simple starvation. I would set the family's expectations honestly that forcing food does not reverse the syndrome. A short trial of dexamethasone 4 mg daily (he is already on it) or megestrol acetate 160 to 320 mg daily (appetite stimulant, limited benefit, thromboembolism risk) may help appetite and wellbeing in the short term [5]. The focus is on comfort feeding (small amounts of preferred foods for pleasure) and on relieving the family's guilt about not feeding enough.

Goals of care, communication, and the wife's distress (4 marks): [1]

This admission marks disease progression despite second-line therapy, and the goals-of-care conversation is central. I would use the SPIKES protocol (Baile 2000) to discuss the progression and the prognosis [2]: a Setting with his wife present, a Perception question (what does he understand), an Invitation (how much does he want to know), Knowledge (honest, plain language, in small chunks, with a warning shot), Emotions (acknowledge, name, validate, allow silence), and a Strategy and Summary (a clear plan, written, with a named contact).

The conversation would explore what matters most to him now — time, comfort, being at home, specific events or family milestones — and would align the medical recommendations with his values. I would discuss a ceiling of treatment (ward-based care, symptom focus, no ICU or further disease-directed therapy if that fits his goals) and a not-for-resuscitation decision framed in the context of his overall illness. I would document the agreed plan and communicate it to the team. [1]

His wife is exhausted and tearful — carer strain is a major driver of admission and of complicated bereavement. I would offer a carer assessment, education about the illness and the symptoms, respite if she needs a break, a community palliative care package, a named contact, and a bereavement risk assessment (anticipatory grief, social isolation, prior mental illness, a death perceived as preventable identify those at risk of complicated grief, who warrant specialist bereavement referral). [1]

SAQ 2 — Anticipatory Prescribing and the Last Days of Life (10 marks, 15 minutes)

Prompt: A 78-year-old woman with end-stage metastatic colorectal cancer is now in her last days of life on the ward. She is bed-bound, barely rousable, taking only sips of fluid, with noisy respiratory secretions and intermittent grimacing. She can no longer swallow tablets. Outline your management of this dying phase, including the recognition of dying, the withdrawal of non-essential medications, the anticipatory prescribing regimen with drug names and subcutaneous doses, and the communication with the family. [1]

Model Answer

Recognition of the dying phase (1 mark): [1]

She has the clinical signs of the last days of life: bed-bound, barely rousable, reduced oral intake, reduced urine output, and noisy respiratory secretions. Recognition triggers a change in the care plan from active treatment to comfort-focused care, in line with the NICE NG31 guideline. [1]

Withdrawal of non-essential medications (1 mark): [1]

I would stop all medications that do not contribute to immediate comfort — any disease-modifying treatment, statins, antihypertensives, oral hypoglycaemics (with a symptom-focused sliding scale if needed), supplements, and antibiotics for a non-symptomatic infection. I would continue the comfort drugs (analgesics, antiemetics, anxiolytics, antimuscarinics), converting them from the oral to the subcutaneous route or a continuous subcutaneous infusion (syringe driver) now that she can no longer swallow. [1]

Anticipatory prescribing — the four medicines (4 marks): [1]

In accordance with NICE NG31, I would prescribe four injectable medicines in advance, available for subcutaneous administration: [1]

1. Analgesic — morphine 2.5 to 5 mg subcutaneously hourly as needed (or oxycodone 2.5 to 5 mg if renal impairment or morphine intolerance), for pain or breathlessness.
2. Sedative or anxiolytic — midazolam 2.5 to 5 mg subcutaneously hourly as needed, for agitation or anxiety.
3. Antiemetic — haloperidol 0.5 to 1.5 mg subcutaneously as needed (or cyclizine 50 mg three times daily if the cause is obstruction), for nausea or delirium.
4. Antimuscarinic — glycopyrronium 200 micrograms subcutaneously every four hours as needed, for the noisy respiratory secretions (the death rattle). Glycopyrronium is preferred over hyoscine hydrobromide because it does not cross the blood-brain barrier and causes less sedation and delirium. [1]

For her noisy secretions specifically, I would start the glycopyrronium early — treatment is more effective when started before the secretions accumulate. I would explain to the family that the noise is from secretions she cannot clear and is usually more distressing to relatives than to the patient, reposition her, and reduce non-essential intravenous fluids. [1]

For her grimacing (possible pain), I would give morphine 2.5 mg subcutaneously and observe the response; if the grimacing settles, the background analgesic requirement is converted to a continuous subcutaneous infusion. If she requires several doses of each anticipatory medicine in 24 hours, I would combine them into a syringe driver (for example morphine 10 to 30 mg, midazolam 10 to 30 mg, haloperidol 5 mg, and glycopyrronium 600 to 1200 micrograms over 24 hours), with the as-needed doses retained for breakthrough. [1]

Communication with the family (3 marks): [1]

I would sit with the family in a quiet space, explain that the patient is in her last days of life in plain language, describe what they can expect (increasing drowsiness, reduced intake, changes in breathing, cool peripheries), reassure them that the symptoms are being actively managed with the anticipatory medicines, and offer them time to be present. I would acknowledge their grief, attend to cultural and spiritual needs (pastoral care if wished), provide a written plan and a named contact, and arrange bereavement support before and after the death. The principle is that good end-of-life care with honest communication and symptom control reduces complicated bereavement in the surviving family. [1]

I would also support the nursing and medical team — the care of a dying patient is emotionally demanding, and a brief team debrief after the death is good practice. [1]