Palliative Care Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"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, right chest-wall pain, nausea, constipation, new agitation, and an 8-kilogram weight loss over 3 months. [1]

His past history includes ischaemic heart disease, hypertension, and a 50 pack-year smoking history. His medications are sustained-release morphine 30 mg twice daily, immediate-release morphine 10 mg as needed, senna, macrogol, and dexamethasone 4 mg daily. [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, and is intermittently disoriented. His CT chest shows a large right pleural effusion and progressive pulmonary metastases. His wife is present and is exhausted and tearful. [1]

His main problems are:

1. Refractory breathlessness with a large right pleural effusion — the most immediately reversible problem
2. Suboptimally controlled chest-wall pain on an under-dosed opioid regimen
3. Nausea and constipation — opioid-related and possibly hypercalcaemia-related
4. Acute delirium — multi-factorial, with reversible precipitants to be sought
5. Cancer anorexia-cachexia syndrome
6. Progressive disease refractory to second-line therapy
7. Carer strain in his wife, and goals-of-care decisions [1]

My integrated plan is to drain the right pleural effusion immediately (intercostal catheter, with pleurodesis or an indwelling pleural catheter if it recurs), give supplemental oxygen for his hypoxaemia, and optimise his background analgesia by increasing the sustained-release morphine to 60 mg twice daily and recalculating the breakthrough dose to 20 mg. I will characterise the chest-wall pain and add a gabapentinoid if there is a neuropathic component. I will check a corrected calcium and renal function, treat hypercalcaemia if present, and start haloperidol for the chemical nausea while up-titrating the senna and macrogol for the constipation. I will systematically seek and treat the reversible precipitants of his delirium, use haloperidol first-line for any distressing agitation, and avoid benzodiazepines first-line. I will involve the specialist palliative care team alongside the oncology team, have a goals-of-care conversation using the SPIKES protocol with his wife present, document a ceiling of treatment and a not-for-resuscitation decision aligned with his values, and support his wife with a carer assessment, respite, and a bereavement risk assessment." [1]

Examiner probing questions and model answers

Q1: "You mentioned increasing his morphine to 60 mg twice daily. How did you calculate that, and what is the new breakthrough dose?" [1]

"He is currently on 30 mg twice daily, which is 60 mg per 24 hours, and he uses 3 to 4 breakthrough doses of 10 mg a day — that is another 30 to 40 mg, so his total opioid use is around 90 to 100 mg per 24 hours. His background dose of 60 mg is under-covering him. I would increase the sustained-release morphine to 60 mg twice daily — that is 120 mg per 24 hours, covering his background plus his usual breakthrough use. The new breakthrough immediate-release dose is one-sixth of the total 24-hour long-acting dose — one-sixth of 120 mg is 20 mg. I would recalculate the breakthrough dose every time the background dose changes, and I would review him within 24 hours. I would also confirm that his stimulant laxative (senna) plus osmotic (macrogol) regimen is titrated up, because opioid-induced constipation is universal and tolerance never develops, and the constipation is likely contributing to his nausea." [1]

Q2: "His oxygen saturation is 88 per cent. Would you give oxygen? And if his breathlessness persists after you drain the effusion, what is your pharmacological first-line?" [1]

"Yes — at 88 per cent on room air he is hypoxaemic, and supplemental oxygen is indicated and will help both his oxygenation and his breathlessness. The Abernethy trial (BMJ 2003) established 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 — oxygen is reserved for the hypoxaemic patient. After I drain the effusion, if he becomes non-hypoxaemic but remains breathless, I would not expect additional oxygen to help, and I would rely on the morphine (which he is already on) plus non-pharmacological measures — sitting him upright and leaning forward, a fan to the face, pursed-lip breathing, and carer education. A benzodiazepine such as lorazepam 0.5 mg sublingually would be added only if anxiety is a prominent component, because benzodiazepines treat the anxiety, not the breathlessness itself." [1]

Q3: "How would you approach the goals-of-care conversation, and how would you break the news that his disease is progressing?" [1]

"I would use the SPIKES protocol of Baile (The Oncologist 2000). Setting — a quiet room, his wife present, time set aside, interruptions minimised. Perception — I would ask what he already understands: 'Tell me what you understand about your illness and what the oncology team has told you about the scan.' Invitation — I would ask how much detail he wants. Knowledge — I would give a warning shot ('I'm afraid the news is not what we hoped for'), then deliver the information that the cancer has progressed despite the immunotherapy, in plain language and in small chunks, with pauses to check understanding. Emotions — I would acknowledge and name the emotion, validate it, and allow silence: this is the step most often skipped and the most important. Strategy and Summary — I would agree a clear plan, give a written summary, name a single contact, and arrange follow-up. The goals-of-care conversation is not a single event — I would explore what matters most to him now (time, comfort, being at home, family milestones), align the medical recommendations with his values, propose a ceiling of treatment and a not-for-resuscitation decision framed in the context of his overall illness, document the agreed plan, and review it regularly." [1]

Q4: "He becomes agitated on the ward. What is your pharmacological approach to his delirium, and what would you avoid?" [1]

"First I would seek and treat the reversible precipitants — hypercalcaemia, hypoxia, opioid neurotoxicity, infection, urinary retention, constipation, metabolic disturbance. The first-line drug for delirium in palliative care is haloperidol 0.5 to 2 mg subcutaneously or orally, repeated as needed. The Hui 2017 randomised trial (haloperidol plus lorazepam versus haloperidol alone for agitated delirium in advanced cancer) supports haloperidol as the foundation, with lorazepam added only for refractory agitation. What I would avoid is a benzodiazepine first-line — benzodiazepines paradoxically worsen delirium and are reserved for alcohol or benzodiazepine withdrawal, or for terminal agitation refractory to an antipsychotic. If his agitation is from opioid neurotoxicity — for example if he has myoclonus, vivid nightmares, or sedation with accumulation of morphine-6-glucuronide in renal impairment — I would rotate the opioid to oxycodone rather than simply escalating the haloperidol." [1]

Q5: "When would you consider methadone, and what are the cautions?" [1]

"Methadone is reserved for refractory cancer pain or neurotoxicity from other opioids that has not responded to standard rotation and adjuvants, and its initiation requires specialist input. It is unique because it combines mu-receptor agonism with NMDA antagonism and noradrenaline and serotonin reuptake inhibition, giving it efficacy in neuropathic and opioid-resistant pain. The cautions are the long and variable half-life (8 to 75 hours) causing accumulation and delayed toxicity, the variable and dose-dependent equianalgesic ratio with morphine (the rotation ratio varies from 4:1 at low morphose doses to 12:1 or higher at high doses), QT prolongation requiring a baseline and periodic ECG, and CYP3A4 and CYP2B6 drug interactions. The Bruera 2004 trial established methadone as a viable first-line strong opioid, though morphine remains the global default. In a general-physician setting I would not initiate methadone myself — I would refer to the specialist palliative care or pain team." [1]

DCE Short-Case Viva — 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 discuss your management." [1]

Candidate's assessment routine (narrated)

"I would begin by confirming her identity, introducing myself, ensuring she is comfortable and not in acute distress, and asking permission to ask about her symptoms. I would use a structured symptom inventory rather than an open question, because palliative patients often under-report symptoms unless asked directly. [1]

For pain, I would use the SOCRATES framework — Site, Onset, Character, Radiation, Associations, Time course, Exacerbating and relieving factors, and Severity on a 0 to 10 scale. I would specifically ask about the character: a somatic pain (sharp, well-localised, worse on movement) suggests bone or soft tissue; a visceral pain (deep, poorly localised, may be referred) suggests an organ; a neuropathic pain (burning, shooting, electric, allodynia, in a nerve or dermatomal distribution) suggests nerve infiltration or compression. I would ask whether the pain wakes her, limits her movement, or prevents her coughing — a functional assessment. I would review her current analgesic regimen: the background opioid, the breakthrough dose and how often she uses it, the adjuvants, and whether she has side effects. [1]

For breathlessness, I would ask about the intensity at rest and on exertion on a 0 to 10 scale, the pattern (constant, episodic, on exertion, nocturnal), the impact on activities and on her mood, and any associated symptoms (cough, sputum, chest pain, orthopnoea). I would check her oxygen saturation and examine for reversible contributors — a pleural effusion, consolidation, wheeze, ascites, anaemia. [1]

Finally, I would ask about her other symptoms — nausea, constipation, appetite, sleep, mood — and about her understanding and her goals. A structured symptom inventory takes five minutes and reveals far more than 'How are you?'." [1]

Presentation template (model answer)

"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. It wakes her at night. She is on sustained-release morphine 30 mg twice daily with 10 mg immediate-release for 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. There is no clear neuropathic component. [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 — consistent with 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 (covering her background plus breakthrough use) and recalculate the breakthrough dose to 20 mg — one-sixth of the total 24-hour dose. I would add an NSAID (if not contraindicated) for the bone pain, confirm the laxative regimen is adequate, and consider palliative radiotherapy to the painful bone metastases. For the breathlessness, I would arrange a chest X-ray or CT to confirm the effusion and drain it if symptomatic; her oxygen 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. I would discuss her goals of care and involve the palliative care team." [1]

Examiner 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 management. 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 or tricyclics for neuropathic pain, NSAIDs or dexamethasone or bisphosphonates 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 to effect, no fixed maximum), and with attention to detail (always a laxative with an opioid). This patient is on Step 3 — she is on 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." [1]

Q: "When would you rotate her opioid, and how?" [1]

"I would rotate her opioid if she had unmanageable side effects on morphine (neurotoxicity — myoclonus, vivid nightmares, delirium from morphine-6-glucuronide accumulation in renal impairment), or if escalating the dose failed to control the pain. The method is: calculate the total 24-hour dose and convert to oral morphine equivalents using the published ratios (oral morphine 30 mg equals parenteral morphine 10 mg equals oral oxycodone 20 mg equals parenteral oxycodone 10 mg equals transdermal fentanyl approximately 12 micrograms per hour); reduce the calculated equivalent by 25 to 50 per cent for incomplete cross-tolerance; choose the new opioid and route; give breakthrough immediate-release at one-sixth of the new daily dose; and reassess within 24 hours. A common rotation is morphine to oxycodone or to transdermal fentanyl; rotation to methadone requires specialist input because of the variable equianalgesic ratio, accumulation, and QT prolongation." [1]

Q: "What is the most important non-pharmacological measure you would teach this patient for her breathlessness?" [1]

"Positioning — sitting upright and leaning forward over a table, to use the accessory muscles and the diaphragm to best effect. Combined with a fan directed to the face (the cool airflow reduces the perceived work of breathing through trigeminal afferents) and pursed-lip breathing, these simple measures are as important as any drug. I would teach them to her and her family, because they can be used at any time and they return a sense of control to the patient. Carer education reduces the panic that drives the breathlessness-anxiety-breathlessness cycle, and a calm family member at the bedside is itself therapeutic." [1]