District Nurse Requesting An Antiemetic — Free SCA Practice Case
District Nurse requesting an antiemetic
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Arthur Pendelton
Age
76 years
Consultation Type
TelephoneAge
76
Caller
Sarah Jenkins (Community / District Nurse)
Situation
Telephone Consultation.
Reason for Encounter
"Telephone call from the District Nurse who is currently at the patient's home. She is requesting a prescription for Metoclopramide for a palliative patient who is vomiting."
Medical Records (Arthur)
- ●PMH: Colorectal Cancer with widespread peritoneal metastases (palliative, end-of-life care pathway), Hypertension, Ischaemic Heart Disease.
- ●Medications: Syringe Driver (CSCI) in situ: Morphine Sulfate 30mg / 24 hours.
- ●PRN SC medications: Morphine 5mg (up to 4-hourly).
- ●Oral: Ramipril 2.5mg, Bisoprolol 2.5mg.
- ●Allergies: NKDA.
Recent Notes
- ●1 week ago: Discharged from oncology. Transitioned to best supportive care at home. Prognosis: short weeks.
Patient Script
For the friend playing the patient role
Character Overview: You are Sarah, a highly experienced but currently rushed District Nurse. You are at Arthur Pendelton's house. Arthur is bedbound and declining rapidly. Today, he is highly distressed. Since last night, he has been vomiting large amounts of foul-smelling fluid. Arthur's daughter, Chloe, is the primary carer and is in a state of absolute panic. She is terrified he is starving to death. Every time he vomits, she tries to force him to drink high-calorie soup, which he immediately brings back up. Because your immediate goal is to "get his stomach moving again" so he can keep some fluids down, you are calling the GP to request Metoclopramide for his syringe driver. You are focused on the vomiting and will not volunteer information about his abdominal pain, his lack of bowel movements, or Chloe's force-feeding unless the doctor specifically takes a structured clinical history. If the doctor asks to speak to Chloe directly on this call, you will explain that she is far too upset and physically occupied with caring for her father to come to the phone right now.
ICE — Ideas, Concerns, Expectations
These reflect both Sarah's clinical perspective and Chloe's lay perspective. They surface only if the doctor directly explores them — Sarah does not volunteer ICE unprompted.
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Ideas: Sarah suspects the vomiting is related to his overall decline — possibly the cancer causing a stomach upset or the morphine making him nauseous. She has not specifically considered a mechanical bowel obstruction. If asked what she thinks is going on: "Honestly, I thought it was either the morphine upsetting his stomach or just part of things progressing. I hadn't really thought beyond that — I just wanted to get something on board to stop the sickness." Chloe's idea, if relayed: "Chloe thinks he's just not eating enough and that's why he's being sick — she keeps saying if she could just get some nutrition into him, he'd perk up."
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Concerns: Sarah is concerned about Arthur's distress and comfort — he is visibly suffering and she feels under pressure to act quickly. She is also worried about Chloe's state of mind. If asked: "I'm worried about both of them, to be honest. Arthur is really suffering — I've never seen him this distressed. And Chloe is falling apart. She's barely slept and she's convinced she's failing him." Chloe's main fear, if relayed: "She keeps saying she thinks he's starving to death. That's what's driving her to push the soup."
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Expectations: Sarah wants a prescription she can draw up immediately to stop the vomiting so the situation is manageable. If asked: "I just need something I can put in the driver now to settle the vomiting, so he's comfortable and Chloe can see he's not suffering. That's my priority."
Consultation Flow & Responses:
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The Opening:
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If the doctor asks an open question: "Hi Doctor, it's Sarah, the District Nurse. I'm over at Arthur Pendelton's. He's been vomiting very heavily since last night, bringing up absolutely everything. I was hoping you could prescribe some Metoclopramide to add to his syringe driver to get his stomach moving so he can keep some soup down?"
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Data Gathering (The Layers):
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Layer 1: The Nature of the Vomit (Checking for Feculent Vomit):
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"It's large volumes. To be honest, it smells awful, almost fecal, and it's dark brown. It's just pooling in his mouth."
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Layer 2: Abdominal Symptoms & Pain (The Pivot to MBO):
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If asked if he is in pain: "Yes, he's getting these terrible cramping pains. He says it comes in waves, like a severe gripping pain across his tummy. I had to give him a PRN dose of Morphine an hour ago, but it didn't touch the cramps."
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If asked about distension/examination: "His abdomen looks very bloated today. It's tympanic when I tap it."
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Layer 3: Bowel Habit (Confirming the Blockage):
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If asked when he last opened his bowels: "Let me ask Chloe... she says he hasn't had his bowels open for six days, and he hasn't passed any wind since yesterday morning."
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Layer 4: Psychosocial / Family Distress:
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If asked how the daughter is coping or what she is feeding him: "Chloe is in a panic. She thinks he's going to starve to death. She keeps forcing him to drink Complan and soup, but it just makes the vomiting and the cramps worse. She just wants the sickness stopped so he can eat."
If Asked — Medical History and Medications
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If asked about his current syringe driver or what's already in it: "He's got a continuous subcutaneous infusion running — Morphine Sulfate 30mg over 24 hours. It's been managing his background pain reasonably well up until yesterday, but these cramps are something different — the PRN Morphine 5mg sub-cut didn't touch them."
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If asked about his heart medications or whether he's still taking oral tablets: "He's prescribed Ramipril 2.5mg and Bisoprolol 2.5mg, but to be honest, he hasn't been able to keep anything oral down since last night. I don't think he's had either tablet today."
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If asked about his cancer diagnosis or prognosis: "It's colorectal cancer with peritoneal metastases. He was discharged from oncology about a week ago — they've stopped all active treatment. The team said we're looking at short weeks. He's on the end-of-life care pathway."
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If asked about his heart conditions and whether they could be relevant: "He has a history of ischaemic heart disease and hypertension, but they've been stable. This doesn't look cardiac to me — it's definitely abdominal."
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If asked about allergies: "No known drug allergies."
Social History and Lifestyle Impact
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If asked about his home situation or who is looking after him: "He's at home — that's where he wanted to be. Chloe, his daughter, is his main carer. She moved in about three weeks ago when he came out of hospital. She's doing everything — washing, feeding, turning him. There's no other family nearby. We've got a care package — I come in daily, and there's a carer morning and evening — but overnight it's just Chloe."
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If asked about how things have been since discharge: "The first few days were manageable. He was sleepy but comfortable. But the last 48 hours have been a different story — the vomiting has completely overwhelmed everything. Chloe hasn't slept. The house smells dreadful and she's trying to keep on top of the washing and the sick bowls while watching her dad suffer. She told me this morning she doesn't know how much more she can take."
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If asked about advance care planning or preferred place of death: "Yes, it's all documented. He wants to stay at home. He definitely does not want to go back into hospital. That's very clear."
If Asked — Associated Symptoms
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If asked about blood in the vomit: "No fresh blood — it's that dark brown, fecal-smelling fluid. No red blood mixed in."
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If asked about fever or signs of infection: "No, he doesn't feel hot. I checked his temperature this morning — it was 36.4. No signs of infection that I can see."
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If asked about urine output: "It's reduced. Chloe says he's only passed a small amount of dark urine since yesterday. He's clearly dehydrated."
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If asked about his conscious level or confusion: "He's drowsy but rousable. He knows who I am and where he is. No confusion as such — just exhausted and in pain."
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If asked about shortness of breath or chest symptoms: "No, his breathing is fine. No cough, no chest pain. It's all abdominal."
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If asked about any rectal bleeding or blood per rectum: "No, nothing like that. He hasn't passed anything at all — no stool, no blood, no wind."
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If asked about leg swelling or DVT signs: "No, his legs look the same as usual. No new swelling."
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If asked about jaundice or skin colour changes: "No, he's not jaundiced. He looks pale and washed out, but no yellowing."
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If asked whether the morphine dose was recently increased: "No, the 30mg over 24 hours has been the same since he came home from hospital. This vomiting started suddenly last night — it's not been a gradual thing."
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If asked about whether he could have a loaded rectum or faecal impaction: "I haven't done a PR exam — I didn't want to put him through that without discussing it first. But given he's got peritoneal mets, I'd be thinking more about an obstruction higher up than simple constipation, wouldn't you?"
Negotiation & Collaborative Management Plan:
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If the Doctor agrees to prescribe Metoclopramide without taking a history:
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Reaction: "Brilliant. I'll draw that up and put it in the driver now." (Candidate critically fails for prescribing a prokinetic in a bowel obstruction, risking bowel perforation and extreme agony).
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If the Doctor diagnoses a Bowel Obstruction and suggests Hyoscine Butylbromide (Buscopan) + Haloperidol:
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Reaction: "Ah, a mechanical blockage. That makes total sense with the colicky cramps. So Metoclopramide would force the gut against the blockage and make it worse. Yes, I'm happy to use Buscopan to dry up the secretions and stop the spasms. And Haloperidol for the central nausea? Perfect."
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If the Doctor asks to speak to Chloe directly on the phone now:
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Reaction: "Honestly, Doctor, she's a mess right now. She's crying and physically holding the bowl for him. She's too overwhelmed to take in medical information at this exact second." (Doctor must adapt and offer a planned call-back).
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If the Doctor offers to call Chloe back in an hour or two once things have settled:
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Reaction: "That would be incredibly helpful. Once I've given him the injection and he's settled to sleep, I'll tell her to expect your call. If you could explain the medical reasons why the food is making it worse, it would take the guilt off her shoulders."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising Malignant Bowel Obstruction: The Clinical Triad
Malignant Bowel Obstruction (MBO) occurs when tumour or peritoneal metastases physically occlude the bowel lumen or freeze bowel segments in place. In advanced abdominal and pelvic cancers, it is a common and life-threatening complication.
- ●The diagnostic triad is: feculent (dark brown, faecal-smelling), large-volume vomiting + absolute constipation with absent flatus + colicky (wave-like, cramping) abdominal pain.
- ●Each element is individually significant; together they are virtually diagnostic of mechanical obstruction and must be actively sought — they will not always be volunteered.
- ●Feculent vomiting indicates that bowel contents proximal to a distal obstruction are refluxing upwards. Large volume and effortless character distinguish this from opioid-induced nausea, which typically produces smaller amounts and is not faecal in odour.
- ●Absolute constipation — no stool and no flatus — is the cardinal sign of complete mechanical obstruction. Flatus absence is the more sensitive marker and must be asked about directly.
- ●Colicky pain in MBO is caused by the distended bowel attempting to squeeze against the obstruction. It is partially opioid-resistant: morphine will blunt the background pain of peritoneal disease but will not relieve smooth muscle spasm. Failure of PRN opioid to control pain that is wave-like in character should prompt reassessment of the pain mechanism.
Why Metoclopramide Is Contraindicated — and Why It Gets Prescribed Anyway
This is the defining safety point of this case.
- ●Metoclopramide and Domperidone are prokinetics. They stimulate gastric emptying and peristalsis by acting on dopamine and 5-HT4 receptors in the gut wall.
- ●In the presence of a mechanical obstruction, a prokinetic forces the bowel to contract forcefully against a closed lumen. This dramatically worsens colicky pain and carries a significant risk of bowel perforation.
- ●The error happens because the presenting complaint — vomiting — is the same symptom prokinetics are routinely used to treat. The prescribing trap is bypassed only by taking a structured history before reaching for a solution.
- ●Metoclopramide is appropriate in gastric stasis (e.g. autonomic failure, large ascites compressing the stomach) where there is no mechanical blockage distally. The drug is not inherently dangerous — the danger is using it without first excluding obstruction.
Palliative Symptom Control in MBO: Choosing the Right Agents
Effective palliation of MBO requires targeting the underlying mechanisms of each symptom rather than treating symptoms generically.
Antisecretory and Antispasmodic: Hyoscine Butylbromide (Buscopan)
- ●Hyoscine Butylbromide is an antimuscarinic agent and the cornerstone of MBO management. It has two critical actions: it reduces gastrointestinal secretions (directly decreasing the volume of feculent vomit) and it relaxes bowel smooth muscle (relieving colicky spasm).
- ●It is administered via continuous subcutaneous infusion (CSCI) in the syringe driver. Typical starting dose is 60mg/24 hours, with PRN SC boluses of 20mg available for breakthrough spasm.
- ●It does not cross the blood-brain barrier in significant amounts and therefore does not cause central sedation — an important advantage in a patient who may wish to remain alert.
Central Antiemetic: Haloperidol
- ●Haloperidol is the antiemetic of choice in MBO because it acts centrally at the Chemoreceptor Trigger Zone (CTZ) via dopamine D2 receptor antagonism, without stimulating gut motility.
- ●Typical CSCI dose: 1.5–3mg/24 hours in palliative care. It is compatible with morphine and hyoscine butylbromide in most syringe driver combinations.
- ●Cyclizine (antihistaminic, acts at the vomiting centre) is an alternative but is prone to crystallisation in the syringe driver when mixed with high-dose opioids — requiring careful nursing review of compatibility before use.
- ●Levomepromazine is a broad-spectrum antiemetic (blocks dopamine, histamine, acetylcholine, and serotonin receptors) used when first-line agents fail or when multi-factorial nausea coexists with agitation. Its significant sedating effect can be advantageous in the actively dying patient.
Analgesic Approach
- ●Do not reflexively escalate the morphine infusion in response to colicky pain before adding hyoscine butylbromide. Smooth muscle spasm is the primary driver; once resolved, the existing morphine background may remain appropriate.
- ●Once antispasmodic is established, reassess background pain and titrate morphine if needed for residual peritoneal or somatic pain.
De-prescribing in the Last Days of Life
Active de-prescribing is a core clinical skill in end-of-life care and must not be overlooked.
- ●Medications that serve no purpose in the context of imminent death — and cannot be absorbed — must be stopped. In Arthur's case: Ramipril and Bisoprolol should be discontinued immediately.
- ●The rationale is threefold: the oral route is no longer viable; the cardiovascular benefits are irrelevant over a prognosis of days to short weeks; and their continuation risks unnecessary distress during medication administration.
- ●A useful framework: at end of life, continue only medications that are contributing to comfort (analgesia, antiemetics, antispasmodics, anxiolytics, antisecretory agents). Stop everything else.
- ●All ongoing medications must be reviewed for route of administration. In a patient who cannot tolerate anything orally, the subcutaneous route via CSCI or bolus injection is the default.
Anticipatory Prescribing
A clinical escalation event — such as new MBO in an actively dying patient — is the trigger to review whether the anticipatory (just-in-case) medication chart is sufficient for the evolving picture.
- ●Standard anticipatory medications for the dying patient cover five symptom domains: pain, nausea, agitation/distress, respiratory secretions, and breathlessness.
- ●In MBO, ensure adequate PRN provision specifically for colicky pain (hyoscine butylbromide SC) and nausea (haloperidol SC) in addition to existing morphine PRN.
- ●If an anticipatory chart does not exist and the patient is deteriorating rapidly, this is the moment to initiate one — ideally in liaison with the palliative care team.
When to Involve the Palliative Care Team
New MBO in a patient on the end-of-life pathway with peritoneal metastases represents a clinical escalation that warrants specialist palliative input.
- ●Contact the community palliative care team or hospice the same day to ensure specialist advice is available and that the patient is known to the service.
- ●Consider hospice admission if symptom control cannot be achieved at home within a reasonable timeframe, or if the carer situation makes safe home management impossible. This should be framed not as failure but as access to a higher level of specialist symptom control.
- ●Hospice admission does not breach Arthur's wish to avoid hospital — a hospice is a separate, appropriate alternative that should be discussed with both Arthur (if capacity allows) and Chloe.
- ●The palliative care team can also provide direct support to the family and to the district nursing team, which is particularly important given Chloe's level of distress and isolation.
Communicating Eating and Drinking at End of Life
This is one of the most emotionally charged conversations in palliative care. Families who are forcing oral intake in a patient with bowel obstruction are causing direct physical harm, driven entirely by love and fear.
- ●The key explanatory frame: the bowel is blocked. Putting food and fluid in is like running a tap into a blocked sink — it overflows and causes pain. This is physiological, not metaphorical, and families respond to it.
- ●Anticipate and address the fear of starvation: in the terminal phase, hunger as a distressing sensation is diminished. The body's metabolic needs are vastly reduced. The distress Arthur is experiencing is from the obstruction, not from lack of nutrition.
- ●Redirect the carer's impulse to nurture: intensive mouth care — moistening lips with small sponge sticks, applying lip balm, offering ice chips to suck if safe — is now the most meaningful physical comfort Chloe can provide. This reframes her role from one of failure to one of active, loving care.
- ●Plan the call-back to Chloe as a purposeful clinical conversation, not an afterthought. Commit to a specific timeframe (one to two hours, once Arthur is settled after the injection) and frame its agenda clearly to the nurse in advance.
Safety Netting in Acute Palliative Deterioration
Clear escalation criteria must be communicated to the district nurse at the close of the call.
- ●Monitor for: worsening abdominal distension, signs of bowel perforation (sudden severe pain, peritonism, collapse), escalating pain or agitation despite medications, and deteriorating conscious level.
- ●Call back or escalate if: current syringe driver medications are failing to control symptoms within two to four hours of initiation, or if there is any clinical sign of perforation or acute deterioration.
- ●Confirm the out-of-hours palliative care contact number is available to the nurse and to Chloe for overnight cover.
- ●Document the management plan clearly in the patient record, including the de-prescribing decisions and the rationale, so that any clinician covering out of hours has a complete picture.
Mapped to the RCGP curriculum topic: People at the End of Life.
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