Family Reporting New Confusion in A Dying Patient — Free SCA Practice Case

Character Overview: You are Sharon, daughter of Raymond, who is 68 and dying of prostate cancer that has spread to his bones. This morning he became confused — muddled, not himself, drifting in and out. He has not opened his bowels for three days despite his laxatives, his tummy is bloated and uncomfortable, and he has been very thirsty and passing lots of urine. He has bad bone pain in his legs. He is at home; your mum (his wife) is caring for him and is exhausted and frightened. You are worried and unsure whether he should go to hospital, given he is under palliative care and has a form saying not to resuscitate him. You are anxious and want to do the right thing for him.

Opening Sentence: "Hello Doctor. It's my dad, Raymond — he's got cancer that's spread to his bones and he's being looked after at home now. This morning he's gone all confused, in and out of it, and he's not himself. I'm frightened. I don't know whether he should go to hospital or not."

History if Asked (Data Gathering Phase)

• ●The confusion: "It came on this morning. He's muddled, drifting in and out, not making full sense. It's new — he was clearer yesterday."
• ●Bowels/tummy: "He hasn't been for three days, even with his laxatives. His tummy's bloated and uncomfortable."
• ●Thirst/urine: "He's been really thirsty and passing a lot of water."
• ●Pain: "Bad pain in his leg bones."
• ●The family: "Mum's looking after him and she's shattered and scared. We all are. We just want him comfortable and to do right by him."

ICE — Ideas, Concerns, Expectations

The caller does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Sharon fears the confusion means the cancer is progressing / he is dying now. "I'm scared this means the cancer's taking over and he's slipping away."
• ●Concerns: Her dominant concerns are his comfort and distress, whether hospital is right or wrong given his palliative status, and her mother's exhaustion. "I want him comfortable, and I don't know if hospital is the right thing or the wrong thing for him. And I'm worried about my mum."
• ●Expectations: She wants guidance on what to do and to keep him comfortable. "I want you to tell me what to do, and to make sure he's not suffering."

If Asked — Reversible-Cause and Palliative Screen

The caller answers these only when directly asked (she can relay observations if a clinician/paramedic has attended, or describe what she sees).

• ●If asked about the confusion (onset, fluctuation, alertness): "New this morning, fluctuating, drifting in and out."
• ●If asked about hypercalcaemia features (thirst, passing lots of urine, constipation, bone pain, nausea, drowsiness): "Yes — very thirsty, weeing a lot, constipated, bad bone pain, and drowsy." (Classic hypercalcaemia.)
• ●If asked about bowels / signs of obstruction (vomiting, distension, absolute constipation): "No vomiting. Bloated and not opened his bowels for three days."
• ●If asked about infection (fever, cough, urinary symptoms, pain passing urine): "No fever that I've noticed, no cough, no obvious water infection."
• ●If asked about urinary retention (not passing urine / distended bladder): "No, he's passing plenty of urine, if anything more."
• ●If asked about opioid use / recent changes / medication: "Just his usual morphine when he needs it — no big change."
• ●If asked about oral intake / dehydration: "He's drinking a bit but seems dry, and he's thirsty."
• ●If asked about the DNACPR / advance care plan / his known wishes: "There's a form saying not to resuscitate him. We've never had a proper conversation about what he'd want otherwise, or about hospital."
• ●If asked about the wife/carer coping: "Mum's exhausted and frightened, doing it all."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains new confusion may have a reversible cause: "So it might not just be him dying — there could be a cause you can treat, like the calcium?" (The tested point is recognising reversible causes of confusion in a dying patient, here hypercalcaemia.)
• ●If the Doctor discusses assessment/admission vs home care in the palliative context: "Would he have to go to hospital? Is that the right thing for him, given everything?" (The tested point is a shared decision balancing reversible-cause treatment against the palliative context and his/the family's wishes.)
• ●If the Doctor focuses on comfort and symptom control: "The main thing is he's comfortable and not in pain or distressed. Can you help with that?" (The tested point is a comfort-focused plan — pain, agitation, constipation — with the family.)
• ●If the Doctor raises advance care planning: "We've never talked about what he'd want. Should we?" (The tested point is sensitively opening advance care planning.)
• ●If the Doctor addresses carer support: "And is there help for my mum? She can't keep doing this alone."