Lung Cancer Whose Morphine Is Making Him Drowsy and Muddled — Free SCA Practice Case

Character Overview: You are Moira Dunmore, a 70 year old retired school secretary, ringing about your husband Alasdair, who is 72. You live in a flat near the harbour. Alasdair was a marine engineer, a quiet, independent man who hates being fussed over. Six months ago he was diagnosed with lung cancer that has spread to his ribs and spine. He has chemotherapy at the cancer centre every three weeks. You give him all his tablets from a dosette box and a list pinned to the fridge. Your daughter Fiona lives 40 minutes away and rings every evening. You are capable and polite, at the kitchen table with the bedroom door open. You keep your voice steady, but it wavers when you talk about the doses. You never use the words "toxicity", "overdose" or "kidney failure". You do not name any diagnosis for what is happening, and you cannot say why it has started. You do not examine Alasdair during the call; if asked, you can count his breaths from the doorway and report.

Opening Sentence: "Hello, doctor, thank you for ringing back. It's about my husband, Alasdair Dunmore. He's been dreadfully sleepy and muddled since last night, he says there are people in the corners of the room, and his hands keep jumping. I don't know what to do."

History if Asked (Data Gathering Phase)

• ●Sleepiness: "Drowsy for about three days, but yesterday evening it got much worse. Today he's slept nearly all morning. I can wake him if I speak loudly or touch his arm, he answers, and then he drifts off mid sentence."
• ●Muddle: "He called me by his mother's name this morning and asked what ship we were on. Usually he's sharp as a tack."
• ●Seeing things: "He keeps looking at the corner by the wardrobe and says two small men in caps are standing there. Last night it was people at the foot of the bed. He's puzzled rather than scared, he said, 'Moira, there's nobody there, is there?'"
• ●Twitching: "His hands and arms jerk, mostly as he's dozing off, like a tiny electric shock. Legs a little too. Quick jumps, then it stops. No fits, nothing stiff or shaking for minutes."
• ●Breathing: "A bit snuffly. I counted this morning, about fifteen a minute, no long pauses, lips a normal colour. He's not struggling."
• ●When it started: "It began a few days after his morphine went up, six days ago. A little worse each day, and last night he got confused."
• ●Pain: "His pain has been better since the increase. Before it was six or seven out of ten in his ribs and back, and he'd cry out turning over. Now he says it's a two."
• ●What he takes: "The slow release morphine, a thirty and a fifteen together, twice a day. I tick them off. He's also had the liquid morphine, five milligrams, about four times yesterday and three the day before. Before the increase it was once or twice a day."
• ●Eating and drinking: "Chemotherapy was twelve days ago. He was sick for two days after it, as always, and it's been hard to get anything into him since. Toast, sips of tea, maybe half a cup of squash yesterday. Hardly any proper drink for about three days."
• ●Passing water: "Very little. This morning on the commode it was a small amount, dark like strong tea."
• ●Bowels: "Not for five days. He's missed his senna the last two nights, too sleepy to swallow it. No cramps, and no vomiting since the weekend."
• ●Thirst and tummy: "Very thirsty with a dry mouth, but he won't drink much because he's so tired."
• ●Headache, weakness, speech: "No headache that he's mentioned. His speech is slow because he's drowsy but not slurred, his face looks the same, and he moves both arms and legs."
• ●Fever or chest: "He doesn't feel hot, his cough is no worse, and he hasn't complained of burning when he passes water."
• ●Fall: "No falls. He hasn't been out of bed except to the commode."
• ●New medicines: "No, just what's on the list, nothing from the chemist."

Ideas, Concerns, Expectations

Gating note: Moira does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for from the call.

• ●Ideas: She thinks the cancer has spread to his head, because he has been muddled and seeing things, and a lady at the cancer centre once mentioned that could happen. At the back of her mind she wonders whether the morphine is doing it, but she is afraid to say so in case someone takes it away. "I thought maybe it's gone to his brain. And I did wonder about the morphine, but I didn't like to say because he needs it, doesn't he?"
• ●Concerns: She is frightened that she gave him too much, because she gave the new doses. She worries that his pain will return if the morphine is lowered, and that he is dying. She is afraid he will be taken into hospital, because he made her promise he would not go back. "Did I do this? I gave him exactly what was written. And I couldn't bear him in agony again. He made me promise, no more hospitals."
• ●Expectations: She hopes someone will come to the house so he is not moved, and wants to know whether to keep giving the tablets. "Can someone come to see him? And should I give him his tablets tonight or not? I don't want to get it wrong."

If Asked: Medical History and Medications

Gating note: Moira answers each of these plainly when the doctor asks about it.

• ●Cancer: "Lung cancer, found six months ago. It's in his ribs and back bones. Chemo every three weeks, next due in nine days. The oncologist said it's not curable but treatable."
• ●Other health problems: "COPD, and his blood pressure is a bit high. Nothing else. No diabetes and no kidney problems that I know of."
• ●Medicines: "Slow release morphine twice a day, liquid morphine when he needs it, senna at night, paracetamol four times a day, ramipril in the morning, and his inhaler. I gave the ramipril this morning."
• ●Allergies: "None."
• ●Support from the palliative team: "Janet, the palliative nurse, visits most weeks. She suggested putting the morphine up. I have her number but haven't wanted to bother anyone."
• ●Plans for his care: "There's a form in the folder. It says he'd like to be at home and not be resuscitated, and that hospital is fine if something can be fixed quickly. But he told me he doesn't want it if it's only the end."

Social History and Lifestyle Impact

• ●Home: A hospital bed is in the bedroom. Moira manages the tablets and the commode but is exhausted, with about four hours of sleep a night.
• ●Family: Fiona could stay tonight if asked.
• ●Before this: Up and dressed most days, doing the crossword by the window, walking to the shop with his stick.
• ●Availability today: Moira is at home all day and could let someone in.

If Asked: Associated Symptoms

Gating note: Moira answers these only when asked. Every one is negative unless stated.

• ●If asked about a swollen tummy or a full bladder: "He doesn't seem uncomfortable. He's passing small amounts."
• ●If asked about fits or collapse: "No, he's always woken up."
• ●If asked about pupils: "They look very small, the black bit in the middle, but the light in the room is dim."
• ●If asked about patches, alcohol or sleeping tablets: "No."

Responses to Management (The Negotiation Phase)

• ●If the doctor says the morphine should be paused or lowered:
  • ●Reaction: Alarmed. "But what about his pain? He was in agony last week." She accepts if told that the dose is more than his body can clear at the moment, that the pain relief will be adjusted rather than stopped, and that someone will help if the pain returns. She asks, "Do I give the liquid morphine if he asks for it tonight?" and "Should I stop everything?"
• ●If the doctor suggests a visit, blood tests or admission:
  • ●Reaction: She is relieved by a visit today. "Yes please, can someone come this afternoon?" If hospital or hospice admission is suggested, she hesitates: "He made me promise." She accepts a short stay if it is explained as a way to get him back home, with the palliative team involved, and asks, "Will he be able to come home?"
• ●If the doctor explains what is causing it:
  • ●Reaction: She asks, "Is it his brain, or is it the tablets?" and "Is it my fault?" If told it looks like a side effect of the morphine, that his kidneys may be struggling because he is so dry, and that this can often be put right, she cries a little: "I thought I'd poisoned him." She asks whether the confusion will clear.
• ●If the doctor explains the cause or the plan (or, if not yet raised by the end of the plan, as a last question):
  • ●Reaction: She asks quietly, "Is this the beginning of the end? Please be honest with me." If the answer is evasive, she says, "That's not an answer." If told that this particular problem is often reversible but his cancer is serious and the doctor cannot say how long, she says, "Thank you for not just telling me it's fine. I needed to hear that."
• ●If the doctor gives safety netting or what to do tonight:
  • ●Reaction: Wants specifics. If vague, such as "ring if it gets worse": "Worse how? What exactly would I look for?" She repeats back clear instructions about when to ring 999, who to ring out of hours and what to do with the next tablets. She asks, "What if he won't wake? Would I be wasting their time?" She will ask Fiona to stay tonight.
• ●If the doctor offers support for her:
  • ●Reaction: Surprised and tearful. "Nobody's asked how I am." She accepts the offer of the nurse's number and says she will ring Janet and Fiona.