Cases/People at the End of Life

Metastatic Bowel Cancer Discussing Ongoing Care — Free SCA Practice Case

Man with metastatic bowel cancer discussing ongoing care

Station Timer

12:00

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

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Thomas Wright

Age

68 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"Patient requested a telephone appointment to discuss a recent hospital letter from his oncologist regarding his ongoing treatment plan."

Medical Records

●PMH: Colorectal Adenocarcinoma with hepatic metastases (diagnosed 2 years ago), Hypertension.
●Medications: Zomorph (Morphine Sulfate SR) 30mg BD, Oramorph 10mg/5ml PRN, Macrogol 1 sachet OD, Ramipril 2.5mg OD.
●Allergies: NKDA.

Recent Notes

●2 days ago: Clinic letter from Medical Oncology uploaded. "Recent CT Chest/Abdo/Pelvis shows disease progression in the liver despite 3rd line palliative chemotherapy. Performance status declining. Discussed options with Mr. Wright, including a potential 4th line palliative regimen versus best supportive care. He asked for time to think. Review in 2 weeks."

Patient Script

For the friend playing the patient role

Character Overview: You are Thomas, a 68-year-old retired postman. You are exhausted. Over the last two years, you have endured surgery, a stoma, and three brutal rounds of chemotherapy. The latest scan showed the cancer is still growing in your liver. The oncologist offered you another round of chemotherapy, but you privately decided the moment you heard the scan results that you are done. The chemo makes you violently sick, you have lost three stone, and you spend most days asleep. However, your wife, Sarah, is terrified of losing you and keeps telling you to "keep fighting" and to "take the new chemo." You booked this telephone call because you trust your GP. You want a medical professional to give you "permission" to stop treatment. You are hiding a deep sense of guilt that you are failing your wife by giving up, and a profound fear that if you say no to the hospital, the doctors will abandon you to die in agony. You will not volunteer your fear of abandonment or the conflict with your wife unless the doctor explores how you are feeling about the news, asks about your support network, or explicitly validates your right to prioritize your quality of life.

ICE — Ideas, Concerns, Expectations

(Actor guidance: Thomas does not raise any of this unprompted. These responses surface only when the candidate directly explores his perspective, beliefs, or worries.)

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Ideas: Thomas does not have a specific theory about why the cancer is progressing — he just knows the chemo has stopped working. "I don't really understand why it's growing again. I thought the chemo was supposed to keep it in check. I suppose my body's just not responding to it anymore."
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Concerns: His deepest concerns are twofold: (1) that stopping treatment means he will be abandoned by the medical system and left to die in uncontrolled pain at home, and (2) that his wife Sarah will see his decision as giving up — as a betrayal of her and the grandchildren. These are already embedded in the script and should surface through Layers 3 and 4.
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Expectations: Thomas is hoping the GP will tell him it is medically reasonable to stop chemotherapy — he wants professional validation that he is not being selfish or foolish. He also wants reassurance that he will still be looked after. "I suppose I just want someone to tell me it's okay to stop. And that someone will still be there when things get worse."

Consultation Flow & Responses:

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The Opening
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If the doctor asks an open question: "Hello Doctor. Thank you for calling. I suppose you've seen the letter from Dr. Harrison at the hospital? The scan wasn't good. The cancer is growing again. He said there's another chemo we could try, but I wanted to talk to you about it first."
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Data Gathering (The Layers)
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Layer 1: Current Symptoms (Verbal Functional Assessment):
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If asked how he is feeling physically: "I'm just so tired. I spend most of the day in the armchair. The pain in my right side is a dull ache, but the Zomorph keeps a lid on it mostly. I'm taking the Oramorph maybe twice a day."
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"I'm not eating much. The thought of food makes my stomach turn."
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Layer 2: Understanding the Prognosis:
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If asked what he understands about the letter: "I know it's incurable. Dr. Harrison was very kind, but I know this new chemo won't cure me. It might just buy me a few extra months."
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Layer 3: The Hidden Dilemma (The Decision):
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If the doctor asks what HE wants to do: You sigh heavily. "Doctor, I can't do it anymore. The last chemo nearly killed me. I want to stop. But Sarah... she's so desperate for me to keep going. She says I have to fight it for the grandkids. I feel like I'm letting her down."
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Layer 4: ICE & The Core Fear (Abandonment) - ONLY REVEAL IF ASKED:
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If the doctor validates his choice to stop or asks what he is worried about:
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Reaction (The Reveal): Your voice cracks over the phone. "Is it okay to just say enough is enough? I'm so scared that if I tell the hospital I'm refusing the chemo, they'll just discharge me and wash their hands of me. Who is going to look after me when the pain gets worse? I don't want to die screaming in agony at home."

If Asked — Medical History and Medications

(Actor guidance: Thomas does not volunteer medication or medical history details unprompted. These responses are for when the candidate specifically asks about his medications or past medical history.)

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If asked about the Zomorph (morphine): "I take one in the morning and one at night. It takes the edge off the ache in my right side. It works alright most of the time, but by late afternoon it sometimes starts wearing off a bit before the next dose is due. That's when I'll take some of the liquid one."
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If asked about the Oramorph (breakthrough pain): "That's the liquid morphine. I keep it by the armchair. I'm using it maybe twice a day — sometimes a bit more if I've had a bad night. It works within about 20 minutes. I measured it out properly like they showed me."
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If asked about the Macrogol (laxative): "Yes, they gave me that because the morphine bungs me up something rotten. I take one sachet a day. To be honest, I'm still not going regularly — maybe every three or four days, and it's hard work when I do. I haven't mentioned it because I thought that was just how it is with these painkillers."
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If asked about the Ramipril (blood pressure): "I've been on that for years for my blood pressure. I don't really think about it — I just take it in the morning. I haven't had it checked in a while, to be honest. It doesn't seem very important compared to everything else."
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If asked about the stoma: "I had the surgery about two years ago — they took part of my bowel out and I had a bag. It was awful at first, but I got used to it eventually. The stoma nurses were very good. It's still working fine, no problems with it."
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If asked about previous chemotherapy: "I've had three lots now. The first one wasn't too bad, but the second and third were horrendous. I was vomiting for days, couldn't eat, couldn't even keep water down sometimes. I ended up in hospital on a drip twice. I've lost about three stone altogether."
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If asked about allergies: "No, no allergies to anything that I know of."

Social History and Lifestyle Impact

(Actor guidance: Thomas will share this naturally in conversation when asked about his daily life, how he is coping, or what his days look like. He does not deliver it as a monologue.)

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Occupation / daily life context: Thomas retired from the Royal Mail five years ago after 40 years as a postman. He used to walk eight miles a day on his rounds and was proud of how fit he was. He and Sarah live in a semi-detached house. They have two grown-up children and four grandchildren. He has a Jack Russell terrier called Biscuit.
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Lifestyle impact of the condition: "I used to take the dog out twice a day — proper walks, not just round the block. Now Sarah has to do it because I can barely get to the end of the street without needing to sit down. The grandkids came over on Sunday and I fell asleep in the middle of playing with them. My youngest granddaughter asked Sarah why Grandad is always sleeping. That broke my heart."
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If asked about his daily routine: "I get up late, sit in the chair, doze off, wake up, try to eat something, can't face it, doze off again. That's my day. I used to be so active. I feel like I'm already half gone."
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If asked about mood or how he is coping emotionally: "Some days I feel alright, like I've accepted it. Other days I sit there while Sarah's at the shops and I just cry. I don't want her to see that. She's got enough to deal with."

If Asked — Associated Symptoms

(Actor guidance: Thomas answers these only when directly asked by the candidate. Keep answers brief and natural.)

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If asked about nausea or vomiting (outside of chemo): "I feel queasy most mornings, but I'm not actually being sick at the moment. Not like when I was on the chemo — that was a different level."
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If asked about bowel habit or stoma output: "The bag's working fine. No blood or anything unusual coming through it. It's just the constipation from the morphine that's a nuisance."
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If asked about jaundice or yellowing of the skin/eyes: "No, nobody's mentioned that. Sarah hasn't said I look yellow or anything."
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If asked about abdominal swelling or bloating: "My belly does feel a bit more swollen than usual, but I thought that was just because I'm not moving around much."
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If asked about breathlessness: "I do get a bit puffed if I try to do anything, like going up the stairs. But I put that down to being so unfit now. I'm not gasping or anything when I'm sitting still."
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If asked about leg swelling: "No, my legs are fine. No swelling."
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If asked about confusion or drowsiness beyond fatigue: "No, my head's clear enough. I'm just exhausted. I know what day it is and all that — I'm not confused."
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If asked about bleeding from anywhere: "No, no bleeding. Nothing in the bag that looks wrong, nothing when I go to the toilet for a wee."
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If asked about fevers or night sweats: "No fevers. I do get a bit sweaty at night sometimes, but I think that might be the morphine. It's not drenching the sheets or anything."
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If asked about weight loss: "I've lost about three stone over the last two years. Most of that was during the chemo. I'm still losing a bit — my trousers are all too big now."
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If asked about his sleep: "I sleep a lot during the day but at night I'm restless. I wake up in the early hours and lie there thinking. That's when the worry is worst."
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If asked about urinary symptoms: "No problems with that. Going normally, no pain, no blood."
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If asked about skin changes or itching: "No itching. No rashes or anything like that."
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If asked about back pain: "No, just the ache in the right side where the liver is. My back's alright."

Negotiation & Collaborative Management Plan

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If the Doctor tries to persuade you to take the chemo or tells you to "discuss it with your oncologist":
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Reaction: Deflated and isolated. "Right. So I just have to keep going back to the hospital then. I thought you might be able to advise me." (Note: Candidate fails for dodging the difficult conversation and failing to provide holistic palliative support).
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If the Doctor validates your choice to focus on quality of life:
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Reaction: Massive relief. "Thank you. Hearing a doctor say it's okay to stop... you have no idea what a weight that takes off my shoulders."
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If the Doctor asks to bring Sarah into the conversation or offers a joint call/visit:
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Reaction: "Would you? If you explained to her that the chemo is doing more harm than good, and that stopping isn't 'giving up', I think she would accept it better from you than from me."
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If the Doctor introduces Advance Care Planning / Hospice / Macmillan support:
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Reaction: "So I won't be abandoned? You and the Macmillan nurses will take over? That's exactly what I want. I want to be at home, with my dog and my wife, comfortable."

Safety Netting / Follow-up

●If the Doctor sets a plan to prescribe anticipatory meds, adjust the analgesia, and arrange a home visit to discuss things with Sarah:
●Reaction: "Thank you, Doctor. I'll take a little extra Oramorph today for the ache, and I'll look forward to seeing you later this week with Sarah."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Transition to Best Supportive Care — Reframing, Not Abandoning

●The transition from active oncological treatment to best supportive care (BSC) is one of the most psychologically fraught moments in a patient's cancer journey; the GP is often the clinician best placed to guide it.
●Affirming capacity and autonomy: A patient with capacity has an absolute right to refuse any treatment, including chemotherapy. The GP should explicitly affirm that declining 4th-line palliative chemotherapy — where evidence of meaningful survival benefit is marginal — is an active, informed, and medically sound decision, not a passive surrender.
●The GP's role as continuity anchor: Patients frequently fear that stopping oncology treatment means being "abandoned" by the medical system. The GP must name this fear directly and counter it: stopping chemotherapy does not mean stopping care — it means shifting the entire focus to keeping the patient comfortable, with the GP coordinating that care.
●Reframing for the patient: Avoid euphemisms. Frame BSC positively: the patient is choosing to protect their remaining time from the toxicity of treatment that is no longer working, and to prioritise quality of life over futile interventions.
●Reframing for the family: Sarah's wish for Thomas to "keep fighting" reflects anticipatory grief and fear of loss, not medical judgement. The GP should acknowledge her distress compassionately while helping her understand that supporting Thomas's autonomous decision is itself an act of love, not defeat.
●Assessing functional status: Verbally establishing the patient's performance status — chair-bound, unable to walk to the end of the street, sleeping through family visits — is essential both to validate the BSC decision and to estimate prognosis. A performance status of ECOG 3–4 supports the clinical judgement that further chemotherapy is unlikely to be tolerated or beneficial.

Palliative Symptom Management — Pain, Constipation, and Nausea

●Opioid titration principle (NICE CKS — Palliative Care: Pain): Thomas is on Zomorph (morphine sulfate SR) 30 mg BD with Oramorph 10 mg/5 ml PRN. If a patient regularly uses ≥2 breakthrough doses per day, the background SR dose is subtherapeutic and should be uptitrated.
●Titration calculation: Total current daily morphine = 60 mg (background) + ~20 mg (2 × Oramorph 10 mg) = 80 mg. New background dose: Zomorph 40 mg BD. The breakthrough dose should be recalculated as 1/6th of the total 24-hour dose (≈13 mg, practically 15 mg Oramorph).
●Opioid-induced constipation (NICE CKS): Every patient on regular strong opioids must be co-prescribed a laxative. Thomas is on Macrogol 1 sachet OD but opens his bowels only every 3–4 days with difficulty — this is inadequate. Management: uptitrate Macrogol to 2 sachets BD, and/or add a stimulant laxative (senna 15 mg ON) to provide both osmotic softening and propulsive motility. Uncontrolled opioid-induced constipation can mimic cancer pain progression and cause significant distress.
●Nausea in advanced malignancy: Thomas's morning nausea with near-total anorexia is a common palliative symptom with multiple potential causes (opioid side-effect, hepatic capsule stretch, gastroparesis, chemical/metabolic). Consider a regular antiemetic: haloperidol 0.5–1.5 mg ON is the preferred first-line antiemetic for chemical/metabolic nausea in advanced cancer with hepatic disease per palliative care guidelines. Metoclopramide 10 mg TDS is appropriate if gastroparesis or functional cause is suspected. Cyclizine is an alternative but should be used cautiously alongside opioids due to additive sedation.

Advance Care Planning, ReSPECT, and Anticipatory Prescribing

●Advance Care Planning (ACP) should be introduced sensitively but proactively once a patient is transitioning to BSC. It is best conducted over more than one conversation; offering a structured home visit — rather than completing by telephone — allows the patient and family to participate together in a familiar, unhurried environment.
●Preferred Place of Care (PPC) and Preferred Place of Death (PPD): Thomas has expressed a clear wish to die at home with his wife and dog. This must be documented, communicated to the MDT, and regularly reviewed — preferences can change as illness progresses.
●ReSPECT (Recommended Summary Plan for Emergency Care and Treatment): A UK-wide process creating personalised recommendations for clinical care in a future emergency where the patient cannot make or express choices. This includes DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions. The GP should explain that completing a ReSPECT form protects Thomas from unwanted interventions — such as hospital admission or resuscitation — that would be inconsistent with his wishes.
●Anticipatory medications ("Just in Case" box) — per NICE NG31 and Gold Standards Framework: Injectable medications prescribed in advance and kept at the patient's home, enabling District Nurses to manage terminal symptoms rapidly without waiting for an out-of-hours GP visit.
●Standard contents: Morphine sulfate SC (pain), Midazolam (agitation/seizures), Hyoscine butylbromide (respiratory secretions), Haloperidol or Levomepromazine (nausea/vomiting).
●Prescribing these proactively communicates to the patient and family that their comfort is planned for, not left to chance — directly addressing Thomas's fear of "dying in agony."

End-of-Life Medication Rationalisation

●As patients approach end of life, the GP should review all medications and stop those that no longer provide net benefit — a process known as deprescribing (NICE NG31).
●Ramipril 2.5 mg OD: Thomas's antihypertensive should be critically reviewed. In a patient with declining oral intake, reduced mobility, and advancing disease, Ramipril carries risk of symptomatic hypotension, acute kidney injury, and falls without meaningful cardiovascular benefit over his remaining prognosis. Consider stopping or arranging a blood pressure review as a first step.
●General principle: At end of life, retain only medications that control current symptoms (analgesics, antiemetics, laxatives, anxiolytics). Stop preventative medications (statins, antihypertensives, bisphosphonates) unless withdrawal would cause immediate symptomatic distress.

Recognising Complications of Hepatic Metastases

●Thomas reports his "belly feels more swollen than usual" — in the context of progressive hepatic metastases, this raises clinical suspicion for malignant ascites, which occurs in up to 50% of patients with liver metastases from colorectal cancer.
●Clinical assessment: The GP should ask about increasing abdominal girth, early satiety, orthopnoea, and ankle oedema. Examination at the home visit should include assessment for shifting dullness and fluid thrill.
●Management: If symptomatic ascites is confirmed, options include therapeutic paracentesis (can be arranged as a day-case or via community palliative care) and consideration of spironolactone 100–200 mg OD in selected patients, though diuretic response in malignant ascites is often poor.
●Other complications to anticipate: Progressive hepatic disease may cause jaundice, hepatic capsule pain (already present as right-sided dull ache), coagulopathy, and in late stages hepatic encephalopathy (confusion, drowsiness, asterixis). These should be included in safety-netting advice.

Supporting the Family and Carer

●Sarah's distress is a clinical priority, not a secondary concern. Her insistence that Thomas "keep fighting" signals anticipatory grief and fear of loss; the GP must address this directly rather than leaving Thomas to manage the conflict alone.
●Offer a direct conversation with Sarah: Either a joint home visit or a separate telephone call to explain the BSC rationale, answer her questions, and validate her emotions. Frame it practically: "This is something we should talk through together — would it help if I spoke with Sarah too?"
●Carer assessment: Under the Care Act 2014, carers are entitled to a needs assessment. Practical carer support includes referral to Macmillan for financial and benefits advice (e.g., Attendance Allowance via SR1 fast-track for terminal illness), Marie Curie or Hospice at Home for overnight sitting and respite, and signposting to local carers' organisations.
●Anticipatory grief support: Acknowledge that Sarah is grieving before Thomas has died. Consider early referral to bereavement counselling services — many hospices offer pre-bereavement support for family members of patients receiving palliative care.

Coordinating the Community Palliative Care MDT

●The GP acts as the coordinator of community-based palliative care, ensuring all agencies are aligned around the patient's wishes:
●Macmillan Clinical Nurse Specialist (CNS): For complex symptom management advice, psychological support, and liaison between primary and secondary care. Referral should be made promptly at the point of BSC transition — not deferred until a crisis.
●District Nurses: For regular home visits, administering anticipatory medications and syringe drivers (continuous subcutaneous infusions) when oral medication is no longer tolerated, stoma care, and pressure area assessment.
●Hospice at Home / Marie Curie Night Sits: Provide practical nursing support in the home during the terminal phase, including overnight care to prevent carer exhaustion.
●Gold Standards Framework (GSF): The GP practice should place Thomas on its palliative care register (GSF coding) to ensure he is discussed at regular MDT/GSF meetings, triggering proactive care planning rather than reactive crisis management.
●Out-of-hours handover: Ensure a special patient note or handover summary is available to the OOH service (e.g., via the electronic palliative care coordination system — EPaCCS) so that any clinician seeing Thomas overnight or at weekends has access to his care plan, medication list, ReSPECT form, and anticipatory prescriptions.

Safety Netting in Palliative Care

●Safety netting in the palliative context is not about excluding serious diagnoses — the serious diagnosis is known. It is about ensuring the patient and carer know what to expect, what to do, and who to call when symptoms change.
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Specific advice for Thomas and Sarah:
- ●Escalating pain: If Oramorph is needed more than 4 times in 24 hours, or pain is no longer controlled, contact the GP or palliative care team — do not wait for the next scheduled appointment.
- ●Inability to swallow medications: Contact District Nurses immediately — this is the indication to convert to subcutaneous medication via syringe driver using the anticipatory medications already in the home.
- ●New or worsening symptoms: Increasing abdominal distension, jaundice (yellowing of skin or eyes), new confusion, breathlessness at rest, or any bleeding should prompt same-day contact.
- ●Out-of-hours: Provide a clear written plan with contact numbers — GP surgery, palliative care CNS, OOH service, NHS 111. Ensure Thomas and Sarah know that an urgent home visit can be arranged and that hospital admission is not the default.
●Arrange a concrete next step: A home visit within the week with both Thomas and Sarah — not a vague "call if you need us." This provides a definite touchpoint and signals ongoing commitment to care.

Common Candidate Mistakes

●Assuming the patient wants to discuss chemotherapy options: The consultation is about Thomas's wish to stop treatment. Beginning with "So the oncologist mentioned a new chemo..." closes the door before it opens.
●Failing to explore the emotional subtext: Thomas's presenting request ("discuss the hospital letter") conceals guilt, fear of abandonment, and marital conflict. Candidates who stay purely biomedical miss the core of the consultation.
●Neglecting active symptom management: Validating the BSC decision without optimising current symptoms (undertreated pain, constipation, nausea) is a significant omission — the patient needs to experience that BSC means better care, not less care.
●Deferring everything to a future appointment: ACP, anticipatory prescribing, Macmillan referral, and medication review can all be initiated in this consultation. Candidates who say "we'll sort all that out later" fail to demonstrate proactive palliative care planning.
●Ignoring the carer: Sarah is mentioned prominently. Failing to offer direct GP-to-carer communication, or dismissing her wish to continue chemotherapy without empathy, loses marks in both domains.
●Not reviewing Ramipril: A preventative medication in a patient with weeks-to-months prognosis and declining oral intake is a prescribing risk that should be identified and addressed.

Mapped to the RCGP curriculum topic: People at the End of Life.

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