Cases/People at the End of Life

Noisy Breathing in a Dying Mother — Free SCA Practice Case

Daughter calling about her dying mother's noisy breathing

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

Try 5 free cases

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

Patient Profile

Full Name

Phyllis Barraclough

Age

88 years

Consultation Type

Telephone

Situation

Telephone Consultation. Phyllis is at home and is not on the call.

Reason for Encounter

"Mum's breathing has gone rattly and loud. I think she's drowning. I want her in hospital."

Medical Records (patient)

●PMH: Chronic heart failure (ejection fraction 25%), atrial fibrillation, CKD stage 3b (eGFR 31). Admitted with fluid overload 3 months ago. ReSPECT form 2 months ago: DNACPR, preferred place home.
●Medications: Furosemide 80 mg twice daily, bisoprolol 1.25 mg daily, apixaban 2.5 mg twice daily, paracetamol as required.
●Allergies: NKDA.
●Social: Lives alone. Carers twice daily, nurses daily.

Patient Script

For the friend playing the patient role

Character Overview: You are Marian Rowe, 61, calling about your mother, Phyllis Barraclough, who is 88 and dying at home from heart failure. You work three days a week on the front desk of a dental practice. Your husband Lionel is on shift until six this evening. You have been sleeping in your mum's spare room since Sunday. Your brother Dennis lives in Perth and lands the day after tomorrow. Last night her breathing started to rattle, and today it is loud and wet. You are frightened and exhausted and you cannot bear to listen to it. You remember how she fought for air in hospital three months ago, when she was admitted with fluid on her lungs and came home after nine days. Your voice shakes and you speak faster when you are frightened, and you go quiet when you talk about being alone with her at night. You never use medical terms such as "secretions" or "end of life". You say "the noise", "the rattle", "her chest" and "she's slipping". The name and age listed for this case belong to Phyllis, the person you are calling about. You are Marian, not Phyllis.

Opening Sentence: "Hello, doctor, it's Marian, Phyllis Barraclough's daughter. Mum's breathing has gone all rattly and loud and I think she's drowning. I can't sit and listen to it. I want her taken into hospital, please, now."

History if Asked (Data Gathering Phase)

●The breathing: "It started about eleven last night, a sort of bubbling in her throat. It's louder this morning. It gurgles with every breath. She isn't coughing and she isn't fighting for air, but there are gaps where she stops for ten seconds or so and then catches up with a big breath. It frightens the life out of me."
●Is she distressed: "That's the odd thing. Her face looks relaxed, she isn't moaning, she isn't gripping the sheets and she isn't screwing her face up. She looks peaceful. It's the noise that sounds like she's suffering."
●The last week: "She's gone downhill all week. More and more sleepy. She stopped eating about five days ago, and for two days she's only had sips of water from a little spoon. She stopped being able to swallow her tablets yesterday teatime. She opened her eyes when I spoke to her around seven this morning, and since then nothing. I can't wake her, even when I rub her hand."
●Her colour and temperature: "Her hands and feet are cold. Her knees have gone blotchy and a bit blue grey."
●Passing water: "Her pad was dry this morning. Nothing since yesterday afternoon."
●Her legs, fluid and infection: "Her ankles are puffy, but no worse than they've been for weeks. She hasn't coughed anything up and there's no pink froth. She doesn't feel hot and she hasn't had a cold."
●Pain: "She hasn't groaned or flinched when we turn her. She only ever took paracetamol for her knees."
●Last visit from the nurses: "The district nurse came yesterday evening and said she was 'very poorly' and to ring the surgery if anything changed. She's due back at about nine tonight. Nobody has left any injections or anything like that."
●Medicines in the house: "Only her usual tablets in the blister pack and the paracetamol. We've stopped giving the tablets because she can't swallow."
●Her wishes: "She had a form done about two months ago with the doctor and the heart failure nurse. It says no resuscitation and that she wants to stay at home. It's in a clear folder on the kitchen worktop. She told me after the hospital stay, 'I'm not going back in that place, love.'"
●The hospital stay three months ago: "She was drowning, that's the only word. She couldn't lie flat, she was gasping, she was terrified. They gave her a drip and a water tablet through it and she picked up within a couple of days. That's what I want again."

Ideas, Concerns, Expectations

Gating note: Marian does not raise any of the following unprompted. Each part comes out only when the doctor asks what she thinks is happening, what is worrying her, or what she was hoping for.

●Ideas: She thinks her mum's lungs have filled with fluid again, exactly as they did last time, and that she is drowning in it. She believes the hospital drip fixed her mum then and could do so again. She also believes that without food or drink Mum will starve and dry out. "It's the same as last time, isn't it? Fluid on the lungs. They sorted it then. And she's had nothing to drink, it can't be right to just let her dry up."
●Concerns: She is afraid her mum is suffering in a way nobody can see. She is afraid of watching her mum die and of being on her own with her tonight. She feels guilty, as if sending her to hospital is the only way to prove she is trying. She is also afraid that she is giving up on her mum if she keeps her at home. "I know what she said about not going in. But if I just sit here and she's choking, I'll never forgive myself. And what if she goes in the night and I'm on my own with her?"
●Expectations: She came expecting an ambulance, or at the very least for someone to do something about the noise. She would also like to know how long this will take. "I want her seen to and someone to stop that noise. And I want to know how long. Is it days, is it hours?"

If Asked: Medical History and Medications

Gating note: Marian answers these plainly when asked and does not volunteer them.

●Her mother's illnesses: "Her heart has been failing for about eight years. She has an irregular heartbeat too, and her kidneys aren't great."
●The usual medicines: "A water tablet, a heart tablet, a blood thinner and paracetamol. No allergies that I know of."
●Last time she was seen by the doctor: "The GP came about three weeks ago and said she was getting weaker and that we would keep her comfortable at home."

Social History and Lifestyle Impact

●Her mother's home: Phyllis lives alone in her own house, widowed for eleven years. Carers come twice a day and the district nurses visit daily. Marian lives 25 minutes away and has been staying since Sunday.
●Marian's family: Lionel can come straight over after six. Dennis cannot get here until the day after tomorrow, and she has not rung him today.
●Her own coping: She has slept about three hours a night this week. If asked how she is managing, her voice wobbles. "I'm not, really. I just don't want to get this wrong."

If Asked: Associated Symptoms

Gating note: Marian answers only when asked. Every answer is negative unless stated.

●If asked about vomiting, bleeding or choking: "No."
●If asked about restlessness, picking at the covers, calling out or agitation: "No. She's been very still."
●If asked about choking on sips or food: "She hasn't had even a sip since about seven this morning. She can't swallow now."
●If asked about a bulging tummy, a full bladder or constipation: "I don't think so. We haven't noticed anything."

Responses to Management (The Negotiation Phase)

●
If the doctor explains that the noise is saliva and secretions in the throat that she cannot clear, and that Mum is unlikely to be aware of it:
- ●Reaction: Doubtful at first. "But how do you know? She can't tell us. She sounds like she's gasping." She accepts it if the doctor explains that Mum is deeply asleep, that the noise is moving air over pooled saliva and that her face is relaxed. "So it's more upsetting for us than for her?" Then she asks, "If it isn't fluid on the lungs, why can't the hospital still do something?"
●
If the doctor advises against hospital and refers to her mother's wishes and her condition:
- ●Reaction: Guilty and torn. "She did say that. But that was before she got this bad. Am I giving up on her?" She softens if told that hospital would not reverse what is happening and that the aim now is comfort at home, where she asked to be. "Right. Then I want to do what she wanted. You'll make sure someone comes, won't you?"
●
If the doctor suggests injectable medicines for the noise and other symptoms:
- ●Reaction: Nervous. "Will that knock her out? Will it make her go quicker?" She accepts when told the doses are small, are given only for the noise, pain, breathlessness or restlessness, and are not meant to hasten anything. "Who gives them? I can't give injections." She wants to know when they can be there. "Tonight? Because I can't be doing this all day."
●
If the doctor discusses food, drink and mouth care:
- ●Reaction: Guilty. "Should we be giving her a drip? It feels wrong not to give her anything." She accepts a clear explanation that the body no longer needs or can use food and drink, that a drip could add to the rattle and that moist lips and mouth care help her comfort. She asks, "What can I actually do for her?" and gladly accepts a task such as turning her on her side, propping her up with pillows and using a mouth sponge.
●
If the doctor describes what to expect and what to do:
- ●Reaction: Wants specifics. "How long? Hours? Days?" She accepts honest uncertainty. If safety netting is vague, such as "ring if you're worried": "Worried about what? I'm worried now. What would mean I need someone straight away, and who do I ring?" She repeats back clear instructions. She also asks, "When she goes, do I ring 999?"
●
If the doctor asks how she is managing, or offers her support:
- ●Reaction: She cracks. "I just don't want her to be frightened. I don't know how to do this on my own." She becomes calmer when she hears that a nurse will visit today, that she can ring a 24 hour number at any hour and that she can ring Dennis and Lionel now. "Lionel can come at six. I'll ring Dennis."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

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 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Marian wants her mother admitted because the noisy breathing sounds like drowning and a hospital drip helped three months ago. Phyllis is 88, has end stage heart failure, has not roused since early this morning, and has a ReSPECT form recording DNACPR and a preference to stay at home. The station tests recognising dying, explaining noisy respiratory secretions, getting anticipatory medicines into the house quickly, and supporting a frightened daughter.
●The model plan has six parts. Say that Phyllis is in the last days or hours of life. Explain that the rattle comes from pooled secretions in a deeply unconscious person and is unlikely to distress her. Decide against emergency admission, because it would not reverse her dying and would go against her recorded wishes. Arrange a same day visit by a GP, district nurse or community palliative team member. Put subcutaneous anticipatory medicines in the house, including one for the secretions, with a nurse to give them. Give specific safety netting with a 24 hour number and say what to do when she dies.
●Acceptable alternatives: the GP visits and prescribes, or the nursing or palliative team sees her and a prescriber authorises medicines by phone, provided the medicines are in the house and nurses can give them within hours. A hospice bed is a reasonable offer if symptoms cannot be controlled or home care breaks down. Starting with non drug measures and then a trial of medicine is equally acceptable.

Recognising the Last Days of Life

●NICE guideline NG31 (Care of dying adults in the last days of life) names the signs: deterioration, reduced responsiveness, noisy respiratory secretions and mottled skin among them. Phyllis has a week of increasing sleepiness, five days without food, loss of swallowing, no response since early this morning, cold mottled extremities, pauses in breathing and no urine since yesterday.
●This is a different event from her admission three months ago, when she was awake, breathless and fluid overloaded and a diuretic by drip reversed it. NG31 asks for reversible causes such as pulmonary oedema to be treated, but a deeply unconscious woman with no cough, no frothy sputum and unchanged ankle swelling points to secretions.
●CKS Heart failure chronic (end stage heart failure, revised August 2026) says to stop treatments no longer giving benefit or causing harm, to discuss goals of care including preferred place of care and death, and to plan anticipatory prescribing and crisis planning.

Noisy Respiratory Secretions Explained

●CKS Palliative care secretions (revised April 2025) and NG31 describe the noise as airway secretions a dying person can no longer cough or swallow. NG31 says to establish whether it affects the dying person or those close to them, to reassure that it is unlikely to cause discomfort, and to be ready to discuss fears.
●So ask whether Phyllis looks distressed (relaxed face, no grimace, no groaning, no restlessness) and how distressed Marian is. The noise often troubles the family more than the patient, but the family's distress is itself a reason to act.
●NG31 advises oxygen only for known or suspected symptomatic hypoxaemia, not routinely for breathlessness in the last days. CKS says antibiotics may not greatly alter the course, and a single dose can be considered only where there is clinical suspicion of infection with profuse purulent sputum. Phyllis has no fever, cough or purulent sputum.

Managing the Rattle

●CKS advises positioning on one side with the upper body raised to encourage postural drainage. Regular mouth care helps.
●Consider medicine if positioning is not enough or if the noise distresses the person or family. NG31 and CKS list glycopyrronium bromide, hyoscine butylbromide and hyoscine hydrobromide, and NG31 also lists atropine. Hyoscine hydrobromide can cause sedation and confusion.
●BNF adult doses for excessive respiratory secretions in palliative care: glycopyrronium bromide 200 micrograms subcutaneously every 4 hours and when required (hourly use is occasionally needed), or 0.6 to 1.2 mg over 24 hours by subcutaneous infusion. Hyoscine butylbromide 20 mg subcutaneously every 4 hours as required, up to every hour, or by subcutaneous infusion over 24 hours.
●Review preferably every 4 hours and at least every 12 hours. Medicines can take up to 12 hours to work, so warn the family that the noise may not stop at once. If it still distresses after 12 hours, change or stop the medicine, and do the same if dry mouth, urinary retention, delirium or sedation persist.

Anticipatory Prescribing

●NG31 asks for individualised anticipatory medicines prescribed as early as possible, with indications and doses, for pain, breathlessness, agitation or anxiety, nausea and vomiting, and noisy secretions. Phyllis has none in the house, so this is the central action of the station.
●Use the subcutaneous route because she cannot swallow, and avoid intramuscular injections. Start with the lowest effective dose and titrate. Consider a syringe pump if more than two or three as required doses are needed in 24 hours.
●NG31 supports an opioid, a benzodiazepine or both for breathlessness, a benzodiazepine for anxiety or agitation, and an antipsychotic for delirium. Her eGFR was 31 two months ago, so choose and dose the opioid with care using local palliative guidance, and take specialist advice if unsure.
●NG31 notes that cyclizine may worsen heart failure and asks that antiemetic choice weigh sedation, other symptoms and interactions. The BNF lists severe heart failure as a caution for cyclizine, so it is best avoided for Phyllis. For new nausea or vomiting at the end of life, CKS suggests subcutaneous levomepromazine, and the BNF also gives subcutaneous haloperidol doses for nausea in palliative care. Either is reasonable; follow the local palliative formulary for the drug and dose.
●Seek specialist palliative advice if symptoms do not improve promptly or there are unwanted effects such as sedation.

Why Hospital Is Not the Answer, and When It Could Be

●Admission would not reverse dying. It would mean a transfer, an unfamiliar ward and probably a death away from the home she chose. Her ReSPECT form and her words after the last admission ("I'm not going back in that place") carry weight.
●Phyllis cannot take part now. A best interests approach under the Mental Capacity Act uses her known wishes and the views of those close to her. Marian is not recorded as holding a lasting power of attorney, so her views are heard but her mother's prior wishes are the strongest evidence.
●Admission or a hospice bed becomes reasonable if symptoms cannot be controlled at home or home care breaks down.

Hydration, Food and Tablets

●NG31 says to discuss clinically assisted hydration with the family: it may relieve distressing symptoms of dehydration but may cause other problems, including pulmonary oedema, and it is uncertain whether it prolongs life or whether withholding it hastens death. For an unconscious woman with heart failure and a rattle already present, a drip is not routine and could worsen the secretions.
●A moist sponge and lip balm give comfort that the family can provide. Offer sips only if she can swallow safely.
●Stop the oral heart failure tablets and apixaban because she cannot swallow them and they give no symptomatic benefit (NG31 1.5.1). Routine observations and blood tests will not change her care. Whether a diuretic by another route would help any fluid related symptom is a specialist palliative decision.

Communication and Support

●Begin by acknowledging how frightening the sound is, then explain it plainly using what Marian has already told you: her mother's face is relaxed.
●Say that Phyllis is dying, with honest uncertainty: probably hours to a few days. Describe what may follow: longer pauses and colour change.
●Address guilt. Staying at home is carrying out what her mother asked for, not giving up. Explain that injections are small doses for comfort, not to hasten death, and give Marian jobs: turning her, mouth care and sitting with her.
●Ask how she is coping, and encourage her to ring Dennis and Lionel.

Safety Netting and Care After Death

●Give a 24 hour number and list what should trigger a call: groaning, grimacing, restlessness, choking, bleeding or Marian's own distress. Calling that number, not 999, means out of hours staff and paramedics know her wishes.
●When Phyllis dies, which is an expected death, Marian should sit with her, there is no rush, and she should ring the nurses or surgery, not 999. A registered nurse can verify the death and the GP will then arrange the certificate. Share the plan with out of hours, the district nurses and the ambulance service, and check the DNACPR copy is in the house.

Common Mistakes in This Station

●Arranging an ambulance to satisfy the daughter without checking the ReSPECT form.
●Treating the noise as acute pulmonary oedema, or starting oxygen or oral diuretic for an unconscious patient.
●Leaving no medicines in the house, or prescribing oral or intramuscular medicines for a dying person.
●Forgetting heart failure when choosing an antiemetic, or kidney function when choosing an opioid.
●Saying "death rattle" without explanation, or reassuring before exploring her fear and guilt.
●Not saying that Phyllis is dying, or giving no time frame.
●Vague safety netting, no number, or telling her to ring 999 at the time of death.
●Missing that Marian is exhausted and alone until six.

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

← Back to Free SCA Practice Cases