GP CCE Cases · palliative-care
Palliative symptom control at home — CCE clinical encounter
CCE-style clinical encounter: a 62-year-old woman with metastatic breast cancer at home, eGFR 22, moderate pain, constipated on morphine, and her family asking about 'the pump'. The candidate must switch opioids for renal function, calculate breakthrough dosing, co-prescribe laxatives, and discuss syringe driver initiation.
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Prompt
A 62-year-old woman with metastatic breast cancer (bone and liver) is at home with community palliative care. Her eGFR is 22 mL/min. She is on oral morphine 30 mg four times daily. She has had no bowel motion for five days. Her husband asks about 'the pump' because she keeps needing extra doses for breakthrough pain. She has not eaten for two days.
Objectives
- Recognise the need to switch opioids because of renal function. [1]
- Calculate equianalgesic conversion and breakthrough dosing. [1]
- Address constipation with laxative co-prescribing. [4] [5]
- Initiate syringe driver and explain the rationale to the family. [1]
- Address the not-eating concern with family communication. [2]
References4ShowHide
- [1]King S, Forbes K, Hanks GW, Ferro CJ, Chambers EJ A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med, 2011.PMID 21708859
- [2]Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ Methylnaltrexone Treatment for Opioid-Induced Constipation in Patients with and without Cancer: Effect of Initial Dose. J Pain Res, 2023.PMID 37533563
- [4]Smallwood NE, Pascoe A, Wijsenbeek M, Russell AM, Holland AE, et al. Opioids for the palliation of symptoms in people with serious respiratory illness: a systematic review and meta-analysis. Eur Respir Rev, 2024.PMID 39384304
- [5]Pereira RA, Barcellos G, Lenz G, Christmann A, de Mello MAJ, et al. Fan Therapy for Dyspnea in Palliative and Supportive Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Respir Care, 2026.PMID 41761933