Palliative Care Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mr James Connolly is a 67-year-old retired builder with metastatic non-small-cell lung cancer, on second-line immunotherapy, presenting with worsening breathlessness, right chest-wall pain, nausea, constipation, new agitation, and an 8-kilogram weight loss over 3 months. [1]

His past history includes ischaemic heart disease, hypertension, and a 50 pack-year smoking history. His medications are sustained-release morphine 30 mg twice daily, immediate-release morphine 10 mg as needed, senna, macrogol, and dexamethasone 4 mg daily. [1]

On examination he is cachectic, tachypnoeic with a respiratory rate of 26 and an oxygen saturation of 88 per cent on room air, has dullness and reduced air entry at the right base, and is intermittently disoriented. His CT chest shows a large right pleural effusion and progressive pulmonary metastases. His wife is present and is exhausted and tearful. [1]

His main problems are:

1. Refractory breathlessness with a large right pleural effusion — the most immediately reversible problem
2. Suboptimally controlled chest-wall pain on an under-dosed opioid regimen
3. Nausea and constipation — opioid-related and possibly hypercalcaemia-related
4. Acute delirium — multi-factorial, with reversible precipitants to be sought
5. Cancer anorexia-cachexia syndrome
6. Progressive disease refractory to second-line therapy
7. Carer strain in his wife, and goals-of-care decisions [1]

My integrated plan is to drain the right pleural effusion immediately (intercostal catheter, with pleurodesis or an indwelling pleural catheter if it recurs), give supplemental oxygen for his hypoxaemia, and optimise his background analgesia by increasing the sustained-release morphine to 60 mg twice daily and recalculating the breakthrough dose to 20 mg. I will characterise the chest-wall pain and add a gabapentinoid if there is a neuropathic component. I will check a corrected calcium and renal function, treat hypercalcaemia if present, and start haloperidol for the chemical nausea while up-titrating the senna and macrogol for the constipation. I will systematically seek and treat the reversible precipitants of his delirium, use haloperidol first-line for any distressing agitation, and avoid benzodiazepines first-line. I will involve the specialist palliative care team alongside the oncology team, have a goals-of-care conversation using the SPIKES protocol with his wife present, document a ceiling of treatment and a not-for-resuscitation decision aligned with his values, and support his wife with a carer assessment, respite, and a bereavement risk assessment." [1]

Examiner probing questions and model answers

Q1: "You mentioned increasing his morphine to 60 mg twice daily. How did you calculate that, and what is the new breakthrough dose?" [1]

"He is currently on 30 mg twice daily, which is 60 mg per 24 hours, and he uses 3 to 4 breakthrough doses of 10 mg a day — that is another 30 to 40 mg, so his total opioid use is around 90 to 100 mg per 24 hours. His background dose of 60 mg is under-covering him. I would increase the sustained-release morphine to 60 mg twice daily — that is 120 mg per 24 hours, covering his background plus his usual breakthrough use. The new breakthrough immediate-release dose is one-sixth of the total 24-hour long-acting dose — one-sixth of 120 mg is 20 mg. I would recalculate the breakthrough dose every time the background dose changes, and I would review him within 24 hours. I would also confirm that his stimulant laxative (senna) plus osmotic (macrogol) regimen is titrated up, because opioid-induced constipation is universal and tolerance never develops, and the constipation is likely contributing to his nausea." [1]

Q2: "His oxygen saturation is 88 per cent. Would you give oxygen? And if his breathlessness persists after you drain the effusion, what is your pharmacological first-line?" [1]

"Yes — at 88 per cent on room air he is hypoxaemic, and supplemental oxygen is indicated and will help both his oxygenation and his breathlessness. The Abernethy trial (BMJ 2003) established that low-dose oral morphine relieves refractory breathlessness in advanced disease, and that in the non-hypoxaemic patient supplemental oxygen offers no benefit over room air — oxygen is reserved for the hypoxaemic patient. After I drain the effusion, if he becomes non-hypoxaemic but remains breathless, I would not expect additional oxygen to help, and I would rely on the morphine (which he is already on) plus non-pharmacological measures — sitting him upright and leaning forward, a fan to the face, pursed-lip breathing, and carer education. A benzodiazepine such as lorazepam 0.5 mg sublingually would be added only if anxiety is a prominent component, because benzodiazepines treat the anxiety, not the breathlessness itself." [1]

Q3: "How would you approach the goals-of-care conversation, and how would you break the news that his disease is progressing?" [1]

"I would use the SPIKES protocol of Baile (The Oncologist 2000). Setting — a quiet room, his wife present, time set aside, interruptions minimised. Perception — I would ask what he already understands: 'Tell me what you understand about your illness and what the oncology team has told you about the scan.' Invitation — I would ask how much detail he wants. Knowledge — I would give a warning shot ('I'm afraid the news is not what we hoped for'), then deliver the information that the cancer has progressed despite the immunotherapy, in plain language and in small chunks, with pauses to check understanding. Emotions — I would acknowledge and name the emotion, validate it, and allow silence: this is the step most often skipped and the most important. Strategy and Summary — I would agree a clear plan, give a written summary, name a single contact, and arrange follow-up. The goals-of-care conversation is not a single event — I would explore what matters most to him now (time, comfort, being at home, family milestones), align the medical recommendations with his values, propose a ceiling of treatment and a not-for-resuscitation decision framed in the context of his overall illness, document the agreed plan, and review it regularly." [1]

Q4: "He becomes agitated on the ward. What is your pharmacological approach to his delirium, and what would you avoid?" [1]

"First I would seek and treat the reversible precipitants — hypercalcaemia, hypoxia, opioid neurotoxicity, infection, urinary retention, constipation, metabolic disturbance. The first-line drug for delirium in palliative care is haloperidol 0.5 to 2 mg subcutaneously or orally, repeated as needed. The Hui 2017 randomised trial (haloperidol plus lorazepam versus haloperidol alone for agitated delirium in advanced cancer) supports haloperidol as the foundation, with lorazepam added only for refractory agitation. What I would avoid is a benzodiazepine first-line — benzodiazepines paradoxically worsen delirium and are reserved for alcohol or benzodiazepine withdrawal, or for terminal agitation refractory to an antipsychotic. If his agitation is from opioid neurotoxicity — for example if he has myoclonus, vivid nightmares, or sedation with accumulation of morphine-6-glucuronide in renal impairment — I would rotate the opioid to oxycodone rather than simply escalating the haloperidol." [1]

Q5: "When would you consider methadone, and what are the cautions?" [1]

"Methadone is reserved for refractory cancer pain or neurotoxicity from other opioids that has not responded to standard rotation and adjuvants, and its initiation requires specialist input. It is unique because it combines mu-receptor agonism with NMDA antagonism and noradrenaline and serotonin reuptake inhibition, giving it efficacy in neuropathic and opioid-resistant pain. The cautions are the long and variable half-life (8 to 75 hours) causing accumulation and delayed toxicity, the variable and dose-dependent equianalgesic ratio with morphine (the rotation ratio varies from 4:1 at low morphose doses to 12:1 or higher at high doses), QT prolongation requiring a baseline and periodic ECG, and CYP3A4 and CYP2B6 drug interactions. The Bruera 2004 trial established methadone as a viable first-line strong opioid, though morphine remains the global default. In a general-physician setting I would not initiate methadone myself — I would refer to the specialist palliative care or pain team." [1]