Instruction for candidate:

Mrs Jennings is a 54-year-old woman with lung cancer and brain metastases. Chemotherapy was unsuccessful and she is now bed-bound and intermittently confused.

She has clearly expressed in the past that she does not want to suffer any pain.

Over the past two days, her regular headaches appear to have worsened in severity and frequency and are not controlled with Oramorph.

The Palliative Care Nurse thinks she should be started on a morphine subcutaneous continual infusion and would like you to discuss this with Mrs Jennings's son.

https://dai.ly/k5WIQ2Cc2FP8vhzy0wA

https://dai.ly/kX6DpqWGHVhJoIzy0wz

Instructions for Examiner:

It is important the candidate recognises the need for consent to speak to a relative. They must offer a statement such as “Mrs X asked if I could speak to you”. The SPIKES model may be a useful tool in this scenario:

• setting – candidate should recognise this is a sensitive topic and suggest speaking in a side room
• patient/relative’s perceptions (understanding of the situation so far) or elicit ideas, concerns and expectations at this point
• invitation to receive information
• give knowledge (Chunk and Check)
• address emotions
• strategy and summarise – a good candidate will arrange a follow-up plan.

Identifying the relative’s expectations may help the candidate to come up with a plan. The plan should be shared and should address both pain and ability to hold conversations.

The candidate may offer a lower initial dose and see how things progress.