Paul Callaway
Age: 77 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset of pain in the foot and calf
- Ask if the pain is unilateral or bilateral
- Ask if the foot feels cold compared to the rest of the body
- Ask if there is any numbness, tingling, or pins and needles in the leg or foot
- Ask if the patient is able to walk or use the leg
- Ask if there is any swelling, redness, or visible veins in the leg (to assess for possible DVT)
- Ask about any shortness of breath, chest pain, or palpitations (to consider possible PE)
- Ask about the home situation and whether the patient has or needs carer support
- Ask the nurse about her observations, concerns, and whether she has examined the patient
- Ask what painkillers the patient has taken so far (dose, frequency, effectiveness)
- Ask about the timing of last Oramorph and Zomorph doses
- Ask if the pain is currently controlled or if breakthrough pain persists.
- Ask about the patient’s preferences and wishes regarding hospital admission and possible escalation of care.
- Give a working diagnosis of likely critical limb ischaemia based on symptoms and findings
Example of explanation to patient
Alice, thank you so much for calling and for the excellent care you’re providing to Mr. Callaway. From what you’ve described — the worsening pain in his left calf and foot, the discolouration, and the absence of pulses, this is highly suggestive of critical limb ischaemia, likely related to the progression of his peripheral arterial disease and advanced cancer.
Given his background, including metastatic prostate cancer, a limited prognosis, and the fact that he has capacity and has clearly declined hospital admission, our focus now should be entirely on comfort and symptom control at home, in line with his wishes.
He’s already on a high dose of morphine, approximately 160mg per day, which is significant. The fact that he’s still experiencing intense pain tells us that his current regime may no longer be sufficient. However, at these levels, any further increases need to be handled carefully and safely to avoid side effects or complications.
We’ll arrange for a face-to-face clinical review today to assess his pain properly, evaluate his morphine use, and decide whether a dose adjustment is needed. If his pain remains difficult to manage even after review, we will escalate to the specialist palliative care team, who can advise on more advanced measures, such as a syringe driver for continuous pain control.
For immediate relief, and provided he has no contraindications, you may give a stat dose of paracetamol or ibuprofen.
Given your observation that his wife appears to be struggling, we’ll inform the social prescriber so that appropriate carer support can be arranged to help relieve some of the pressure she’s under. I’ll also ensure an SR1 form is completed, which will allow Paul to access additional palliative care support and financial benefits.
I’ll review his anticipatory medication plan to ensure he has all the necessary “just in case” medications at home.
I also noticed that Paul does not currently have an advance care plan (ACP) in place. During my visit, I will take time to begin that discussion with him, including his preferences for place of care, place of death, escalation decisions (such as admission or resuscitation, though a DNACPR is already in place), and how we can best support both him and his wife during this time. This will ensure that his care remains consistent and fully aligned with his wishes.
We’ll also ensure that both Paul and his wife are given the Daffodil Line number, a dedicated contact line for palliative care patients to access the GP team directly during working hours. This will help us provide timely support and make it easier to manage his care at home during his final days.
Management
- Respect the patient’s decision to decline hospital admission and focus on managing him at home in line with his wishes.
- Arrange an urgent face-to-face clinical review today to assess pain, check the limb, and review current opioid dosing
- For immediate symptom relief, consider prescribing NSAIDs with paracetamol, after confirming there are no allergies or contraindications.
- If adequate pain control cannot be achieved, escalate to the specialist palliative care team for further support and consideration of a syringe driver if needed.
- Offer to discuss and document an advance care plan, including “just in case” medications.
- Complete and submit an SR1 form (formerly known as DS1500) to support access to appropriate financial benefits and fast-tracked services, including carer support for the patient’s wife, who appears to be struggling. Involve the social prescriber to provide additional input and coordinate support services in this context.”
- Provide the Daffodil Line contact details to both the patient and wife or any of their carers. This is a dedicated palliative care phone line designed to give patients rapid access to support without the delays often experienced through standard routes. While the name of this line (Daffodil line) may vary locally, the key purpose is to ensure timely and prioritised care for palliative patients.
- Express appreciation to the district nurse for her continued support and dedication in caring for the patient.
- Safety-net by advising the nurse and family to contact the surgery or out-of-hours team urgently if there is any worsening pain, new confusion, any concerns or distress
Learning point from this station:
This station highlights the importance of delivering compassionate, patient-centred care in the final phase of life, particularly when managing complex symptoms such as pain from critical limb ischaemia in a patient with advanced metastatic cancer.
In palliative care, it’s essential to remember that some patients may still benefit from treatment aimed at relieving symptoms, even if the overall goal is not to prolong life. For example, had this patient chosen hospital admission, the team would need to consider potential interventions such as vascular stenting. While such procedures might offer symptom relief, they also carry risks and burdens. Therefore, all options should be weighed without bias, carefully balancing the benefit, burden, and risk of treatment in relation to the patient’s overall condition, goals, and stage of illness.
In such cases, clinicians must ensure the patient understands that proposed treatments are not intended to prolong life, but to reduce suffering, improve comfort, or preserve dignity. This allows for shared decision-making that is both ethically and clinically appropriate.
When managing patients on high doses of opioids, such as morphine ≥120mg/24hrs, it’s essential not to escalate doses hastily, especially over the phone, without proper reassessment and dose calculation. Instead, titration should be done carefully, and if pain remains uncontrolled, input from the specialist palliative care team should be sought to guide safe and effective management.
Additionally, this station reminds us that opioids are not the only option in palliative pain management. Simple adjuncts like paracetamol and NSAIDs, when used appropriately, can provide valuable additional pain relief, but are often overlooked in this context.
Key principles reinforced by this scenario include:
- The need to initiate and document an Advance Care Plan (ACP) to reflect the patient’s values and guide future decisions
- The importance of equalities and human rights — all patients, including those nearing the end of life, must receive the same quality of care as others
- Recognising and addressing carer strain, using tools like the SR1 form and involving a social prescriber to support family wellbeing
- Using services such as the Daffodil Line (or equivalent local palliative care access routes) to ensure timely, prioritised care
- Ensuring that patients and those close to them are treated with dignity, respect, and compassion, especially when making complex or emotionally challenging decision.