Station 47
Pete Barns
Age: 65 years old male
Full Case
Patient’s Data
Patient’s Name: Pete Barns
Age: 65-year-old male
Past medical history
- Metastatic Prostate cancer on
- Had palliative radiotherapy –now discharged from oncology care (awaiting discharge notes)
Alerts and QOFs
- No documented advance care plan
- DNACPR in place
Drug and Allergy History
- Oramorph 10mg/5ml- 2.5ml every 4 hours as needed
- Lactulose 15ml once daily
- Senna 15mg at night
- No Known drug Allergy
Paramedic Keith Howard is on the phone seeking advice regarding the patient’s current condition and care needs.
Patient's Story (Role player’s brief)
Patient’s Story
You are Paramedic Keith Howard, calling the GP surgery regarding a patient named Pete Barns (65 years old) , who you believe is registered with the practice.
You were contacted by Mr. Barns’ neighbour, who expressed concern after speaking with Pete’s wife. The neighbour explained that the wife was worried because Pete seemed a bit confused this morning. She also reported that he hasn’t opened his bowels for the past three (3) days, despite regular use of two prescribed laxatives. He appears bloated and has been experiencing some generalised abdominal discomfort.
If asked about patient’s wife: Pete’s wife is hard of hearing and is unable to speak on the phone. She is currently upstairs with the patient.
If asked to speak directly to Pete: He is fluctuating in and out of confusion and may not be able to engage meaningfully in a telephone consultation.
Additional Information (if prompted):
Pete reports increased thirst and is urinating more frequently than usual. No other symptoms reported
You have examined him. On examination- Temperature: 36.0°C Blood Pressure: 120/75 mmHg, Pulse: 99 bpm, Oxygen Saturation: 98% on air
He appears mildly dehydrated. Abdomen: Soft, non-tender, mildly distended; bowel sounds reduced but present
No vomiting, and no obvious signs of obstruction. No back pain, although Pete mentioned some bone pain in both legs
Social History: Pete lives at home with his wife. She appears to be struggling to cope with his care needs. He is a retired bus driver. He does not smoke or drink alcohol.
Idea: You suspect that Pete’s symptoms could represent a progression of his metastatic cancer.
Concern: You’re particularly concerned about his confusion, abdominal discomfort despite no tenderness, and the fact that he’s not opened his bowels for several days despite laxatives.
Expectation: You’re unsure whether hospital admission is appropriate given that Pete is under palliative care, and you’re seeking advice on whether to manage him at home or escalate further.
Pete’s wife, and Pete himself, have expressed that they are comfortable with healthcare professionals making decisions on their behalf over the phone.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about the confusion: when it started, whether it is new or fluctuating, how it affects orientation, communication, and level of alertness
- Ask about bowel habits: last bowel movement, usual pattern, straining, incomplete emptying, and laxative adherence
- Ask about red flags for bowel obstruction: vomiting, abdominal distension, nature of abdominal pain, and presence or absence of bowel sounds
- Ask about symptoms of hypercalcaemia: bone pain, increased thirst, polyuria, palpitations, nausea, or fatigue
- Kindly ask the paramedic if any examinations were performed and request findings including temperature, pulse, blood pressure, oxygen saturations, hydration status, and abdominal examination (tenderness, distension, bowel sounds)
- Ask about social history including home situation, presence of any carers, and whether the wife appears to be struggling with the patient’s care needs.
- Ask about the patient’s wishes or preferences regarding treatment and hospital admission, if known, and whether the wife is aware of them
- Make a diagnosis of Hypercalcaemia secondary to bone metastases
Example of explanation to patient
Thanks for all the detailed information, Keith. From what you’ve described, I agree with your impression that this could represent a progression of Pete’s cancer. The confusion, abdominal discomfort, and signs of dehydration could well be linked to hypercalcaemia (High calcium), which is not uncommon in advanced prostate cancer.
Given that he’s currently symptomatic and fluctuating in and out of confusion — and especially as there’s no advance care plan or documented preferences in place — I think it would be appropriate and in his best interest to admit him to hospital. The aim would be to keep him as comfortable as possible, run some blood tests, and start fluids to help stabilise things. I’ll liaise with the acute medical or oncology team so they’re aware on arrival.
Would you be able to start some fluids on the way to the hospital, if that’s okay? That might help with his hydration and comfort.
You mentioned his wife is struggling, and that’s important to address. Please let her know that once Pete is discharged, I will arrange a home visit to speak with her and Pete. Together, we will put a proper care plan in place. This will include discussing Pete’s wishes, exploring an advance care plan, and assessing ongoing care needs. I’ll also ask occupational therapy to visit and review whether having carers at home would help support them both.
Additionally, there’s a form called the SR1 — it supports access to benefits for patients with progressive illness — and I’ll ask our social prescriber to help coordinate that with the family.
Thanks again, Keith. You’re doing an absolutely fantastic job. Take care of yourself and feel free to call us anytime you need support.
Management
Management
- Advise hospital admission for possible hypercalcaemia, as the patient is symptomatic, confused, and has no advance care plan in place or wishes
- Explain that treatment may include IV fluids and possibly bisphosphonates, and that this will be to help stabilise him and improve his comfort
- Ask the paramedic to kindly inform the patient and his wife about what to expect in hospital
- Request the ambulance crew to initiate IV normal saline enroute to hospital if feasible and within their scope
- Offer to contact the hospital (acute medical or oncology team) in advance to alert them of the patient’s arrival and clinical background
- Offer to arrange a home visit after discharge to discuss advance care planning with Pete and his wife
- Propose involving the community palliative care team or Macmillan nurses for ongoing support
- Suggest assessment of care needs, including referral to occupational therapy and a social prescriber as wife seems to be struggling
- Offer to complete the SR1 form (formerly DS1500) to support benefits and care planning
- Thank the paramedic sincerely for their efforts and compassionate care
Learning point from this station:
Palliative care and end-of-life care are related and often used interchangeably, but they are distinct. Understanding the difference is vital in making appropriate, patient-centred decisions.
Palliative care is a holistic approach designed to support individuals with life-limiting illnesses that cannot be cured. Its focus is on managing pain, controlling distressing symptoms, and improving quality of life. This type of care also addresses emotional, psychological, social, and spiritual needs, for both the patient and their loved ones.
End-of-life care, on the other hand, refers specifically to the care provided during the final phase of life, typically the last months, weeks, or days. The emphasis here is on maximising comfort and dignity, often as part of a broader palliative care approach.
According to NICE Clinical Knowledge Summaries (CKS), the treatment of hypercalcaemia of malignancy typically involves IV fluids and bisphosphonates. However, NICE also states that “treatment may not be appropriate if the person is receiving palliative care and is felt to be approaching the end of life.”
In this case, the decision to admit was based on several key factors:
- Patient is symptomatic and confused, which suggests a need for urgent symptom relief
- He does not have an advance care plan or documented wishes against hospital admission. In addition, both he and his wife have deferred decisions to healthcare professionals.
- The aim of hospital care is not curative, but to stabilise him, manage distressing symptoms, and ensure comfort
- There remains uncertainty about his exact trajectory, so supporting him through this acute deterioration aligns with best practice in palliative care
Following stabilisation, discussions around future care planning, preferences, and support for his wife, who may have additional needs herself, should be initiated via a home visit, SR1 form, and community team involvement.
This station reinforces the principle that hospital care can be appropriate in palliative patients, especially when the goal is comfort and dignity, and when clear care preferences have not yet been established. It also highlights the importance of early advance care planning to guide decisions when patients lose capacity or deteriorate.
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