KFP – Palliative care

Leonard Brough, aged 74, is a retired mechanical engineer who presents to your clinic with his wife. He has metastatic non-small cell lung cancer with bony metastases and a recent diagnosis of spinal cord compression treated with high-dose dexamethasone and radiotherapy. He was discharged from hospital two weeks ago. Today his wife reports increasing confusion, agitation, and episodes of visual hallucinations over the past three days. She also notes that he has become more drowsy and is struggling to take oral medications.

Medications: Fentanyl patch 50mcg/hr (changed every 3 days), dexamethasone 2mg daily, lactulose, paracetamol 1g QID, haloperidol 0.5mg PRN

Past history: Hypertension, osteoarthritis, depression

Social history: Lives with wife, has two adult children. Advanced care directive completed; he wishes for comfort-focused care at home. Wife is primary carer, receiving limited community nursing support.

Examination findings: Drowsy but rousable, confused to time and place, mild myoclonic jerks observed, dry mucous membranes, reduced urine output. No focal neurological deficits. BP 105/65, HR 92, RR 18, SpO2 96% on room air, temp 36.9°C.

What are the most appropriate next steps in his management? Select four (4) from the following list:

Margaret Liu, aged 68, is a retired teacher with widely metastatic breast cancer. She has opted for home-based palliative care and is supported by her husband and a visiting community nurse. You are called to her home because of escalating pain in her pelvis and spine, and new-onset nausea and vomiting over the last 24 hours. She has not opened her bowels for five days.

Medications: Oxycodone controlled release 20mg BD, oxycodone immediate release 5mg PRN (used 5 doses in last 24 hours), amitriptyline 10mg at night, coloxyl with senna BD, metoclopramide 10mg TDS

Past history: Depression, constipation, hypertension

Social history: Lives with husband, two adult children visit on weekends. Advanced care directive completed – she wishes to remain at home and avoid hospital admission.

Examination findings: Mildly distended abdomen with palpable stool in the left lower quadrant, sluggish bowel sounds, tenderness over lower spine. She is alert but appears uncomfortable. BP 120/70, HR 84, RR 18, afebrile.

What are the most appropriate next steps in her management? Select three (3) from the following list:

Ravi Suresh, aged 58, is a man with metastatic pancreatic cancer who is being cared for at home by his wife. He was recently transitioned to comfort care after failed chemotherapy. His wife calls you to review him because he has become increasingly drowsy, and she is struggling to administer his oral medications. He has had minimal fluid intake for three days and has not passed urine in over 24 hours.

Medications: Morphine SR 30mg BD, morphine liquid 5mg PRN, metoclopramide 10mg TDS, escitalopram 10mg daily, docusate/senna BD, paracetamol 1g QID

Past history: Type 2 diabetes (diet controlled), depression, chronic back pain

Social history: Married, wife is primary carer. No advance care directive is documented. Expressed wishes at last review were to die at home if possible.

Examination findings: Unresponsive to verbal command, responds to painful stimulus. Skin is warm, dry and mottled. Respiratory rate 10 with shallow breaths, pulse 60, BP 85/55, SpO2 89% on room air. No signs of respiratory distress. Pupils small and reactive. Chest clear, abdomen soft. No urine in catheter bag.

What are the most appropriate next steps in his management? Select three (3) from the following list:

Joan McAllister, aged 82, is a widowed woman with metastatic colorectal cancer and end-stage chronic kidney disease. She has opted for non-dialysis management and is receiving palliative care in her residential aged care facility (RACF). You are contacted by staff due to her increasing restlessness and agitation overnight. She has not spoken coherently for 24 hours, and is now frequently moaning and attempting to get out of bed. She appears frightened and is pulling at her nightgown. She has had minimal oral intake for three days and has not passed urine in 36 hours.

Medications: Fentanyl patch 25mcg/hr, lactulose, amlodipine 5mg daily, haloperidol 0.5mg PRN (given once overnight)

Past history: Hypertension, vascular dementia, osteoarthritis

Social history: Resident of RACF for 18 months. No documented advance care directive. Family have previously expressed a desire for comfort-focused care.

Examination findings: Moaning intermittently, non-verbal. Pulling at clothes and fidgeting. Skin cool and mottled peripherally. Respiratory rate 22, HR 102, BP 95/60, SpO2 92%. Chest clear, abdomen soft but mildly distended. Pupils pinpoint and reactive.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Nguyen, aged 45, is a man with metastatic melanoma involving the liver and brain. He has been receiving palliative care at home with support from his partner and a community nursing team. You are asked to visit urgently due to sudden onset of severe headache, confusion, and right-sided weakness. He has been drowsy and intermittently agitated over the last 48 hours.

Medications: Dexamethasone 8mg daily, sustained-release morphine 30mg BD, morphine liquid 5mg PRN, haloperidol 0.5mg PRN, esomeprazole 20mg daily

Past history: Intracranial metastases (treated with whole brain radiotherapy 6 weeks ago), hypertension, depression

Social history: Lives with long-term partner, no children. Advance care plan completed – patient prefers to remain at home if possible and not undergo further hospital interventions.

Examination findings: Drowsy but rousable. Slurred speech and right facial droop present. Right arm weakness (power 2/5). BP 160/95, HR 78, RR 14, SpO2 97%, Temp 36.5°C. No neck stiffness. Pupils equal and reactive.

What are the most appropriate next steps in this patient’s management? Select three (3) from the following list:

Barbara Kerr, aged 76, is a woman with metastatic ovarian cancer who is currently being managed in a palliative care inpatient unit. She has been experiencing intermittent episodes of severe colicky abdominal pain, vomiting, and absolute constipation for the past 48 hours. She has had no flatus for two days. The nursing staff report that she appears distressed during these episodes but settles between them.

Medications: Morphine SR 15mg BD, morphine liquid 5mg PRN, metoclopramide 10mg TDS, hyoscine butylbromide 20mg PRN, senna/docusate BD, ondansetron 4mg PRN

Past history: Total abdominal hysterectomy and bilateral salpingo-oophorectomy 2 years ago, chemotherapy completed 6 months ago, hypertension

Examination findings: Distended but soft abdomen, high-pitched tinkling bowel sounds, no palpable masses. No flatus or bowel movements. BP 110/65, HR 92, afebrile. Painful episodes every 20–30 minutes with intervening periods of rest.

What are the most appropriate next steps in her management? Select three (3) from the following list:

David Robertson, aged 69, is a man with metastatic prostate cancer and spinal metastases causing significant pain and reduced mobility. He is being cared for at home by his wife. Today she contacts you urgently because David is having increasing episodes of confusion and drowsiness. She notes that over the past few days, he has had vivid dreams, occasional visual hallucinations, and myoclonic jerks. He is now very drowsy and has urinated only once in the past 24 hours.

Medications: Oral morphine SR 60mg BD, morphine liquid 10mg PRN (used 6 times in past 24 hours), amitriptyline 25mg nocte, paracetamol 1g QID, lactulose, coloxyl with senna

Past history: Depression, hypertension, chronic constipation, renal impairment (eGFR 35)

Social history: Married, lives with wife, who is primary carer. Wishes to remain at home and avoid hospitalisation where possible.

Examination findings: Drowsy but rousable, confused. Dry mouth, coarse myoclonic jerks noted in upper limbs. BP 110/65, HR 88, RR 14, SpO2 95%, temp 36.7°C. Pupils pinpoint. No signs of meningism or focal neurology.

What are the most appropriate next steps in his management? Select three (3) from the following list:

Sharon Wallace, aged 66, is a woman with advanced metastatic breast cancer. She is admitted to a rural palliative care unit for symptom control of refractory dyspnoea. Despite stable oxygen saturations and no radiological evidence of pulmonary embolism or pneumonia, she reports persistent and distressing breathlessness, especially at night. She has a background of anxiety and has not tolerated morphine well in the past.

Medications: Oxycodone SR 10mg BD, lorazepam 0.5mg nocte, sertraline 100mg daily, paracetamol 1g QID, PRN salbutamol via spacer

Past history: Anxiety disorder, osteoarthritis, COPD (mild), no cardiac disease

Social history: Former smoker, widowed, lives with daughter. Wishes to remain in rural town for end-of-life care.

Examination findings: Alert, mildly tachypnoeic (RR 24), O2 saturation 95% on room air, no cyanosis. Uses accessory muscles but is not in acute distress. BP 130/80, HR 82. Chest clear on auscultation, no peripheral oedema. Mood low but cooperative.

What are the most appropriate next steps in symptom management? Select three (3) from the following list:

Helen Spiteri, aged 71, is a woman with advanced pancreatic cancer and liver metastases. She is in a metropolitan inpatient palliative care unit. Over the last 24 hours, she has developed increasing respiratory secretions described by staff as a ‘rattly’ chest. She is no longer responsive and is in the final phase of life. Her family is distressed by the sound and asks whether she is choking or suffering.

Medications: Subcutaneous morphine infusion 10mg/24h, midazolam infusion 5mg/24h, paracetamol ceased, dexamethasone ceased

Past history: Type 2 diabetes (diet controlled), hypertension, depression (remitted)

Social history: Long-time carer for her partner, who died 6 months ago. Has two children at bedside. Advance care directive clearly states preference for non-invasive, comfort-only care.

Examination findings: Unresponsive, breathing irregular and shallow, with noisy upper airway secretions. No signs of pain or respiratory distress. Chest clear to auscultation. SpO2 not measured. Skin cool and mottled peripherally.

What are the most appropriate next steps in managing Helen’s respiratory secretions and family distress? Select three (3) from the following list:

Michael Drew, aged 63, is a man with metastatic renal cell carcinoma and progressive cachexia. He has been managed at home with the support of his wife and a community palliative care nurse. You are asked to review him due to increasing fatigue, poor oral intake, and progressive weakness. He has not eaten more than a few bites per day for the last week, and has been mostly bedbound for three days. His wife is distressed and wants to know whether he should be given IV fluids or a feeding tube.

Medications: Oxycodone SR 10mg BD, breakthrough oxycodone liquid 5mg PRN, metoclopramide 10mg TDS, paracetamol 1g PRN

Past history: Type 2 diabetes (diet controlled), hypertension, prior nephrectomy, anaemia of chronic disease

Social history: Married, lives with wife, no advance care directive but previous conversations documented a preference for comfort care and staying at home.

Examination findings: Cachectic, frail-appearing man. Drowsy but can respond in short sentences. Dry mucous membranes. No distress. BP 90/60, HR 88, RR 16, SpO2 95%. Chest clear, abdomen soft, no evidence of acute pathology.

What are the most appropriate steps in managing Michael’s current condition? Select three (3) from the following list:

Fatima El-Badri, aged 60, is a woman with metastatic endometrial cancer admitted to your regional hospital’s palliative care ward. She has a long history of type 2 diabetes and now presents with reduced consciousness, dry oral mucosa, and deep, laboured respirations. She has not eaten or drunk for over 24 hours. Her family say she was drowsy this morning but has become more unresponsive over the past few hours.

Medications: Regular metformin ceased 1 week ago, subcutaneous morphine infusion 15mg/24h, midazolam infusion 10mg/24h, haloperidol 1mg PRN, PRN paracetamol ceased yesterday

Past history: Type 2 diabetes, hypertension, peripheral vascular disease

Social history: Fatima and her daughter have previously discussed her wish to avoid invasive investigations or transfers and to receive comfort care only.

Examination findings: GCS 6 (E2V1M3), Kussmaul breathing, dry tongue, cool peripheries, BP 100/60, HR 90, RR 24, SpO2 97% on room air, no signs of seizure or focal neurology. Capillary blood glucose: 22.1 mmol/L

What are the most appropriate next steps in management? Select three (3) from the following list:

Andrew Collins, aged 81, is a man with metastatic lung cancer and severe COPD. He has been admitted to a palliative care unit following increasing breathlessness and anxiety. Despite regular opioids and midazolam for dyspnoea and distress, nursing staff report that he appears increasingly agitated, particularly overnight. He frequently tries to get out of bed, speaks to people who aren’t present, and has trouble settling.

Medications: Subcutaneous morphine 20mg/24h, subcutaneous midazolam 10mg/24h, haloperidol 0.5mg PRN, ipratropium/salbutamol MDI PRN, sertraline 100mg daily (ceased on admission)

Past history: Severe COPD, ischaemic heart disease, anxiety disorder, major depression (well-controlled)

Social history: Widowed, lives in aged care facility. No advance care directive but notes in file confirm patient wanted comfort-only care if dying.

Examination findings: Confused, intermittently alert. Speaking to unseen people. Restless. RR 26, SpO2 91% on room air, HR 88, BP 115/75, temp 36.9°C. No signs of pain or respiratory distress. Chest with reduced air entry bilaterally and scattered wheeze.

What are the most appropriate next steps in managing Andrew’s symptoms? Select three (3) from the following list:

Isobel Ryan, aged 78, is a woman with metastatic breast cancer to bone and liver. She is receiving community-based palliative care. Her daughter calls your clinic to report that Isobel has developed new confusion, increasing fatigue, and muscle weakness over the past 48 hours. She has also been complaining of nausea and constipation. The daughter notes that Isobel is still taking her medications but is mostly bedbound and ‘not herself’.

Medications: Oral morphine SR 20mg BD, morphine liquid 5mg PRN, ondansetron 4mg PRN, docusate/senna BD, vitamin D, letrozole (ceased 3 weeks ago)

Past history: Osteoporosis, breast cancer, hypertension

Social history: Lives with her daughter, prefers to remain at home, documented goals of care indicate comfort focus and avoidance of hospitalisation unless symptoms cannot be managed at home.

Examination findings (home visit): Drowsy but rousable. Mildly confused. Dry mucous membranes, slow reflexes, no focal neurology. BP 105/65, HR 80, RR 16, afebrile. Abdomen soft, mild constipation. No evidence of infection or opioid toxicity.

What are the most appropriate next steps in management? Select three (3) from the following list:

James O’Donnell, aged 84, is a retired builder with metastatic bladder cancer and a background of vascular dementia. He resides in a residential aged care facility (RACF) and is on a palliative care pathway. Nursing staff report he has developed noisy breathing, increased oral secretions, and agitation over the last 12 hours. He is not rousable but occasionally vocalises and appears restless. His family, who are present, are distressed by his appearance and sounds.

Medications: Subcutaneous morphine 10mg/24h, midazolam 5mg/24h, glycopyrrolate 200mcg PRN (not yet administered), paracetamol 1g PRN

Past history: Vascular dementia, hypertension, atrial fibrillation, stroke 4 years ago (non-verbal since)

Social history: Widowed, two adult children involved in care. Goals of care documented: no hospital transfer, symptom management only. Family wishes to maintain comfort-focused care within RACF.

Examination findings: Unresponsive to voice, responds to pain. RR 22, HR 78, BP 110/70, SpO2 94%, gurgling respiratory sounds, no respiratory distress. Myoclonic twitches present. Skin cool and mottled. Pupils equal and reactive.

What are the most appropriate next steps in James’s care? Select three (3) from the following list:

Elena Marquez, aged 72, is a woman with metastatic gastric cancer and ascites. She has been managed at home by her husband with support from the community palliative care team. Over the last week, she has developed increasing abdominal distension, early satiety, nausea, and mild peripheral oedema. She remains alert and oriented and wishes to remain at home if possible. Her husband reports that she is eating very little due to discomfort and feeling ‘full’.

Medications: Morphine SR 15mg BD, metoclopramide 10mg TDS, spironolactone 25mg daily, PRN oxycodone 5mg

Past history: Refractory gastric cancer, hypertension, osteoarthritis

Social history: Married, culturally Spanish-speaking, lives with husband and has two adult children nearby. Advance care directive completed and specifies home-based symptom control and no hospital interventions.

Examination findings: Alert, abdomen markedly distended, tense, with shifting dullness. Mild bilateral pedal oedema. Respiratory rate 18, SpO2 96%, HR 88, BP 125/72. No jaundice, no signs of infection. Bowel sounds present. No signs of peritonism.

What are the most appropriate next steps in managing Elena’s symptoms? Select three (3) from the following list:

Peter Johansson, aged 57, is a man with metastatic colorectal cancer involving liver and peritoneum. He has been admitted to a rural palliative care unit with escalating pain despite increasing oral opioid doses. He is now requiring frequent PRN breakthrough doses and reports poor sleep due to pain. Nursing staff note that he is becoming more drowsy and has experienced several episodes of mild confusion in the evenings. He is keen to avoid hospital transfer and prefers to stay in the palliative unit for the remainder of his life.

Medications: Oral morphine SR 60mg BD, morphine liquid 10mg PRN (used 6 doses in last 24h), docusate/senna BD, metoclopramide 10mg TDS, paracetamol 1g QID

Past history: Type 2 diabetes, diverticulosis, anxiety (no current treatment)

Social history: Lives alone on a farm. No advance care directive, but previous conversations indicate a clear wish to avoid invasive treatments and stay local. Two adult children live interstate.

Examination findings: Drowsy but rousable, mild confusion. Abdomen distended, non-tender. No focal neurology. RR 18, HR 82, BP 110/70, SpO2 96%. Appears fatigued. No clinical signs of infection.

What are the most appropriate next steps in management? Select three (3) from the following list:

Nancy Hargreaves, aged 75, is a woman with metastatic ovarian cancer and known peritoneal disease. She is being managed at home with the support of her son and a palliative care nurse. Her son contacts you for a home visit due to progressive nausea and several episodes of non-bilious vomiting over the past two days. She has not opened her bowels for four days and is no longer tolerating oral medications. She remains alert and states she does not want to go to hospital under any circumstances.

Medications: Morphine SR 10mg BD, metoclopramide 10mg TDS, haloperidol 0.5mg PRN, lactulose BD, paracetamol 1g PRN

Past history: Ovarian cancer with peritoneal carcinomatosis, hypertension, anxiety

Social history: Lives with son in rural town. Advance care directive states home-based care with no transfer unless explicitly requested.

Examination findings: Alert, oriented, appears fatigued. Abdomen distended with mild tenderness, bowel sounds present but high-pitched. No flatus for 48 hours. BP 115/70, HR 88, afebrile, no signs of peritonism or infection.

What are the most appropriate next steps in management? Select three (3) from the following list:

Raymond Flynn, aged 80, is a man with end-stage chronic obstructive pulmonary disease (COPD) and frailty. He is currently residing in a residential aged care facility (RACF) and has been receiving palliative care. Staff call you to assess him after a significant overnight deterioration. He is now minimally responsive, with irregular breathing and episodes of apnoea. His daughter is at the bedside and tearfully asks whether anything can be done to ‘make him more comfortable’.

Medications: Salbutamol and ipratropium inhalers ceased 1 week ago, oral morphine 2.5mg PRN for dyspnoea (used three times in last 24 hours), midazolam 2.5mg PRN (used once overnight)

Past history: Severe COPD, chronic heart failure, anxiety disorder, ex-smoker

Social history: Widowed, lives in RACF for 2 years. Advance care plan clearly states a wish for no hospitalisation or invasive treatments. Family supportive of palliative care approach.

Examination findings: GCS 4 (E1V1M2), RR 8 with Cheyne–Stokes pattern, SpO2 85% on room air, HR 58, BP 90/55, peripheries cool, intermittent terminal secretions. No evidence of respiratory distress. Terminal phase confirmed by nursing team.

What are the most appropriate next steps to support comfort care in Raymond’s final hours? Select three (3) from the following list:

Lucille Tran, aged 65, is a woman with metastatic breast cancer involving her spine and ribs. She has recently been diagnosed with a pathological vertebral fracture and is experiencing severe back pain that limits her mobility. She is currently in a rural palliative care unit. Despite oral morphine, she describes the pain as sharp, burning, and shooting down her left leg. She finds it difficult to lie flat and is unable to sleep due to pain. She is cognitively intact and requests better pain control without feeling overly sedated.

Medications: Morphine SR 30mg BD, morphine liquid 5mg PRN (used 5 times in last 24 hours), paracetamol 1g QID, senna/docusate BD

Past history: Depression, hypertension, mastectomy and radiotherapy 5 years ago

Social history: Lives alone in rural town. Her sister visits daily. Goals of care: comfort-focused with a desire to stay alert and remain in the current facility.

Examination findings: Alert and oriented. Pain aggravated by movement, tender over thoracolumbar spine. No motor deficit. Mild allodynia on the left lateral thigh. No bladder or bowel symptoms. Vitals stable.

What are the most appropriate next steps in her pain management? Select three (3) from the following list:

Angela Rowe, aged 83, is a woman with advanced Alzheimer’s dementia and end-stage congestive cardiac failure. She is residing in a high-care residential aged care facility (RACF). Staff contact you to review her as she has developed increasing lethargy, decreased oral intake, and signs of fluid overload over the last five days. She is now bedbound, with laboured breathing, and has not spoken in 48 hours. Her family are present and ask whether diuretics should be restarted or if she needs hospital care.

Medications: Frusemide 40mg daily (ceased 1 week ago), morphine 2.5mg subcut PRN (used twice today), glycopyrrolate PRN (used once), paracetamol 1g BD

Past history: Alzheimer’s dementia, CHF, atrial fibrillation, chronic kidney disease stage 4

Social history: Widow, lives in RACF. Advanced care directive: comfort-focused care only, no transfer to hospital. Family supportive but concerned she may be ‘drowning’ due to fluid overload.

Examination findings: Drowsy, no verbal response. RR 26 with mild accessory muscle use. Bibasal crackles. Mild pitting oedema to mid-shins. SpO2 88% on room air, BP 100/65, HR 78 irregular. Abdomen soft, not distended. No fever.

What are the most appropriate next steps in her palliative care management? Select three (3) from the following list:

Mohammed Almasri, aged 74, is a man with end-stage liver failure secondary to hepatitis C and alcohol-related cirrhosis. He is being managed in a palliative care unit and is noted to have developed increasing confusion and irritability over the past three days. Nursing staff report that he is sleeping during the day, agitated at night, and occasionally shouting incoherently. He has a distended abdomen, reduced oral intake, and minimal bowel movements over the past week. He has no known history of brain metastases.

Medications: Morphine SR 10mg BD, lactulose 15mL TDS (poor compliance), furosemide 40mg daily, thiamine 100mg daily, midazolam PRN

Past history: Decompensated cirrhosis, portal hypertension, hepatic encephalopathy (previous), oesophageal varices (banded), anxiety disorder

Social history: Widower, lives alone prior to admission. Family interstate. ACP in place requesting symptom control only. No hospital transfer.

Examination findings: Drowsy, alternating with periods of agitation. Asterixis present. Abdomen distended with ascites, non-tender. Jaundiced. HR 88, BP 100/60, RR 18, SpO2 96%. No signs of infection or focal neurology.

What are the most appropriate next steps in his symptom management? Select three (3) from the following list:

Deborah Miles, aged 70, is a woman with metastatic melanoma involving lungs and adrenal glands. She has been under home-based palliative care and is now in the terminal phase. Her son calls your practice expressing concern that she is ‘not eating anything’, hasn’t spoken in two days, and seems to be breathing strangely. He asks if she needs to be taken to hospital or ‘put on a drip’.

Medications: Morphine 15mg/24h via syringe driver, midazolam 10mg/24h, PRN glycopyrrolate, paracetamol ceased two days ago

Past history: Metastatic melanoma, chronic anxiety, no history of diabetes or cardiac disease

Social history: Lives with son. Advance care directive completed stating desire to die at home, no hospital transfers or IV interventions.

Examination findings (home visit): Unresponsive, shallow irregular breathing with occasional apnoeas. Skin mottled, extremities cool. GCS 3. RR 10. HR 60. BP 85/50. No signs of pain or respiratory distress. No urine output in last 24 hours.

What are the most appropriate actions to take at this time? Select three (3) from the following list:

Keith Wallace, aged 59, is a man with advanced pancreatic cancer and known liver metastases. He presents to your rural general practice with new-onset jaundice, dark urine, and increasing fatigue over the past week. He has had progressive anorexia and mild nausea, but no vomiting or pain. He wishes to remain at home and is not interested in further hospital-based treatment. His daughter is concerned that his symptoms indicate worsening disease and asks what can be done at home.

Medications: Oxycodone SR 10mg BD, metoclopramide 10mg TDS, docusate/senna BD, PRN paracetamol

Past history: Pancreatic cancer with liver metastases, weight loss, prior biliary stent (placed 6 months ago)

Social history: Lives with adult daughter, independent in ADLs until recently. No formal advance care directive, but verbal preferences documented for home-based care and no hospital transfer.

Examination findings: Alert, fatigued. Deep jaundice, scratch marks on forearms. Abdomen soft, mild RUQ tenderness. No guarding or rebound. No focal neurological findings. BP 110/70, HR 80, RR 16, afebrile.

What are the most appropriate next steps in his symptom management? Select three (3) from the following list:

Jacqueline Taylor, aged 67, is a woman with metastatic endometrial cancer. She has been receiving home-based palliative care with support from her daughter and community nurses. Her daughter contacts you for an urgent review due to Jacqueline’s increasing restlessness, agitation, and vocalisations over the past 12 hours. She has not spoken clearly, is not eating or drinking, and frequently attempts to get out of bed. Her daughter is worried that she is in pain or ‘losing her mind’.

Medications: Morphine SR 30mg BD, breakthrough morphine liquid 5mg PRN, paracetamol 1g PRN (not used in 48 hours), metoclopramide ceased 1 week ago

Past history: Anxiety, osteoarthritis, venous thromboembolism (on ceased anticoagulation)

Social history: Lives with daughter. Wishes to die at home. No formal advance directive but consistent notes and discussions around comfort-based care.

Examination findings: Confused, not following commands. Attempts to speak incoherently. Myoclonic jerks in upper limbs. Vitals: HR 92, BP 115/70, RR 20, SpO2 94%, Temp 36.8°C. No signs of infection, respiratory distress, or urinary retention. Pupils pinpoint and reactive. Dry mucous membranes.

What are the most appropriate next steps in managing Jacqueline’s symptoms? Select three (3) from the following list:

David McKenna, aged 62, is a man with metastatic prostate cancer involving the spine and pelvis. He has recently become bedbound and is being cared for at home by his partner and a visiting palliative care nurse. His partner contacts you for a home visit due to a large, non-healing sacral pressure ulcer that has developed over the past two weeks. It has become malodorous, with some yellow-green discharge and increasing surrounding erythema. David is unable to tolerate dressing changes and becomes agitated due to pain. He has no fever or systemic signs of infection.

Medications: Fentanyl patch 50mcg/hr, oxycodone liquid 5mg PRN (used 4 times daily), haloperidol PRN, paracetamol 1g QID, senna/docusate BD

Past history: Spinal cord compression, urinary retention (IDC in situ), depression (treated)

Social history: Lives with long-term partner. Wishes to remain at home. No hospital transfer. Advance care plan completed.

Examination findings: Alert and orientated. Large sacral ulcer with slough and malodour. Local erythema but no crepitus or systemic signs. HR 88, BP 110/65, RR 18, afebrile. Restless during dressing change.

What are the most appropriate next steps in David’s management? Select three (3) from the following list:

Teresa Faulkner, aged 88, is a woman with end-stage chronic kidney disease (eGFR <10), managed conservatively without dialysis. She lives in an aged care facility and is receiving palliative care. Over the last few days, she has become progressively drowsier and confused, with reduced oral intake. Staff report a strong ammonia-like odour to her breath and note that she has had one generalised tonic-clonic seizure lasting approximately one minute this morning. She is now post-ictal but breathing comfortably.

Medications: PRN morphine liquid 2.5mg, PRN midazolam 2.5mg, paracetamol 1g BD, lactulose 10mL BD, calcium carbonate

Past history: Hypertension, CKD stage 5, osteoporosis, no known malignancy

Social history: Lives in RACF, widowed, no children. Advance care directive in place indicating comfort-only care, no hospital transfer, no resuscitation.

Examination findings: Drowsy, GCS 11 (E3V3M5), slow to respond. Breath smells of ammonia. RR 14, HR 70, BP 120/60, SpO2 97% on room air, afebrile. No focal neurological signs. Chest clear, abdomen soft. Dry mucous membranes noted.

What are the most appropriate next steps in Teresa’s palliative management? Select three (3) from the following list:

Alfred Koenig, aged 77, is a man with metastatic oesophageal cancer. He is being managed in a metropolitan palliative care unit. He has had progressive dysphagia for several months, and for the past week has only tolerated sips of fluid. He now presents with a new onset of frequent coughing during swallowing and has experienced two episodes of choking with food. He expresses a desire to continue eating ‘something, even if small amounts’, and wishes to remain at the palliative unit. He does not want any ‘tubes or machines’.

Medications: Oxycodone SR 10mg BD, oxycodone liquid 5mg PRN, paracetamol 1g QID, omeprazole 20mg daily, metoclopramide PRN

Past history: Metastatic oesophageal cancer, PEG declined previously, aspiration pneumonia 2 months ago

Social history: Widowed, lives alone, recently transitioned to inpatient palliative care for support. Clear verbal wishes documented to focus on comfort and avoid invasive interventions.

Examination findings: Alert, thin, coughing intermittently. Speech slightly hoarse. No stridor. Chest clear. RR 18, SpO2 94% on room air. Mild dehydration, but no signs of acute infection.

What are the most appropriate next steps in Alfred’s management? Select three (3) from the following list:

Linda Barnes, aged 69, is a woman with metastatic breast cancer and a history of depression. She is currently being cared for at home by her husband and has been receiving palliative care support for several months. Her husband calls the practice distressed because Linda has become increasingly withdrawn over the past week. She is refusing food and medications and told him she is ‘ready to die’. She has not expressed suicidal ideation but has become non-verbal in the last 24 hours. He is unsure whether this is physical decline or depression and wants your advice on what to do next.

Medications: Oxycodone SR 15mg BD, paracetamol 1g QID, mirtazapine 30mg nocte, haloperidol PRN

Past history: Metastatic breast cancer, recurrent depression, vertebral metastases, osteoporosis

Social history: Married, no children. Husband is primary carer. Linda has previously stated she wishes to die at home and not have hospital interventions. No formal advance care directive completed.

Examination findings (home visit): Linda is lying in bed with eyes closed but rouses to voice. She does not respond to questions. No signs of pain or respiratory distress. Dry mucous membranes, mild jaundice, afebrile. Vitals: HR 82, BP 100/65, RR 16, SpO2 95%.

What are the most appropriate next steps in Linda’s care? Select three (3) from the following list:

Gurdeep Singh, aged 72, is a man with advanced lung cancer and known vertebral metastases. He is being managed at home with support from his daughter and the community palliative care team. His daughter contacts you early in the morning to report that Gurdeep suddenly lost power in both legs overnight and is now unable to walk or stand. He reports back pain that worsened yesterday. He is continent but says he has numbness around his inner thighs. He is alert and oriented and wants to stay at home if possible.

Medications: Oxycodone SR 20mg BD, paracetamol 1g QID, breakthrough oxycodone 5mg PRN, senna/docusate BD

Past history: Non-small cell lung cancer, T12 vertebral metastasis (previously irradiated), hypertension

Social history: Widower, lives with daughter, strong preference for home-based care. No formal advance care directive, but consistent documentation of goal to avoid hospitalisation unless absolutely necessary.

Examination findings: Alert, unable to move legs. Reduced sensation in both legs and perianal area. Tenderness over lower thoracic spine. Normal upper limb function. No signs of sepsis. BP 110/70, HR 84, RR 16, afebrile.

What are the most appropriate immediate steps in his management? Select three (3) from the following list:

Miriam Goldberg, aged 85, is a woman with advanced vascular dementia and frailty, residing in a high-care residential aged care facility. Over the past week, she has become increasingly somnolent and is now bedbound. She is taking minimal oral intake, and staff report she has not had a full meal in five days. Today she appears more drowsy, with shallow breathing and dry lips. Her family are concerned that she may be dehydrated and ask whether she needs fluids via drip or tube to ‘keep her going’.

Medications: Paracetamol 1g BD, PRN subcutaneous morphine 2.5mg, PRN midazolam 2.5mg, PRN glycopyrrolate 200mcg

Past history: Advanced dementia, recurrent aspiration pneumonia, cerebrovascular disease, hypertension

Social history: Lives in RACF, widowed, children visit regularly. Advance care directive specifies no artificial nutrition or hydration and a preference to die in place.

Examination findings: Drowsy, responds to voice with eye opening. Skin cool, dry mucous membranes. RR 10, SpO2 95%, HR 72, BP 100/60. No signs of respiratory distress or pain. Chest clear. No focal neurological signs. No evidence of infection.

What are the most appropriate next steps in Miriam’s care? Select three (3) from the following list:

Angela Martins, aged 52, is a woman with metastatic triple-negative breast cancer. She is admitted to a regional palliative care unit due to escalating pain and anxiety. She reports severe burning pain over her right chest wall and left upper thigh, which she describes as sharp, shooting, and constant. She is distressed, has difficulty sleeping, and fears she is ‘losing control’ of her symptoms. She is currently able to eat and drink, but says she feels nauseated often and her bowels have not opened for three days.

Medications: Oxycodone SR 20mg BD, oxycodone IR 5mg PRN (used 6 times in 24h), metoclopramide 10mg TDS, paracetamol 1g QID, coloxyl with senna BD

Past history: Chemotherapy-refractory breast cancer, anxiety disorder, opioid-induced constipation

Social history: Lives with partner. Recently stopped working. Keen to remain in the palliative unit until symptoms are better controlled. No advance care directive completed yet.

Examination findings: Alert and distressed. Complains of burning pain over ribs and thigh. Reduced bowel sounds. Mild suprapubic tenderness. BP 120/75, HR 86, RR 18, SpO2 98% on room air, afebrile.

What are the most appropriate next steps in managing Angela’s symptoms? Select three (3) from the following list:

John Ramierez, aged 79, is a man with metastatic colorectal cancer and recent hepatic metastases. He has been receiving home-based palliative care with his wife as primary carer. She contacts you urgently because John has had several episodes of confusion and agitation over the past 48 hours. He has also been increasingly drowsy and now does not recognise her. His oral intake is minimal, and he has not had a bowel motion for 6 days. He is incontinent of urine and appears to be picking at the bed sheets and mumbling incoherently.

Medications: Morphine SR 20mg BD, breakthrough morphine 5mg PRN, paracetamol 1g QID, haloperidol 0.5mg PRN, lactulose 15mL BD (ceased 1 week ago)

Past history: Colorectal cancer with liver and peritoneal spread, type 2 diabetes (diet-controlled), hepatic encephalopathy (prior episode 3 months ago)

Social history: Retired farmer, lives rurally with wife. Verbalised strong preference to remain at home. No hospitalisation or invasive procedures. No formal ACP completed.

Examination findings (home visit): Drowsy, fluctuating level of consciousness. Not oriented to person or place. Asterixis present. Abdomen soft but distended. No focal neurology. Vitals: HR 84, BP 105/70, RR 18, afebrile.

What are the most appropriate next steps in John’s management? Select three (3) from the following list:

Elaine Robertson, aged 68, is a woman with metastatic ovarian cancer. She has peritoneal disease and significant ascites, managed with regular therapeutic paracentesis. She is being cared for at home with support from her daughter and community palliative care. Her daughter calls you concerned that Elaine has stopped asking for food, is sleeping most of the day, and seems to be experiencing shortness of breath. Elaine remains verbally responsive but is very fatigued and says she is ‘ready to let go’.

Medications: Fentanyl patch 25mcg/hr, ondansetron 4mg PRN, paracetamol 1g PRN, spironolactone 25mg daily

Past history: Metastatic ovarian cancer, recurrent ascites, deep vein thrombosis (previously on anticoagulation, ceased 2 months ago)

Social history: Widowed, lives with daughter. Expressed strong preference for home death. No formal ACP completed, but multiple notes of comfort-only approach.

Examination findings (home visit): Drowsy, oriented briefly when roused. RR 24, SpO2 92% on room air. Abdomen distended but soft. Mild peripheral oedema. No signs of respiratory distress. Chest clear. BP 105/65, HR 88, afebrile.

What are the most appropriate next steps in her palliative management? Select three (3) from the following list:

Peter Langford, aged 66, is a man with advanced pancreatic cancer. He has been admitted to a palliative care unit with uncontrolled nausea and vomiting. He reports persistent nausea, occasional dry retching, and two episodes of non-bilious vomiting in the past 24 hours. He has lost 4kg in two weeks and has minimal oral intake. He is still ambulant but appears fatigued and disinterested in food. There is no abdominal pain.

Medications: Morphine SR 20mg BD, metoclopramide 10mg TDS, paracetamol 1g QID, senna/docusate BD

Past history: Advanced pancreatic cancer, opioid-induced constipation, prior chemotherapy (ceased 3 months ago)

Social history: Lives with wife. Wishes to stay in the palliative unit. No formal ACP, but documented preference for symptom control and quality of life.

Examination findings: Alert, appears nauseated. Abdomen soft, mild epigastric fullness, no tenderness. No bowel sounds noted. No distension. HR 82, BP 110/68, afebrile. No signs of infection or dehydration. No focal neurology.

What are the most appropriate next steps in Peter’s symptom management? Select three (3) from the following list:

Samira Ali, aged 64, is a woman with metastatic renal cell carcinoma involving the lungs and spine. She is currently receiving palliative care at home. Her daughter calls urgently because Samira is experiencing loud gurgling breathing, is no longer responsive to voice, and appears to be in the final hours of life. The daughter is distressed by the sound and fears Samira is choking. She requests urgent advice and asks whether Samira needs oxygen or to be moved to hospital.

Medications: Morphine infusion 10mg/24h via syringe driver, midazolam 5mg/24h, paracetamol 1g PRN, glycopyrrolate 200mcg PRN (not yet used)

Past history: Renal cell carcinoma with widespread metastases, prior nephrectomy, anaemia of chronic disease

Social history: Lives at home with daughter, who is primary carer. Verbalised preference to die at home. No formal advance care directive signed, but documented preferences noted.

Examination findings (home visit): Unresponsive, GCS 3. RR 10 with gurgling respiratory sounds. Skin cool and mottled. No signs of respiratory distress or pain. HR 60, BP 85/50, SpO2 89% on room air.

What are the most appropriate next steps in managing Samira’s symptoms and supporting her family? Select three (3) from the following list:

Matthew Callahan, aged 58, is a man with metastatic prostate cancer involving the spine and liver. He is currently receiving palliative care in a regional inpatient unit. Over the past two days, staff report that he has become increasingly agitated, restless, and unable to settle. He is speaking incoherently and trying to climb out of bed. His partner is distressed and believes he is in pain, although he is receiving regular analgesia and does not indicate pain when asked directly.

Medications: Fentanyl patch 75mcg/hr, PRN fentanyl 25mcg subcut (used twice overnight), paracetamol 1g QID, lactulose BD, haloperidol 0.5mg PRN (not used), temazepam 10mg nocte

Past history: Metastatic prostate cancer, prior spinal cord compression (treated), mild renal impairment

Social history: Lives with long-term partner, both engaged in care planning. No ACP completed, but verbal goals focused on comfort, no hospital transfer.

Examination findings: Restless, disoriented, talking to people not present. Myoclonic jerks in upper limbs. Pupils small but reactive. BP 105/60, HR 90, RR 20, afebrile. No signs of infection or pain on palpation.

What are the most appropriate next steps in Matthew’s management? Select three (3) from the following list:

Emily Chen, aged 73, is a woman with metastatic cholangiocarcinoma, admitted to a palliative care unit for symptom management. She has progressive jaundice, generalised pruritus, and intermittent nausea. Over the past week, she has developed dark urine, pale stools, and worsening itch, which is now affecting her sleep. She is eating small amounts and taking her medications with some effort. She is not interested in further active treatment and wants symptom control only.

Medications: Paracetamol 1g QID, metoclopramide 10mg TDS, mirtazapine 15mg nocte, oxycodone IR 5mg PRN

Past history: Inoperable cholangiocarcinoma, mild hepatic encephalopathy (prior), depression, atrial fibrillation (rate-controlled)

Social history: Lives with husband. Previously independent. Goals of care documented: symptom-focused, no hospital transfer, no invasive procedures.

Examination findings: Jaundiced, scratching limbs. Alert and oriented. Abdomen soft with mild right upper quadrant tenderness. No peritonism. No signs of infection. BP 120/70, HR 86, RR 16, afebrile.

What are the most appropriate next steps in Emily’s management? Select three (3) from the following list:

Thomas Beattie, aged 61, is a man with metastatic melanoma involving the brain, lungs, and bones. He is currently admitted to a palliative care unit with confusion and falls. Over the last 48 hours, he has become more drowsy, is not eating, and has had two witnessed tonic-clonic seizures. He has no history of epilepsy. His family is concerned that he might be in pain or distressed and are unsure whether further investigations or treatment are appropriate. Thomas previously expressed a wish for comfort-focused care only, and no hospital transfer.

Medications: Subcutaneous morphine 15mg/24h, midazolam 10mg/24h via syringe driver, PRN midazolam 2.5mg subcut, dexamethasone 4mg daily (started 1 week ago), paracetamol 1g QID

Past history: Advanced melanoma, brain metastases (previously treated with radiotherapy), type 2 diabetes

Social history: Lives with partner, previously active, currently bedbound. No formal ACD but documented care goals focus on remaining in palliative care and avoiding invasive treatment.

Examination findings: Drowsy, responds to pain only. RR 18, HR 72, BP 100/60, SpO2 95% on room air. Pupils equal and reactive. No signs of focal neurology. Post-ictal phase noted. Family present and anxious.

What are the most appropriate next steps in Thomas’s care? Select three (3) from the following list:

Karen O’Malley, aged 74, is a woman with metastatic breast cancer and spinal metastases. She is currently being cared for in a palliative care unit. Over the past three days, staff have observed increasing somnolence and reduced oral intake. She has not passed urine for over 24 hours and is no longer taking oral medications reliably. Her daughter, who is present at the bedside, is distressed by Karen’s declining condition and asks whether she is suffering or if anything more can be done.

Medications: Morphine SR 20mg BD (ceased 2 days ago), morphine 5mg subcut PRN, midazolam 2.5mg subcut PRN, paracetamol 1g BD, hyoscine butylbromide 20mg PRN

Past history: Breast cancer with spinal and liver metastases, chronic back pain, opioid-induced constipation

Social history: Widowed, daughter is next of kin and has been closely involved in care decisions. Verbal goals: comfort care only, avoid hospitalisation or burdensome interventions.

Examination findings: Unresponsive, no verbal output. GCS 5 (E2V1M2). Skin cool, extremities mottled. Respirations irregular, occasional shallow breaths. No response to painful stimuli. HR 64, BP 85/55, RR 10, SpO2 88%.

What are the most appropriate next steps in Karen’s care? Select three (3) from the following list:

Brian Watkins, aged 70, is a man with advanced non-small cell lung cancer. He is currently in a regional palliative care unit. Over the past week, he has become increasingly short of breath at rest, with minimal exertion triggering distress. He has mild peripheral oedema and is sleeping in a semi-reclined position. He is alert, but anxious about ‘suffocating’ and asks if there is anything more that can be done to help him breathe easier.

Medications: Morphine SR 10mg BD, morphine liquid 2.5mg PRN (used 4 times in last 24h), frusemide 20mg daily, salbutamol MDI PRN, sertraline 50mg daily

Past history: Advanced lung cancer with pleural involvement, mild chronic heart failure, anxiety disorder

Social history: Widowed, two adult children. Wishes to remain in palliative care unit and avoid invasive interventions. ACP completed: comfort care only.

Examination findings: Mild respiratory distress at rest. RR 24, SpO2 92% on room air. Chest: reduced breath sounds and dullness over right base. Mild ankle oedema. HR 88, BP 120/70, afebrile.

What are the most appropriate next steps in his management? Select three (3) from the following list:

Rachel Andrews, aged 55, is a woman with metastatic breast cancer involving bone and liver. She has been receiving home-based palliative care and is now mostly bedbound. Her partner contacts you for a home visit because Rachel is becoming increasingly confused, drowsy, and agitated. He reports that she hasn’t opened her bowels for over a week despite regular laxatives and that her abdomen feels bloated. Rachel is intermittently vocal and attempts to get out of bed. She is not tolerating oral medications and has minimal fluid intake.

Medications: Oxycodone SR 20mg BD, breakthrough oxycodone 5mg PRN (used 4 times yesterday), haloperidol 0.5mg PRN (not used), paracetamol 1g BD, coloxyl/senna BD, lactulose BD (ceased 3 days ago due to nausea)

Past history: Breast cancer with extensive skeletal and hepatic metastases, opioid-induced constipation, anxiety

Social history: Lives with long-term partner, has previously expressed wish to die at home. No formal ACD, but consistent documentation of comfort-focused care goals.

Examination findings: Agitated and confused. GCS 10 (E3V2M5). Abdomen distended, tympanic, with mild tenderness in the lower abdomen. No focal neurological signs. BP 115/70, HR 90, RR 20, SpO2 96%, afebrile.

What are the most appropriate next steps in Rachel’s palliative care management? Select three (3) from the following list:

Felicity Rhodes, aged 82, is a woman with advanced ovarian cancer and extensive peritoneal disease. She has been admitted to a palliative care unit due to recurrent malignant ascites and anorexia. She is drowsy but rousable, and has not eaten more than a few mouthfuls in the past five days. Her abdomen is distended and she occasionally complains of nausea and early satiety. Her daughter is concerned that Felicity is ‘starving to death’ and asks whether she should be given a feeding tube or IV fluids to help her regain strength.

Medications: Paracetamol 1g PRN, haloperidol 0.5mg PRN, PRN morphine 2.5mg subcut (used once yesterday), ondansetron 4mg PRN

Past history: Advanced ovarian cancer, recurrent ascites, hypertension, previous chemotherapy (ceased 6 months ago)

Social history: Lives with daughter. No advance care directive, but consistent verbal and documented goals to avoid hospitalisation and focus on comfort.

Examination findings: Drowsy, mild nausea. Abdomen distended but non-tender. Mild pedal oedema. Vitals: HR 78, BP 105/60, RR 18, SpO2 94%, afebrile.

What are the most appropriate next steps in Felicity’s palliative management? Select three (3) from the following list:

Daniel Cooper, aged 69, is a man with advanced oesophageal cancer. He has had progressive dysphagia over the past month and is now only tolerating small sips of water. He is being cared for in a rural palliative care unit and has expressed a wish to avoid invasive interventions. Over the last few days, he has become increasingly fatigued and has had two episodes of coughing while drinking. He remains alert but is becoming drowsier and tells staff he feels ‘ready’. His family is concerned that he may be ‘starving’ and want to know whether he should be fed through a tube or taken to hospital.

Medications: Subcutaneous morphine 10mg/24h, midazolam 5mg/24h, haloperidol 0.5mg PRN, paracetamol 1g PRN

Past history: Inoperable oesophageal cancer, progressive dysphagia, anxiety disorder

Social history: Lives alone but now in inpatient palliative unit. Children involved in care. No formal ACD, but documented preference for comfort-only care and no hospitalisation.

Examination findings: Alert but fatigued. Occasional cough on sips of water. RR 20, SpO2 94% on room air, HR 78, BP 110/65. Abdomen soft. No fever, no signs of pain or infection.

What are the most appropriate next steps in Daniel’s care? Select three (3) from the following list:

Leonard “Len” Fraser, aged 79, is a man with advanced chronic obstructive pulmonary disease (COPD) and frailty. He is a long-term resident of a rural residential aged care facility (RACF). Staff have contacted you because Len has become more breathless over the past 24 hours, has stopped eating, and appears drowsy. He has an advance care directive that clearly states his wishes to receive comfort care only, and to avoid hospitalisation or resuscitation. His son is at the bedside and is distressed by the way Len is breathing, asking if ‘he is suffocating’.

Medications: Salbutamol and ipratropium via MDI PRN, morphine liquid 2.5mg subcut PRN (used twice today), midazolam 2.5mg subcut PRN, paracetamol 1g PRN

Past history: Severe COPD (FEV1 25%), atrial fibrillation, previous smoking history, osteoporosis, cachexia

Social history: Widower, lives in RACF. Goals of care documented: palliative only. Family aware of advanced disease but distressed by current symptoms.

Examination findings: Drowsy but rousable. Respiratory rate 28, shallow breathing. Accessory muscle use present. SpO2 86% on room air, HR 94, BP 105/60. No cyanosis. Auscultation: quiet breath sounds bilaterally. No fever.

What are the most appropriate next steps in Len’s care? Select three (3) from the following list:

Anna Reilly, aged 76, is a woman with advanced endometrial cancer with pulmonary and hepatic metastases. She has been under home-based palliative care and her son now calls urgently to report that Anna is having episodes of restlessness, hallucinations, and picking at the sheets. She has not eaten or had oral medications in over 24 hours. Her breathing has become irregular, and she is intermittently groaning but does not respond when spoken to. Her son is worried she is suffering and asks if she should be moved to hospital or ‘put on a drip’.

Medications: Morphine 10mg/24h via subcutaneous infusion, midazolam 5mg/24h, haloperidol 0.5mg PRN (not yet used), paracetamol PRN

Past history: Endometrial cancer, hypertension, depression (stable)

Social history: Lives with son, clear preference for home-based care and no hospital transfer documented in community palliative records

Examination findings (home visit): Unresponsive to voice. GCS 4. RR 10, irregular pattern. HR 70, BP 90/50, SpO2 88% on room air. Skin cool and mottled. No signs of pain or respiratory distress. Picking movements observed.

What are the most appropriate next steps in managing Anna’s symptoms? Select three (3) from the following list:

George Malouf, aged 71, is a man with metastatic prostate cancer and spinal metastases. He has recently been admitted to a palliative care unit for symptom management. Over the last week, he has developed new symptoms of urinary incontinence, increasing lower limb weakness, and unsteady gait. He is still ambulant with assistance but reports a deep aching pain in the lower back and legs, worse at night and not relieved by his regular analgesia.

Medications: Oxycodone SR 20mg BD, oxycodone IR 5mg PRN (used 4 times in the last 24h), paracetamol 1g QID, senna/docusate BD

Past history: Prostate cancer with known bone metastases, hypertension, osteoarthritis

Social history: Retired mechanic. Widower. Clear preference for comfort care. No hospital transfer unless essential for symptom control documented in progress notes.

Examination findings: Alert. Power 3/5 in both lower limbs. Decreased perianal sensation. Reflexes diminished in lower limbs. Tenderness over thoracolumbar spine. No fever. BP 130/75, HR 82, RR 18, SpO2 97%.

What are the most appropriate next steps in George’s management? Select three (3) from the following list:

Julie Tran, aged 62, is a woman with metastatic pancreatic cancer and known hepatic and peritoneal spread. She has been receiving palliative care at home and is now in the terminal phase. Her husband calls the service to report that she has become non-verbal, is breathing irregularly, and has not opened her eyes all day. He asks whether she should be taken to hospital or if there is anything that needs to be ‘done urgently’.

Medications: Morphine 15mg/24h via syringe driver, midazolam 10mg/24h, PRN haloperidol 0.5mg, PRN glycopyrrolate 200mcg

Past history: Pancreatic cancer with extensive spread, type 2 diabetes (diet-controlled)

Social history: Lives with husband. Clear care plan in place indicating home death is preferred, no transfer to hospital, focus on symptom management only.

Examination findings (home visit): Unresponsive. Irregular breathing with occasional apnoeas. Skin mottled and cool. No signs of distress. HR 60, BP 90/50, RR 10, SpO2 88%. Terminal secretions audible. Family visibly distressed.

What are the most appropriate next steps in Julie’s palliative care? Select three (3) from the following list:

Margaret Lawson, aged 80, is a woman with metastatic colorectal cancer and significant hepatic metastases. She is currently being cared for at home with daily support from her daughter and community palliative nursing. Her daughter contacts your practice concerned that Margaret is increasingly jaundiced, confused, and agitated. She has also noted that Margaret’s urine has turned dark and her skin is intensely itchy. Margaret is not tolerating oral medications and has not had a bowel motion in four days.

Medications: Morphine 10mg/24h via syringe driver, PRN midazolam 2.5mg subcut, PRN haloperidol 0.5mg, PRN paracetamol 1g, lactulose (ceased due to poor intake)

Past history: Metastatic colorectal cancer, hepatic encephalopathy (prior episode), hypertension, type 2 diabetes

Social history: Lives with daughter, strong preference to die at home. No hospital transfer per verbal and documented wishes.

Examination findings (home visit): Jaundiced, scratching skin. Agitated, talking incoherently. Asterixis present. Abdomen distended but soft. BP 110/70, HR 86, RR 20, SpO2 95%. No signs of infection or respiratory distress.

What are the most appropriate next steps in Margaret’s symptom management? Select three (3) from the following list:

Philip Zhao, aged 68, is a man with advanced head and neck cancer involving the oropharynx and cervical nodes. He is receiving inpatient palliative care for progressive dysphagia, weight loss, and pain. He has had minimal oral intake for the past 10 days and has now developed halitosis and visible oral thrush. He is able to communicate but has difficulty swallowing and is declining oral medications. His wife is distressed, stating that ‘he’s starving and in pain’ and wants to know what else can be done to improve his comfort.

Medications: Fentanyl patch 50mcg/hr, PRN oxycodone 5mg liquid (ceased), paracetamol 1g BD, haloperidol 0.5mg PRN, miconazole oral gel (ceased due to poor oral intake)

Past history: Squamous cell carcinoma of the oropharynx, hypertension, type 2 diabetes

Social history: Lives with wife. Has verbalised wish to remain in the palliative care unit and not be transferred to hospital. No artificial feeding desired.

Examination findings: Cachectic. Poor dentition. Visible pseudomembranes on tongue and buccal mucosa. Mild halitosis. No fever. HR 82, BP 115/70, RR 18, SpO2 97%. Appears fatigued but not in visible distress.

What are the most appropriate next steps in Philip’s management? Select three (3) from the following list:

Barbara Neill, aged 88, is a woman with end-stage congestive heart failure (CHF) and frailty. She lives in a residential aged care facility (RACF) and has been receiving comfort-focused palliative care. Over the past two days, she has become increasingly drowsy and minimally responsive. Staff report she has stopped eating and is having periods of irregular breathing. Her daughter is at the bedside and is worried that her mother is in pain or ‘drowning’ due to a recent increase in gurgling breath sounds.

Medications: Subcutaneous morphine 10mg/24h, PRN midazolam 2.5mg subcut, PRN glycopyrrolate 200mcg subcut (used once today), frusemide ceased 3 days ago

Past history: Severe CHF, atrial fibrillation, chronic kidney disease, prior myocardial infarction

Social history: Widowed, in RACF for 3 years. Advance care directive completed: no hospitalisation, comfort care only, preference for natural death in the facility.

Examination findings: Unresponsive. Irregular, noisy breathing with terminal secretions audible. RR 8, HR 62, BP 90/55, SpO2 89%. Cool peripheries. No signs of respiratory distress or pain. Daughter tearful and seeking reassurance.

What are the most appropriate next steps in Barbara’s care? Select three (3) from the following list: