Introduction
End-of-life OSCE stations test your ability to have sensitive, honest conversations about dying, advance decisions, and symptom management. Mark schemes heavily reward empathy, clear explanation, checking understanding, and use of silence.
💎 Clinical Pearl
Use silence. Pause after delivering difficult information. Silence gives the patient space to process — do not rush to fill it. "Would it be alright if I just sat with you for a moment?" is a powerful clinical phrase.
Total Pain — Cicely Saunders Framework
Palliative care addresses total pain: suffering at end of life is not only physical.
🧠 Mnemonic
PSSS — Physical, Psychological, Social, Spiritual
- Physical: pain, nausea, dyspnoea, constipation, fatigue
- Psychological: anxiety, depression, fear of death, fear of pain, loss of control
- Social: role loss, financial worries, family distress, isolation
- Spiritual: meaning, purpose, guilt, reconciliation, religious needs
Addressing only physical symptoms while ignoring the others leaves suffering unresolved.
WHO Analgesic Ladder
| Step | Analgesia | Example |
|---|---|---|
| Step 1 | Non-opioid | Paracetamol plus or minus NSAID |
| Step 2 | Weak opioid | Codeine, tramadol, low-dose oral morphine |
| Step 3 | Strong opioid | Oral morphine, oxycodone, fentanyl patch |
| Adjuvants (any step) | Neuropathic or bone pain | Amitriptyline, gabapentin, dexamethasone, bisphosphonates |
🧠 Mnemonic
"By the mouth, by the clock, by the ladder" — the three WHO principles:
- 1Oral route where possible
- 2Regular dosing (not PRN alone) to maintain steady analgesia
- 3Step up the ladder when the current step fails to control pain
Syringe Driver Medications
A continuous subcutaneous infusion is used when the patient can no longer swallow:
| Drug | Purpose |
|---|---|
| Morphine or diamorphine | Pain and dyspnoea |
| Midazolam | Agitation, anxiety, terminal restlessness |
| Cyclizine or haloperidol | Nausea and vomiting |
| Hyoscine butylbromide | Respiratory secretions (death rattle) |
| Levomepromazine | Broad-spectrum: nausea, agitation, pain |
⚠️ Red Flag
Never mix levomepromazine with cyclizine in the same syringe — precipitation occurs. Check drug compatibility in the Palliative Care Formulary before combining agents.
DNACPR — Key Principles
- 1DNACPR applies to CPR only — it does not restrict antibiotics, fluids, analgesia, or hospital admission
- 2The decision is made by the senior responsible clinician — not the patient's decision alone, but must be discussed with the patient where possible
- 3It must be communicated to nursing staff, out-of-hours teams, and documented clearly
- 4It must be reviewed if clinical circumstances change
How to Have the DNACPR Conversation
- 1Prepare: know the clinical situation; choose a quiet, private space; offer to have a relative or nurse present
- 2Establish what the patient already knows: "What have the doctors told you about where things are with your illness?"
- 3Explain honestly and gently: "I want to talk with you about what would happen if your heart were to stop..."
- 4Explain the clinical reality: CPR success rates in serious illness are very low (under 5% to discharge); it is often violent and unlikely to restore quality of life
- 5Frame as a clinical recommendation: "My recommendation is that if your heart were to stop we would not attempt resuscitation, because I do not believe it would succeed and I worry it would cause more harm than benefit"
- 6Check understanding: "Is there anything you would like me to explain differently?"
- 7Explore values: "What matters most to you at this time?"
💎 Clinical Pearl
Never say "There is nothing more we can do." The correct framing is: "We want to focus all our efforts on keeping you as comfortable and well as possible." There is always something we can do in palliative care.
Advance Care Planning Documents
| Document | Purpose |
|---|---|
| Advance Decision to Refuse Treatment (ADRT) | Legally binding refusal of specific treatments if patient loses capacity. Must be in writing; must be signed and witnessed if refusing life-sustaining treatment |
| Advance Statement | Expression of wishes and preferences — not legally binding but must be considered |
| Lasting Power of Attorney (Health and Welfare) | A nominated person makes health decisions if the patient loses capacity — only activated on loss of capacity |
| DNACPR form | Clinician-completed form for resuscitation status — not an advance directive |
Recognising the Dying Phase
Signs that death is likely within hours to days:
- Mottled, peripherally cool skin
- Cheyne-Stokes or irregular breathing
- Reduced urine output or retention
- Increasing drowsiness and reduced consciousness
- Pooling of secretions (death rattle)
- Difficulty swallowing
When this is recognised: stop non-essential medications, ensure anticipatory medications are prescribed, communicate with family, and involve specialist palliative care if not already done.
Anticipatory Prescribing
Prescribe PRN medications in advance to prevent distress when the patient is dying:
| Symptom | Drug | Route | Dose |
|---|---|---|---|
| Pain | Morphine | SC | 2.5-5 mg |
| Agitation | Midazolam | SC | 2.5-5 mg |
| Nausea | Haloperidol | SC | 0.5-1.5 mg |
| Secretions | Hyoscine butylbromide | SC | 20 mg |
| Dyspnoea | Morphine | SC | 2.5 mg |
"What is the difference between an ADRT and an advance statement?"
An Advance Decision to Refuse Treatment (ADRT) is a legally binding document in which a person with capacity refuses a specific treatment in advance for when they lose capacity. If it refuses life-sustaining treatment it must be in writing, signed, and witnessed. An advance statement is a broader expression of preferences and values (preferred place of death, personal care wishes) — it is not legally binding but healthcare professionals must take it into account.
"DNACPR is not the same as withdrawing all treatment — how do you explain this?"
A DNACPR decision applies only to cardiopulmonary resuscitation if the heart stops. All other active treatments — antibiotics, fluids, oxygen, analgesia, hospital admission — remain available and will be given if clinically beneficial. The decision reflects a clinical judgement that CPR would not succeed and would cause more harm than benefit.
"What drugs are commonly used in a syringe driver and why?"
Common drugs: morphine or diamorphine (pain and dyspnoea), midazolam (agitation and terminal restlessness), cyclizine or haloperidol (nausea), hyoscine butylbromide (respiratory secretions). A continuous subcutaneous infusion is used when the patient can no longer swallow. Drug compatibility must be checked before combining agents in one syringe.
"What is total pain and why is it important?"
Total pain is a concept from Dame Cicely Saunders recognising that suffering at end of life has four components: physical (uncontrolled symptoms), psychological (fear, depression, loss of control), social (role loss, family burden, financial worry), and spiritual (meaning, existential questions). Addressing only physical symptoms while ignoring the others leaves the patient in distress. Holistic palliative care requires attention to all four dimensions.
Related guides: [Breaking Bad News OSCE](/blog/breaking-bad-news-osce-guide) | [Consent and Capacity OSCE](/blog/consent-and-capacity-osce) | [Angry or Distressed Patient OSCE](/blog/angry-distressed-patient-osce)