Band: 5-7 Focus

Patient: Mr. Khan, 72, with metastatic lung cancer.

Scenario: You are asked to support Mr. Khan's wife, who is visibly distressed. She asks directly, “Is he dying?” while Mr. Khan is resting. The consultant has not yet had a conversation with the family about prognosis. You must consider your role, professional boundaries, and how to communicate honestly yet sensitively.

Reflection prompts:

• How would you respond, and why?
• What communication frameworks or skills could you draw on?
• Thinking about your current role, what might be your limits in giving information?
• How could you involve the wider MDT and what might be the benefit of doing this?

Band: 5–8a Focus

Patient: Mrs. Davies, 68, with pancreatic cancer and severe abdominal pain

Scenario: Despite regular oral morphine sulphate, Mrs. Davies reports ongoing pain (score 7/10). You notice increasing sedation and hallucinations. The family is concerned about giving Mrs Davies "too much morphine”. You must review her analgesia and liaise with the palliative team or pain service.

Reflection prompts:

• How could you assess her pain?
• How could you assess for opioid side effects?
• What adjustments might you suggest or things you may escalate?
• How could you explain the rationale for changes to the family?
• What safety considerations are there?

Band: 5–7 Focus

Patient: Mr. Osei, 60, with advanced gastric cancer

Scenario: Mr. Osei has persistent nausea and occasional vomiting despite regular metoclopramide. He is anxious, and his oral intake has reduced. You are asked to review and offer symptom management.

Reflection prompts:

• What assessments could you carry out?
• Explain how you would consider the cause of nausea (for example, chemical, mechanical)?
• What antiemetic changes might be considered or made?
• How did could you support Mr. Osei, both emotionally and nutritionally?

Band: 5–8a Focus

Patient: Mrs. Patel, 80, with end-stage heart failure

Scenario: Mrs. Patel is currently receiving end-of-life care in hospital, and while her family are visiting, she becomes acutely breathless with laboured breathing. Her family are concerned and asks for emergency oxygen and resuscitation. Mrs. Patel has a valid DNACPR and ReSPECT form indicating her ceiling of care is for end-of-life care and symptom control only. You must manage the situation clinically and emotionally.

Reflection prompts:

• What immediate clinical actions might you take?
• How would you involve the family while maintaining the care plan?
• What communication techniques might help de-escalate anxiety?
• How could you document and escalate Mrs Patels care if needed?

Band: 6–8a Focus

Patient: Mr. McBride, 78, with end-stage COPD

Scenario: Mr. McBride is deteriorating. The medical team recommends ward-based care only, but the family demands transfer to the intensive care unit (ICU). Mr. McBride previously said he would not want intensive treatment, and this includes transfer to the ICU. You are involved in family discussions and care planning.

Reflection prompts:

• What ethical principles are involved (autonomy, beneficence)?
• How could you advocate for Mr. McBride’s wishes?
• Describe any potential communication challenges with the family?
• How might the MDT collaborate to resolve this?

Band: 5–7 Focus

Patient: Mrs. Liu, 84, with advanced dementia and pneumonia

Scenario: Mrs. Liu is semi-conscious, not swallowing, and nearing the end of life. Her daughter insists on NG feeding and IV fluids. The palliative team has documented a comfort-focused care plan, and that diet and fluid can be given as per the Eating and Drinking with Acknowledged Risk (EDAR) guidelines. You are asked to discuss the current plan with the daughter.

Reflection prompts:

• What clinical indicators might inform the decision to stop artificial hydration/nutrition?
• How would you explain this sensitively to the family?
• How could you manage any emotional responses?
• What support might you need to give to other staff involved?

Band: 5–7 Focus

Patient: Mr. Ahmad, 67, with advanced liver cancer

Scenario: Mr. Ahmad, a practising Muslim, becomes unconscious in his final hours. His family requests that he be positioned facing Mecca and that only male staff provide personal care. The ward is busy, and some staff are unsure how to meet these requests while maintaining care for other patients.

Reflection prompts:

• How would you respond to the family's spiritual and religious needs?
• What actions might you take to accommodate their wishes?
• How could you balance religious sensitivity with clinical priorities and staff availability?
• What do you understand about cultural competence in palliative care?

Band: 6-8a Focus

Patient: Mrs. Gallagher, 75, with progressive motor neurone disease (MND)

Scenario: During a routine review, Mrs. Gallagher expresses concern about choking and future hospitalisation. She asks about “putting things in place now” so her wishes are respected later. The family appear uncomfortable with the conversation and change the subject.

Reflection prompts:

• How could you facilitate the conversation around advance care planning?
• How might you balance the patient’s autonomy with family dynamics?
• What documentation and MDT input may be required following the discussion?
• What strategies could you use to revisit the topic with the family?

Band: 5 - 7 Focus

Patient: Miss Roberts, 40, died from metastatic breast cancer overnight

Scenario: You are the nurse allocated to provide care after death (last offices) and support Miss Roberts' family, who arrive visibly distressed. Miss Roberts was close to her sister and wants to help wash and dress the body. A junior nurse expresses that she has not participated in care after death before and feels some discomfort about Miss Robert’s sister helping.

Reflection prompts:

• How can you ensure respectful, person-centred care after death?
• What legal, cultural, or professional considerations might you factor in?
• How would you support the junior nurse and family member in this process?
• What might be the impact of this experience on your own practice?

Band: 5-8a Focus

Patient: Mr. Bennett, 74, with advanced glioblastoma

Scenario: Mr. Bennett is in the last days of life. He becomes increasingly agitated, pulling at bedclothes, moaning and appearing frightened. He is unable to communicate clearly. The family is distressed and asks whether he is in pain or “suffering”. No syringe driver is yet in place and PRN medications have had limited effect.

Reflection prompts:

• How would you assess and interpret the signs of terminal agitation?
• What non-pharmacological and pharmacological strategies could you implement or escalate?
• How would you communicate with the family about what was happening?
• What would you consider when escalating to the palliative care team or adjusting medication?
• How might you manage the emotional impact of managing visible distress at the end of life?

Band: 5 - 8 Focus

Patient: Mrs Ellis, 72-year-old lady with advanced MND.

Scenario: Mrs Ellis was diagnosed with MND three years ago. Over time, she has lost the ability to speak, move independently, and swallow without assistance. Her cognitive function remains intact, and she communicates using an eye-tracking device. She has expressed deep distress over her loss of autonomy and the physical suffering she endures daily.

Mrs Ellis has been receiving palliative care for several months. Despite optimal symptom management, she reports persistent feelings of hopelessness and emotional anguish. She has repeatedly voiced her desire to end her life peacefully, citing dignity and control as her primary motivations. Mrs Ellis asks to talk about end-of-life options, including assisted dying.

Reflection prompts:

• How can you provide an open and honest dialogue around assisted dying within the bounds of ethical and legal practice?
• How would you respond compassionately?
• What documentation and MDT input may be required following the discussion?
• What might be the impact of this experience on your own practice?

Topic: Recognising and responding to signs of dying

Scenario: You are on placement on a medical ward. An older patient with advanced heart failure is noted to be increasingly drowsy, not eating or drinking, and has cool extremities. The nurse in charge discusses that the patient may be entering the last days of life. You are asked to support care and observe changes.

Learning opportunities:

• Recognising clinical signs of dying
• How to provide comfort-focused care (for example, mouth care, pressure relief)

Reflection prompts:

• What signs might help the team identify that the patient is dying?
• What could you do to make you feel confident about this situation in your role?
• How could you ensure the patient’s dignity is preserved?
• Why might it be important to ensure multidisciplinary working in end-of-life care?

Topic: Compassionate communication with relatives

Scenario: A patient’s daughter approaches you during visiting hours, tearful and anxious about her father’s condition. She asks you questions you aren’t sure how to answer. You stay with her, listen, and later update the nurse in charge about her concerns.

Learning opportunities:

• Active listening and emotional presence.
• Knowing when and how to escalate concerns.
• Developing confidence in professional communication.
• Understanding boundaries and your scope of practice as a student.

Reflection prompts:

• How could you support the relative?
• What communication techniques might you use?
• How could you manage your own emotions?

Scenario/case study: ____________________________________________________________

Date of learning session: _________________________________________________________

Brief description: _______________________________________________________________

What do you think you did learn from this learning section and case study? ________________________________________________________________________

What would you do in response? __________________________________________________

How might this improve or influence your future practice? ______________________________________________________________________

Relevant parts of the NMC Code (tick):

☐ Prioritise people ☐ Practise effectively ☐ Preserve safety ☐ Promote professionalism and trust