Breaking Bad News OSCE - Terminal Prognosis Discussion

Diagnosis: Terminal Prognosis Discussion

Case Overview

  • Age/Sex: 74-year-old male
  • Occupation: Retired (former factory worker)
  • Setting: Oncology outpatient clinic / results appointment
  • Chief complaint: "I'm here for test results"

Patient Script

Who I Am

I'm 74, retired, I live alone in a small flat — used to work in a factory.

What Brings Me In

I'm here because I was told there were some tests and they rang to say I should come back for the results.

My Story

I've been getting more and more breathless over the last 2 months, and I've lost about 12 kg over the last 3 months without trying. For the past week I've been coughing more; sometimes there's a little blood in the sputum. My chest can hurt on the right side, especially when I breathe in deeply, and I feel much more tired — I can barely walk from my living room to the kitchen now. I had a bout of what my GP called bronchitis and I took a course of antibiotics 10 days ago, but I didn't really get better. I have hardly any appetite and I've been constipated the last few weeks. The nurse said they did scans and bloods and I should come back for the results today.

My Medical Background

  • Past medical history: long history of heavy cigarette smoking (stopped 2 years ago), osteoarthritis, treated with knee injections in the past
  • Medications: occasional ibuprofen for knee pain, paracetamol at night, multivitamin supplement
  • Allergies: none known
  • Social: lives alone, son lives 40 miles away, former smoker ~40 pack-years, drinks 2–3 units of alcohol a few times a week
  • Family history: father died of heart disease, brother has prostate cancer

What I Think & Worry About

  • I think this might be something serious like cancer — I worry I might be dying.
  • I'm frightened about being alone and who will look after me if I'm not well.
  • I want to know what can be done — I don't know whether to expect treatment or just keep comfortable.

If You Ask Me About Other Symptoms...

  • Fever or sweats: "No fevers, but I sometimes wake up hot at night."
  • Cough: "Yes, coughing more for 2 months, sometimes sticky phlegm and once or twice there was a little blood."
  • Chest pain: "I get sharp pain on the right side when I breathe in — it's been worse the last 3 weeks."
  • Legs/shortness: "I had a sore calf a month ago after a long drive but it got better — no swelling now." (red herring)
  • Weight/appetite: "I can hardly eat — food tastes of nothing and I've been losing weight."
  • Memory/Neurology: "I've been a bit more forgetful but nothing major — tripped once going down the stairs a fortnight ago." (distractor)
  • Recent infections: "I was given antibiotics for bronchitis by my GP 10 days ago but I felt only a little better." (red herring)
  • Bowel/urine: "Constipated for weeks, no problems peeing."
  • Pain elsewhere: "My knees ache from osteoarthritis but that's always been there."

Clinical Summary

Examination

  • General: thin, cachectic man, appears frail and mildly distressed by breathlessness
  • Vitals: T 37.4°C, HR 104 bpm (sinus), BP 110/68 mmHg, RR 24/min, SpO2 90% on room air (improves to 94% on 2 L/min O2)
  • Weight: 58 kg (documented loss ~12 kg over 3 months)
  • Respiratory: reduced expansion on the right, dullness to percussion and decreased breath sounds R upper zone with bronchial breathing over a mass; bibasal crackles minimal; small right-sided pleural effusion signs
  • Cardiovascular: heart sounds normal, no raised JVP, no peripheral oedema
  • Neurological: alert, oriented to person/place/time, mild slowed responses but no focal deficit on brief exam
  • Abdomen: soft, non-tender; no palpable organomegaly though mild hepatomegaly may be suspected on percussion
  • Performance status: ECOG 3 (limited self-care; spends >50% of waking hours in bed/chair)

Investigations

  • Chest X-ray: large irregular right upper lobe mass ~6 cm with multiple bilateral pulmonary nodules and small right pleural effusion (suspicious for metastatic disease)
  • CT chest/abdomen/pelvis: right upper lobe mass 6.5 cm with mediastinal lymphadenopathy, multiple bilateral lung metastases, several hypodense lesions in the liver consistent with metastases, small right pleural effusion
  • CT brain: multiple enhancing lesions consistent with cerebral metastases
  • CBC: Hb 95 g/L (normocytic anaemia), WBC 11.2 x10^9/L, Platelets 320 x10^9/L
  • U&E: Na 140 mmol/L, K 4.4 mmol/L, Creatinine 110 µmol/L (slightly elevated), eGFR ~55 mL/min
  • Calcium: corrected Ca2+ 3.00 mmol/L (elevated — likely contributory to symptoms)
  • LFTs: ALP 220 U/L (elevated), ALT 75 U/L, Albumin 28 g/L (low)
  • CRP: 68 mg/L (moderately elevated)
  • ABG (on room air): PaO2 ~8.0 kPa, PaCO2 4.6 kPa
  • ECG: sinus tachycardia

Diagnosis

  • Primary diagnosis: Advanced metastatic lung cancer (most likely non-small cell lung carcinoma) with multi-organ metastases (lungs, mediastinum, liver, brain) and paraneoplastic hypercalcemia — overall very poor prognosis consistent with a terminal phase.

    • Evidence: marked weight loss, progressive dyspnoea, large right upper lobe mass on imaging, multiple metastatic lesions in liver and brain, ECOG 3 and metabolic disturbance (hypercalcaemia).

  • Differentials and reasoning:

    • Complicated pulmonary infection/treated bronchitis: recent antibiotics and mild CRP elevation, but imaging shows mass and metastases making infection less likely as sole cause.
    • COPD exacerbation: long smoking history could contribute, but focal mass and systemic features point to malignancy as primary problem.
    • Pulmonary embolism: acute worsening dyspnoea could suggest PE (and a prior calf pain is a red herring), but imaging and systemic picture support metastatic disease instead; consider if sudden deterioration occurs.
    • Heart failure: less likely given exam (no raised JVP or oedema) and imaging findings.

Management

  • Communication and planning:

    • Arrange an honest, private discussion about scan and blood results; explain diagnosis, likely prognosis, and focus on goals of care (use structured approach to break bad news, allow time for questions).
    • Assess patient’s understanding, preferences, and who he wants involved (son, other family) and evaluate capacity for decisions.
    • Discuss that disease is advanced and likely not curable; discuss options (palliative/comfort-focused care vs. potentially limited interventions), emphasise symptom control.

  • Symptom control and immediate medical management:

    • Treat hypercalcaemia: IV fluids (careful given age), consider IV bisphosphonate (e.g., zoledronic acid) and short course of IV/SC calcitonin if symptomatic; monitor electrolytes and renal function.
    • Manage dyspnoea: start low-flow oxygen to maintain comfort, consider low-dose opioids (morphine) for refractory breathlessness, consider benzodiazepine if severe anxiety contributing to dyspnoea.
    • Analgesia: assess pain and start appropriate opioid titration; avoid NSAIDs given renal function and GI risks.
    • Manage brain metastases symptoms: give dexamethasone to reduce cerebral edema and improve symptoms if headaches or focal deficits present.

  • Palliative care and onward referrals:

    • Urgent referral to palliative care team for symptom management and discussion of hospice care, community nursing support, and social services given he lives alone.
    • Discuss possible palliative radiotherapy for symptomatic lesions (e.g., painful metastasis or brain metastases) with oncology/palliative radiation team — weigh against performance status.
    • Oncology input: consider whether systemic anticancer therapy is appropriate (likely not given poor performance status and multi-organ disease) but document that discussion has occurred.

  • Advance care planning and practical steps:

    • Discuss and document goals of care including DNACPR and preferred place of care/death, ensure clear documentation of discussions and involve family/support person as per patient wishes.
    • Arrange practical support: physiotherapy for mobility if helpful, district nurse visits, medication delivery, and social work assessment for home help/hospice placement.
    • Provide written information and follow-up appointment; ensure phone contact for worsening symptoms and clear plan for emergency care prioritising comfort.

Key Learning Points

  • In patients with new/worsening respiratory symptoms and significant weight loss and smoking history, consider lung cancer; imaging and systemic signs (liver/brain lesions, hypercalcemia) indicate advanced disease and poor prognosis.

  • Breaking bad news requires clear, compassionate communication: assess patient understanding, invite questions, involve family/support, explain prognosis honestly, and prioritise symptom control and the patient’s goals.

  • Immediate management in terminal metastatic cancer focuses on symptom relief (dyspnoea, pain, hypercalcaemia), early palliative care involvement, and practical planning for community support rather than aggressive curative interventions.

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