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Challenging · Discharge · Nursing

Going home to die: a syringe driver and a family disagreement

This case practises: A clear timeline · Putting the care plan where the reader acts on it · Choosing which medicines to mention · Leaving out what the reader doesn't need

Writing task

Today's date: 6 December 2026. You are the registered nurse on the Oncology Ward, Riverdale General Hospital. Write a letter to Ms Amara Okeke, Community Palliative Care Nurse, Riverdale Hospice at Home Team, Riverdale Hospice, 4 Meadow Lane, Riverdale, whose team will take over Mr Fischer's care at home after his discharge today. Write in full sentences, not note form, using letter format. Aim for a body of about 180–200 words.

Case notes

In the test you get 5 minutes to read, then 40 minutes to write.

Patient details
- Mr Leonard Fischer, DOB 12/04/1958 (68 y.o.)
- 3 Willow Court, Riverdale (bungalow)
- Admitted 28/11/2026; discharge home 06/12/2026

Social background
- Lives with wife (Mrs Ruth Fischer), main carer
- Son (Daniel) lives locally; daughter in Germany with 2 grandchildren
- Retired bank manager; enjoyed golf until 2025
- Has a dog; neighbour walks it
- Non-smoker; drank socially
- Enjoys classical music; radio on in his room
- Brother died of bowel cancer 2015
- Chaplain visited 02/12 at his request

Medical history
- Metastatic pancreatic cancer (liver metastases), diagnosed 03/2025
- Chemotherapy 2025 - stopped 08/2026 (disease progression)
- Cholecystectomy 2009
- Hypertension; high cholesterol
- Hearing aids both ears
- Flu vaccine 10/2026

Admission
- 28/11: abdominal pain 8/10, nausea, vomiting; unable to take oral meds
- CT: progression of liver metastases; bilirubin 68 µmol/L
- Hb 101 g/L; albumin 26 g/L
- Weight 58 kg (72 kg in 01/2025)
- Subcutaneous syringe driver (CSCI) started 29/11
- 01/12: unsure where he wants to be cared for
- 03/12: states clearly he wishes to die at home - capacity assessed, documented
- 04/12: family meeting - wife supports home; son prefers hospice, worried wife "won't cope"; agreed to try home with full support, review if needed
- DNACPR in place (original sent with pt)
- Prognosis: likely short weeks

Syringe driver (CSCI, 24 h, changed daily at 10:00)
- 29/11: morphine 10 mg + metoclopramide 30 mg
- 03/12: morphine increased to 20 mg (pain 6/10)
- 04/12: midazolam 5 mg added (restlessness at night)
- 05/12: metoclopramide stopped (nausea resolved)
- Current: morphine 20 mg + midazolam 5 mg / 24 h; pain 2/10

Anticipatory (PRN SC) meds at home
- Morphine 5 mg PRN pain/breathlessness
- Midazolam 2.5 mg PRN agitation
- Levomepromazine 6.25 mg PRN nausea
- Glycopyrronium 200 mcg PRN secretions

Stopped
- Ramipril, atorvastatin, Creon (eating very little)

Current status
- Drowsy but rousable; sips of fluid only
- Sacrum: skin intact, redness; 2-hourly turns
- Catheter in situ (urinary retention 30/11)

Discharge plan
- Palliative team: daily visit - refill syringe driver 10:00; review symptoms and PRN use
- Hospital bed + pressure-relieving mattress delivered 05/12
- Pressure care; mouth care
- Support wife; review home vs hospice if wife not coping (son's concern)
- GP (Dr Kelly) informed; home visit within 2 days
- 24-h hospice advice line given to wife

Write your letter

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Model answer Try writing your own letter first
Ms Amara Okeke
Community Palliative Care Nurse
Riverdale Hospice at Home Team
Riverdale Hospice
4 Meadow Lane
Riverdale

6 December 2026

Dear Ms Okeke,

Re: Mr Leonard Fischer, DOB 12/04/1958

I am writing to hand over the care of Mr Fischer, a 68-year-old man with metastatic pancreatic cancer who is going home today for end-of-life care, and to request daily visits to manage his syringe driver and support his wife.

Mr Fischer's prognosis is likely to be short weeks. He has clearly stated, with capacity, that he wishes to die at home, and a DNACPR form accompanies him. He is drowsy but rousable, takes sips only and has a urinary catheter.

His syringe driver, changed daily at 10:00, now contains morphine 20 mg, increased on 3 December, and midazolam 5 mg, added on 4 December for night-time restlessness. Metoclopramide was stopped as his nausea has resolved, and his pain is now 2/10. Anticipatory medicines for pain, agitation, nausea and secretions are at home.

I would be grateful if you could refill the syringe driver daily, review his symptoms and continue two-hourly turns for sacral redness. His wife is his main carer; however, his son worries she will not cope, so please review whether hospice care is needed if she struggles. His GP will visit within two days.

Yours sincerely,

Registered Nurse
Oncology Ward
Riverdale General Hospital

What the reader needs

  • Metastatic pancreatic cancer; going home today for end-of-life care, prognosis likely short weeks
  • His capacitous wish to die at home; DNACPR in place
  • Current syringe driver: morphine 20 mg and midazolam 5 mg over 24 hours, changed daily at 10:00
  • Morphine increased to 20 mg; midazolam added; metoclopramide stopped as nausea resolved
  • Anticipatory medicines at home for pain, agitation, nausea and secretions
  • Request: daily visits to refill the syringe driver and review symptoms
  • Family disagreement: wife supports home, son worried she won't cope; review if she isn't coping

Details to leave out

  • Retired bank manager, golf, dog
  • Daughter and grandchildren in Germany
  • Smoking and alcohol history
  • Chemotherapy history and cholecystectomy
  • Hypertension, cholesterol and the stopped tablets
  • CT and bilirubin results
  • Admission symptoms in detail (pain 8/10, vomiting)
  • Music, brother's history, chaplain visit
  • Hearing aids and flu vaccine
  • Blood results and weight history

One good way to write this letter, not the only one. Written by Kurippu; awaiting nurse review.