Station 18 · Care home call

Candidates: do not open until you have consulted.

Persona and manner

• Martin Cole, 55, Ernest's son; distressed, insistent; you use medical words from the internet; you feel guilty about the distance; you suspect the home is giving up and that the doctor is saving money.
• You soften only when your guilt and your father's own words are acknowledged.

Opening line (verbatim)

• “It's about my dad, Ernest Cole — the home says he's stopped eating and they're just going to 'keep him comfortable'. That's not good enough. He needs a feeding tube — a PEG — and I want him in hospital where they can actually do something.”

The story

• “They're giving up on him.” “The DNACPR was never explained to me.” “My sister's too soft.”
• If asked about the last visit: Dad did not recognise you; “he squeezed my hand”.
• You have read that PEG feeding keeps people alive. You have not spoken to the speech therapist or the home's nurse.
• If asked well what your father would have wanted: after Mum died he said, “Don't let me end up like that.” Susan says Dad would hate this.
• You are frightened of letting him starve. You ask whether the doctor is just saving money. You want a second opinion.
• You live in Newcastle; work is relentless; you have not been able to visit; you cry if this is acknowledged.
• If asked about the last admission: you were not told until discharge; you found out from Susan; you feel cut out.
• If the doctor is defensive: you have read the home's inspection report and it said “requires improvement” in 2023.
• If given the opening: “If it was your dad, what would you do?” Listen to the answer.

Ideas, concerns and expectations

• Idea: “Starving to death, and a tube would fix it.”
• Concern: Guilt at living far away; letting Dad die; the sister and the home deciding without you.
• Expectation: A PEG, admission, everything done.

Impact

• Distance: Newcastle; work relentless; the last visit a month ago.
• Family: Susan visits weekly and accepts the situation; you feel cut out.
• Your own state: you have not slept; you are angry with everyone, including yourself.

Red flags

• Present: A family member in conflict with the care plan; a ReSPECT decision the son says was never explained to him; a risk that an admission or a procedure is arranged to end a phone call.
• Absent: No evidence that Ernest is in pain or distress uncontrolled at the home; no new reversible cause reported; no dispute between the home and the daughter.

Hidden facts and their triggers

• “Don't let me end up like that” — released only only if asked what his father would have wanted, in those words or close to them
• The hand squeeze — released only if asked about the last visit
• The guilt and the distance, and the tears — released only if the doctor acknowledges how hard it is to be far away
• That he was not told about the last admission until discharge — released only if asked how he found out things, or about the home's communication
• The inspection report — released only only if the doctor becomes defensive

Behaviour

• Minute 1: “They're giving up on him.”
• Minute 3: “He squeezed my hand.”
• Minute 5, only if asked what his father would have wanted: “Don't let me end up like that.”
• If the doctor listens, acknowledges the guilt and the distance without judgement, explains that Dad cannot make this decision and how the law says it is made (family consulted, his known wishes weighed, burdens and benefits), explains honestly why a tube is not recommended in advanced dementia and what comfort feeding actually involves, reframes starving, goes through the ReSPECT form with you, offers a meeting with the home, the speech therapist, Susan and you by video, offers palliative care involvement and a second opinion, and a plan for keeping you informed: tearful. “So he won't be in pain? And I can still come and feed him myself?”
• If the doctor concedes an admission or a tube referral to end the call: “Fine.”
• If the doctor refuses without explanation: “You're not listening. I'll go to the papers.”
• If the doctor sides with Susan: “So she's decided, has she?”

Examination findings, if the candidate states what they would examine and why

• None: audio-only telephone consultation with a relative; the patient is not present. There are no examination findings to give.
• If the candidate asks what the home has observed: Ernest is comfortable, sleeping most of the day, taking sips and spoonfuls when offered, coughing on thin fluids; no pain behaviours; no fever.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Arguing the evidence on tube feeding before the fear of starving and the guilt about the distance have been heard (statement R2)
• Conceding an admission or a tube referral to end the call (statement C1)
• Refusing without explanation, or hiding behind the form, so that he says “You're not listening” (statement R4)

What the examiner is listening for in the last four minutes

By 8:00 the formulation should have been stated: the last phase of advanced dementia, with Ernest unable to decide and a best-interests decision to be made with the family. The examiner is listening for: no tube and no admission, with the reasons given plainly and kindly; comfort feeding explained as care; the ReSPECT decision reviewed with him; the meeting by video, the palliative care involvement and the second opinion offered; a safety-net for pain or distress; the named contact and the date; and Martin's own words on what he has understood and what role he will take.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Do not routinely use enteral (tube) feeding in people living with severe dementia unless the dysphagia is thought to be a transient phenomenon; encourage and support people living with dementia to eat and drink, taking into account their nutritional needs, and consider involving a speech and language therapist. NICE — NG97 Dementia: assessment, management and support for people living with dementia and their carers, section 1.10, managing other long-term conditions: nutrition and hydration, June 2018, checked 10 Oct 2026
2. A person must be assumed to have capacity unless it is established that they lack it; an act done for a person who lacks capacity must be in their best interests; in determining best interests the decision-maker must consider the person's past and present wishes and feelings, any written statements, and the views of anyone engaged in caring for the person or interested in their welfare. UK Parliament — Mental Capacity Act 2005, sections 1 and 4, the principles; best interests, 2005, checked 10 Oct 2026
3. Where there is no attorney or deputy, the decision-maker for a treatment decision is the clinician responsible, who must consult those close to the person; where the family and clinicians disagree about serious medical treatment, a best-interests meeting, a second opinion, an independent advocate or, if unresolved, the Court of Protection are the routes. GOV.UK (Ministry of Justice) — Mental Capacity Act 2005: Code of Practice, chapter 5, best interests; chapter 15, settling disputes, 2007, checked 10 Oct 2026
4. Reduced oral intake, pocketing food and coughing on fluids are features of the last phase of advanced dementia; comfort (careful hand) feeding with modified textures, good mouth care and symptom control are the recommended approach; a speech and language therapist's assessment guides the textures and the risk conversation with the family. NICE CKS — Palliative care: general issues, management: nutrition and hydration at the end of life, current online version, checked 10 Oct 2026
5. The ReSPECT process records recommendations for a person's clinical care in an emergency, including whether admission and cardiopulmonary resuscitation are wanted or appropriate; the recommendations are made with the person where possible and with those close to them, are reviewed when circumstances change, and do not prevent care for comfort. Resuscitation Council UK — ReSPECT: Recommended Summary Plan for Emergency Care and Treatment, the ReSPECT process, version 3, 2020, checked 10 Oct 2026
6. Recognise when a person is entering the last days or weeks of life, communicate this to those important to them, and agree an individualised plan for symptom control, hydration and nutrition that includes anticipatory prescribing and the involvement of specialist palliative care where needed. NICE — NG31 Care of dying adults in the last days of life, section 1.1, recognising when a person may be in the last days of life; section 1.2, communication; section 1.4, maintaining hydration, December 2015, checked 10 Oct 2026
7. Family members of a person who lacks capacity are entitled to be consulted and to have their views taken into account, and to be told how decisions are being made; information about a patient may be shared with those close to them where this is in the patient's best interests and does not go against their known wishes. GMC — Confidentiality: good practice in handling patient information, paragraphs 41 to 49, patients who lack capacity to consent, 2017 (updated 2018), checked 10 Oct 2026
8. Clinically assisted nutrition and hydration, including feeding by tube, is medical treatment, and the decision about it is made like any other treatment decision. For a patient who lacks capacity and is not expected to die within hours or days, if the clinician judges that clinically assisted nutrition would not be of overall benefit, the decision is discussed with those close to the patient and a second opinion from a senior clinician is sought before it is withheld. GMC — Treatment and care towards the end of life: good practice in decision making, clinically assisted nutrition and hydration, paragraphs 109 to 127, 2010 (in force 1 July 2010), checked 10 Oct 2026
9. A decision not to attempt cardiopulmonary resuscitation applies only to CPR and does not mean that other treatment or care is withheld. Where the patient lacks capacity, those close to the patient are consulted about the decision and told what has been decided and why, unless doing so would cause the patient harm; the decision is recorded, reviewed when circumstances change, and explained to the family again when they ask. GMC — Treatment and care towards the end of life: good practice in decision making, cardiopulmonary resuscitation, paragraphs 128 to 146, 2010 (in force 1 July 2010), checked 10 Oct 2026
10. Prescribe anticipatory medicines for the symptoms likely in the last days of life (pain, breathlessness, nausea and vomiting, agitation and delirium, noisy respiratory secretions) at the earliest opportunity, with the indication and dose for each. Support the dying person to drink if they wish and are able, check for swallowing problems, and give mouth care; do not routinely start clinically assisted hydration, but discuss its risks and benefits with those close to the person. NICE — NG31 Care of dying adults in the last days of life, section 1.4, maintaining hydration; section 1.5, anticipatory prescribing, NG31, 2015, checked 10 Oct 2026
11. People approaching the end of life and those important to them should know whom to contact for advice and support at any time of day or night, and the care plan, including the ReSPECT recommendations, is shared with the out-of-hours service and the ambulance service so that an emergency call does not lead to an admission the person did not want. Care is coordinated by a named lead professional. NICE — NG142 End of life care for adults: service delivery, providing information; sharing information; providing end of life care coordination and out-of-hours support, NG142, 2019, checked 10 Oct 2026
12. An independent mental capacity advocate must be instructed for a serious medical treatment decision only where the person lacks capacity and there is no one other than paid carers whom it is appropriate to consult. Where family members are available and willing, as here, they are the people consulted, and the advocate is not required; a best-interests meeting with them is the usual next step. UK Parliament — Mental Capacity Act 2005, section 37, provision of serious medical treatment by NHS body, 2005, section 37, checked 10 Oct 2026
13. The curriculum expects the GP to recognise when a person with advanced dementia is entering the last phase of life, to lead advance care planning with the person where possible and with those close to them, to apply the Mental Capacity Act to decisions such as feeding and admission, to work with the care home and specialist palliative care, and to support relatives, including those who disagree with the plan. RCGP — GP curriculum: People at the end of life, recognising dying; advance care planning; capacity and best interests; working with care homes, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

13 statements, 797 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-18