SCA practice case · Telephone consultation
Older adults: SCA practice case
A care-home manager’s request about insulin
Telephone consultation
Older adult patient
Someone else speaking
Hard
Older adultsProfessional & ethical dilemmas
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Iris Delaney (caller: Paula Nwosu, registered care-home manager) · 84-year-old woman
Setting
Telephone consultation with a care-home manager about a resident who is declining her insulin.
Past history
- Mixed Alzheimer’s and vascular dementia (MMSE 14/30 six months ago)
- Type 2 diabetes (20 years); on insulin for 6 years
- Hypertension
- Stage 3a chronic kidney disease (eGFR 52 four months ago)
Medication
- Insulin glargine 18 units each morning (given by nursing staff)
- Metformin 500 mg twice daily
- Amlodipine 5 mg once daily
- Donepezil 10 mg at night
Allergies
No known drug allergies
Recent notes
HbA1c 58 mmol/mol four months ago. Two hypoglycaemic episodes (3.1 and 3.4 mmol/L) in the summer, both in the early morning. Nursing home resident for 14 months. DoLS urgent authorisation granted by the home and standard authorisation applied for five months ago; not yet assessed by the local authority. Son, Michael Delaney, holds LPA for property and financial affairs only. No advance decision recorded.
Reason for contact
Telephone call from the registered manager requesting a letter authorising covert administration of insulin and “confirming the DoLS” today.
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
A request for a ’covert medication letter’ is a request to bypass the Mental Capacity Act. Covert administration requires a decision-specific capacity assessment, a documented best-interests decision involving family, staff and a pharmacist, and regular review; and an insulin injection cannot be given covertly. A DoLS authorisation does not authorise treatment. The clinical task is to find out why she is refusing: here a probable urinary infection with delirium, sore over-used injection sites and possibly a wish to stop. The safeguarding task is the restraint that caused bruising. The relational task is to support a well-meaning manager under pressure while holding the line.
The guidance behind it
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