My reflections on a challenging nightshift caring for a dying patient.

By Dr Ailie Brennan-Davies
General Hospital Medical Officer, St Vincent’s Hospital Melbourne

After years of planning, months of paperwork and weeks of packing – I was finally working in Australia. When I moved from London to Melbourne after foundation training, I anticipated a learning curve with new systems and guidelines, but I didn’t expect to be tested so quickly in the emotionally charged space of end-of-life care

While nervously receiving handover for the wards I would cover during my first nightshift in Australia, I was made aware of a patient who was in the final stages of dying. She was comfortable, with prescribed anticipatory medications and her family present. Reassured, I placed a comfort check lower on my mental priority list but soon received a page requesting non-urgent review: the patient’s family were concerned about pain and requesting further opioids.

The patient had recently transferred from another hospital, and the notes were limited. I had no real sense of her baseline presentation or prior discussions around her care goals. Had there been family meetings about comfort versus sedation? What had treating team explained about the symptoms of dying, anticipatory medications, and syringe drivers? Her chart included PRN doses of hydromorphone, an opioid I was less familiar with, last given 40 minutes ago.

This lack of background and continuity is a constant challenge for an on-call doctor, particularly in situations where rapport and trust are crucial. Families often see you as a continuation of “the team,” but in reality, we step in with little context and heavy emotional expectations.

I braced myself before entering the room; midnight introductions to grieving families are never easy. I was met by ten relatives with voices overlapping —some red-eyed, others pacing. Realising an eleven-way conversation was not going to work, I stood aside with her primary next-of-kin. His distress was evident; his mother was in pain and needed more drugs — now. The word “inhumane” was used, and there was little patience for my questions. Beneath his frustration, I could feel genuine concern.

I carefully assessed the patient under many expectant eyes. She was frail, pale, and breathing irregularly but gently, appearing asleep and comfortable. I explained that I could see no need for further doses at that moment, though I acknowledged that my assessment was just a snapshot. The family did not agree, although they struggled to articulate what worried them.

I felt the tension between clinical judgement and family expectations. It can be tempting to appease the family and avoid conflict, but this clearly went against what I felt was right for the patient. I sensed the family’s grief was manifesting as a need for control, but recognised that their requests came from distress, not confrontation. Taking a moment to explain the signs of dying and justify my rationale, helped reassure them that their mother was not in distress. At this inopportune moment, I was paged about a deteriorating patient and was pulled away. Despite my best attempts to explain, the family’s frustration was evident, and I feared that the rapport I had built had been fractured.

Back on the ward, I needed more information before proceeding. The bedside nurse’s insight was invaluable: the patient was drowsy, intermittently grimacing or groaning, but settled well after anticipatory medications at the prescribed intervals. We both agreed that the current dosing was sufficient, with more risking oversedation. Given the number of doses required, it seemed appropriate to consider a syringe driver – something I had never initiated independently or prescribed on paper charts before.

I called the medical registrar, a lifeline in times of uncertainty, who agreed with my plan but was also unfamiliar with starting a syringe driver. Unable to find the local guideline, and with the BNF firmly out of reach, I needed specialist palliative care guidance.

It can be daunting to call a senior colleague overnight. There’s always that hesitation — am I overreacting, should I be able to manage this myself? After some hesitation, making the call ended up being the right decision. The on-call consultant’s guidance not only clarified safe prescribing but also supported the nursing team and gave the family confidence that expert oversight was in place. The situation de-escalated: the patient remained comfortable, the family settled, and the palliative care team would review the case in the morning.

Looking back, several reflections stand out:

First, listen first and medicate second.

Communication is as much a part of palliative care as pharmacology. It is often complex, and that night I faced multiple barriers including fatigue, unfamiliarity with the case, and a highly distressed family. Building rapport with many relatives at once, while balancing other clinical priorities, was challenging. Despite this, families facing loss need to feel heard, and listening empathetically can sometimes ease their anxiety more than medication changes. Introducing myself to the family earlier may have reassured them that support was available and built trust before things reached crisis point.

Second, communicate early and document well.

This situation reinforced the importance of discussing death early. Although often fraught conversations, addressing what to expect and what can be offered helps manage family expectations and reduce anxiety and distress in the long run. Good documentation and clear handover to our out-of-hours colleagues are crucial. On cover-shifts since, I have strived to better understand current management, and whether discussions about next steps have taken place.

Third, seek help without hesitation.

Knowing your limits and seeking support early is a strength, not a weakness. Overnight, with limited resources and support, involving senior clinicians can turn a tense situation into a collaborative one. In hindsight, I delayed calling the consultant due to my own anxieties, but getting expert advice took only minutes and provided clarity, reassurance, and best care for my patient.

I’m reminded that palliative care is rarely black and white. Comfort is subjective, and as clinicians, we must balance multiple perspectives — our clinical assessment, the nursing team’s insights, and the family’s emotional needs. The goal is not simply to adjust medication, but to align care with the patient’s dignity, comfort, and safety.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.