The SCE Palliative Medicine is one of the smaller SCEs by candidate volume but one of the most clinically grounded. It tests symptom management at a pharmacological depth that goes well beyond what most general physicians encounter, combined with communication frameworks, ethical reasoning, and the management of non-malignant end-stage disease. The exam sits once per year, typically in June.
What makes it challenging
The palliative medicine curriculum is pharmacology-heavy in a way that differs from other medical specialties. You must know opioid conversion ratios between morphine, oxycodone, fentanyl, alfentanil, hydromorphone, and methadone — including the non-linear conversion for methadone at higher doses. You must know syringe driver drug compatibility (which drugs can be mixed in the same syringe driver, which are incompatible, and which require specific diluents). You must know the pharmacology of anti-emetics in the palliative context — cyclizine, levomepromazine, haloperidol, ondansetron, metoclopramide — including their receptor profiles and the rationale for selection based on the cause of nausea.
The Palliative Care Formulary (PCF) is the primary pharmacological reference, not the BNF. Many drugs are used off-label in palliative care, and the exam expects you to know these off-label uses, the evidence base for them, and the dosing conventions specific to palliative practice.
Topic weighting
Pain management accounts for roughly 18 per cent of questions — nociceptive, neuropathic, and bone pain, opioid titration and rotation, adjuvant analgesics (gabapentinoids, antidepressants, corticosteroids, ketamine), interventional techniques, and opioid toxicity management. Nausea and vomiting account for 8 per cent. Respiratory symptoms (breathlessness in advanced disease, death rattle, cough) account for 8 per cent.
End-of-life care accounts for 12 per cent — recognition of dying, individualised care planning, anticipatory prescribing, withdrawal of treatment, and the distinction between proportionate symptom management and the ethical boundaries of end-of-life interventions. Communication and ethics account for 10 per cent — breaking bad news, advance care planning, capacity assessment in the dying patient, and ethical frameworks for decisions about treatment limitation.
GI symptoms (malignant bowel obstruction, constipation, ascites) account for 8 per cent. Syringe driver prescribing and drug compatibility account for 10 per cent — this is a distinctly palliative skill and is tested at a practical level that expects you to prescribe a syringe driver, not just know the theory. Neurological symptoms (seizures in the dying patient, spinal cord compression, raised intracranial pressure) account for 6 per cent.
Non-malignant palliative care — heart failure, COPD, renal failure, MND, and dementia — accounts for 10 per cent and is an area where many candidates have less clinical exposure. The remaining questions cover psychological and psychiatric aspects, bereavement, and legal frameworks.
Opioid conversion
Opioid conversion questions appear in virtually every sitting. You must be able to convert between oral morphine, oral oxycodone, subcutaneous morphine, subcutaneous oxycodone, transdermal fentanyl, subcutaneous alfentanil, and oral/subcutaneous methadone. The conversion ratios must be memorised: oral morphine to subcutaneous morphine is 2:1, oral morphine to oral oxycodone is 1.5:1, oral morphine to transdermal fentanyl uses the standard conversion table. Methadone conversion is complex and non-linear — the ratio increases at higher morphine equivalent doses.
Practise these calculations until they are automatic. They are free marks if you know the ratios and avoidable errors if you do not.
Revision strategy
Three months of focused revision. Start with pain management (the largest domain) and opioid pharmacology. Ensure you can perform opioid conversions reliably before moving on. Month two should cover nausea, respiratory symptoms, GI symptoms, and syringe driver prescribing. Month three should cover end-of-life care, communication ethics, non-malignant palliative care, and legal frameworks.
The PCF should be your primary pharmacological reference throughout. The BNF is useful for standard drug information but does not cover the off-label palliative uses that the exam tests.
iatroX's SCE Palliative Medicine bank contains over 1,500 questions referencing the PCF, NICE, and APM guidelines. Opioid conversion calculation questions are tagged for focused practice. Syringe driver compatibility and prescribing questions replicate the practical decision-making tested in the real exam. All included at £29 per month or £99 per year.