Planning for a good death: responding to unexpected events

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Abstract
Case history A 19 year old man was diagnosed with rhabdomyosarcoma of the prostate with lung metastases and bone marrow disease. He was treated with four chemotherapeutic regimens. Although the pulmonary metastases completely resolved, the disease progressed at the primary site and regional lymph nodes. He had multiple complications from the chemotherapy, which resulted in lengthy hospital admissions. Controlling his pain, particularly neuropathic pain in his left leg, was difficult. He had many plans for the future and promising career prospects ahead of him. Despite several attempts, we were unable to open a discussion with him about his prognosis or end of life issues in the days preceding the emergency event. A Bench in Paris by Osmond Caine, 1960 Credit: PRIVATE COLLECTION/BAL While he was an inpatient on the palliative care ward at the tertiary referral unit he developed intermittent melaena sufficient to require blood transfusion. Gastroscopy showed no abnormality. Angiography was arranged for the following day at a nearby hospital to locate the bleeding point. That evening, however, the rate of bleeding became catastrophic, and an immediate decision had to be made about his management. He was transfused with large volumes of blood products. By midnight, it was clear that he would die without further intervention. At this point he was fully alert and oriented, aware of what was happening and of the consequences of continued blood loss. Staff from different disciplines were present—an oncology registrar and senior house officer, a haematology registrar, a surgical registrar, a palliative care consultant, and ward nursing staff. In addition the oncology, surgical, and anaesthetic consultants were contacted at home for advice. Both the patient's parents were present. The nearby hospital was unable to perform angiography and embolisation that night because it had no critical care beds available. By 3 am we had found another hospital with facilities to perform the procedure, but it was several miles away. Our patient was faced with a traumatic and frightening death. The dilemma was whether to sedate him on the ward or take the risks of transferring him to another unit for a potentially life saving procedure, despite the terminal phase of his illness. Footnotes Contributors All authors were closely involved in the care of this patient and discussion with stakeholders Competing interests None declared.