Education And Debate

Planning for a good death: responding to unexpected events

BMJ 2003; 327 doi: (Published 24 July 2003) Cite this as: BMJ 2003;327:204
  1. Y Saunders, specialist registrar (,
  2. J R Ross, specialist registrar1,
  3. J Riley, consultant1
  1. 1Department of Palliative Medicine, Royal Marsden Hospital, London SW3 6JJ
  1. Correspondence to: Y Saunders
  • Accepted 9 June 2003

When a terminally ill patient develops an acute problem, risky emergency treatment may seem futile to medical staff. But sometimes patients are not ready to die. What is a good death in such circumstances and how do we achieve it?

In palliative care we aim to provide good symptom control and ultimately a good death. Patients and their families need time to prepare for death. Sometimes acute situations arise that can interfere with this process, leading to a distressing and undignified end. Decision making in emergency situations is difficult. We use a case history to illustrate the problems surrounding such decisions.

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.

Embedded Image

A Bench in Paris by Osmond Caine, 1960


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 …

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