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 …