Palliative care emergencies are well recognised. Hypercalcaemia, spinal cord compression, and obstruction of the superior vena cava are standard fare in terminal illness, and their management is often taught. But how often do we recognise communication as a genuine palliative care emergency?

A 67 year old man was transferred to our hospice from the local district general hospital on a Friday. He had end stage cardiac failure, and an implantable cardioverter defibrillator was in place. The referral was clear enough: he was coming to us to die. Just as clear was the fact that he didn't know his prognosis but was apparently expecting rehabilitation.

By the time I (MP) had admitted him he had turned blue three times, and during one of these cyanotic attacks the defibrillator had discharged. It was clear that he was very near the end. As I began to explore his understanding of the illness and what the future held for him, I felt a subtle squeeze on my elbow from his wife, as much as to say, “Don't tell him he's dying.” It was 4 30 on a Friday afternoon, and this had all the makings of a bad death.

This was obviously a communication emergency. Certain things had to be communicated clearly in a short period of time in order to prevent his death being a complete mess for him and his family. The first priority was to speak with his wife …