We were confused by the discharge letter. Our patient had been transferred from the hospital after a two-week admission. During the admission, the Oncology treatments had been stopped. On discharge, it appeared that the medications had been restarted. The Oncologist’s plan was unclear. On the second day, the patient developed a new abdominal pain. The pain was so severe that the patient felt they were ready to die. We changed their pain relief and also tried to cover the shortness of breath. By the afternoon the patient was more comfortable and able to sleep. The family had received a phone call asking for the patient to return to the hospital for further treatment. This surprised the family and our hospice team as the patient had barely been in the inpatient unit for 24 hours, and the hospital asked them to return. We called Oncology to find out what was going on. They wanted to give radiotherapy treatment to the patient’s back, for pain relief. We said we would see how the patient was the next morning as we were unsure if they’d be well enough to return to the hospital.

The patient had a more comfortable night and was well enough to go back to the hospital for radiotherapy treatment. Over the next days, pain relief needed to be increased as the patient’s pain worsened. They made good progress and we would start the discharge process after the weekend if everything stayed calm. Pain and breathlessness were under control but the patient became confused which frightened the family. Mental acuity had always been what the patient had been well-known for. We postponed the discharge plan and explained to the family that we would try to clear our patient’s mind as much as possible. Maybe the pain relief had become too strong. Or maybe it was the continued progression of the disease. No surprises – we warned the family of the possibility of the patient’s condition worsening. If further deterioration occurred we would keep the patient for end of life care.

Everything had worsened the next day despite the medication changes we had made. Our patient mumbled but the only words I could understand were, “I can’t handle this.” We gathered the family and discussed our patient’s deterioration. We thought our patient was dying and we promised to keep them comfortable. The patient’s spouse told us clearly that they had discussed their wishes for no resuscitation. We agreed that CPR would be inappropriate as well as other life-prolonging treatments. We were asked how much time was left. We talked about a time frame of hours to days being left, but that it could be much shorter as the illness worsened.

The patient was kept comfortable and their family was supported during the two days prior to death. They didn’t make it to the Oncology appointment scheduled for three days later.