I have often wrestled with the unenviable task of defining the skill set suited to the designation of a palliative oncologist. I have tried to do so in my presentation on “case presentation in  palliative medicine”, which received the MASCC scholarship award in 2021, where initiating chemotherapy was the main prerequisite for the position and revisited it, while working in a tertiary cancer centre in the middle-east (where Palliative care in Oncology was surreptitiously, and perhaps suspiciously, referred to as Oncology Palliative Care). Was being given direct responsibility of oncology patients during on-call duties and working in close coordination with Medical oncologists, enough to merit the designation? Or perhaps, there was something else, like prescribing bisphosphonates, that require a separate chemotherapy form or prescribing oral metronomic chemotherapy or low-dose immunotherapy, even?

Earlier today while sitting in front of a grossly edematous patient with multicentric HCC with macrovascular involvement with rapidly refilling ascites, who seemed way too young, and perhaps immature, to grasp the enormity of the situation and contemplating management related decisions, the following realization dawned upon me.
The female seated on a wheelchair in front of me, who had undergone removal of 8 liters of fluid over the past 7 days, had been referred for consideration of an ascitic drain insertion.
History taking revealed that she wasn’t willing to undergo ascitic drain re-insertion as the one that she had undergone in the recent past, had led to infection and deterioration in her sensorium, necessitating referral to another centre (where the event – fever with altered sensorium was labelled as encephalopathy, though she denied occurrence of jaundice).
She had also been started on spironolactone and furosemide (50 mg and 20 mg) two times daily (and, that this had been labelled as refractory ascites was in itself, erroneous).

And then, she had also been started on Lenvatinib.
A cursory evaluation of the scenario revealed multiple reasons why she was less than a suitable candidate for Lenvatinib,
Poor performance status,
rapidly refilling ascites (a possible marker of hepatic decompensation),
recent history of hepatic encephalopathy.
A decision was taken to stop the targeted treatment.

Spironolactone was re-dosed to 100 mg once daily,
Morphine was added, along with a suitable anti-emetic and laxative.
Directions for re-review after three days for confirmation of adequate natriuresis and further optimization were given.

Does stopping targeted treatment, when it might prove to be potentially detrimental and instituting goal-concordant care with prognostication and goals of care discussion, mark the qualities desirable in a real Palliative oncologist?
And am I inching towards being one? or Am I there already?

Disclaimer – Every attempt has been made to safeguard the identity of patients referred to in the vignettes and any circumstances arising out of this moral treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s or organization’s reputation and has tried his level best to ensure that identities are fiercely protected.