To gastroenterology for feasibility of palliative biliary stenting in malignant biliary obstruction,

to urology for assessing feasibility of stenting in hydroureteronephrosis,

to neurology for confirming compressive myelopathy,

to neurology again for ruling out brachial plexus involvement in the absence of demonstrable recurrent disease,

to nuclear medicine for metastatic neuroendocrine tumor,

to orthopaedics to rule out non-cancer causes of lower back pain,

to medical oncology for assessing feasibility of oral metronomic chemotherapy,

to anaesthesia for difficult to obtain peripheral venous access.

Even a cursory eye-balling of the list of referrals sought during my tenure as an assistant professor on contract basis (two years) and senior specialist (one month and four days) would lead to the undeniable impression that these carry a critical weight, one that might help debunk the myth of palliative medicine being a dead end specialty and shine a light on the kind of patients being referred to a specialist setting in the public sector (no surprises here – do not constitute the heavily pretreated, physically unfit and psychologically parched population that may be considered typical of the traditional pastiche of the palliative patient and are more in line with those recently diagnosed with advanced cancer).

This treatise is driven by the two critical suggestions that I received from the medical oncology team while navigating the day-to-day workings of a model of service delivery envisaged as a integration between oncology and specialist palliative care and other experiences collected from places supposed to be in terminal decline and nitpickings from interviews where my candidature was rejected without providing any particular justification – one might call it ideological ineligibility – for the want of words.

While the first one concerned the discussion of referrals and listing consultation liaisons provided outside the super-speciality block (in the old college building), the second one has forced me to re-visit an issue which lies long buried within the heaps of carefully collected propaganda that positions the system as resource constrained and contains a question that is relevant to all specialists. The second request, concerned more scrutiny on the number of fentanyl patches that I had been prescribing (that the number of patches prescribed over one month had reached a number equivalent to those prescribed over the past six months by the oncologist).

While there have been muted discussions around the use of methadone in cancer pain, including the pointed question about the positioning of methadone as a routine drug in a high-stakes interview (like any self-respecting specialist with allegiance to UK-based teaching, I positioned it as a reserve drug, to the consternation and the deep seated repulsion of the interview panel consisting of subject experts, other than Palliative care).

There has been very little discussion about the use of transdermal fentanyl and discussions have been limited to positioning it as a reserve drug due to its prohibitive cost (which is but a fraction of the immunotherapy drugs that have been approved for use in the same advanced cancer population). The fact that there has been a recent move towards the use of low dose nivolumab in the metronomic setting in the same resource constrained setting makes this comparison even more tenuous.

Having seen doctors from other specialties, prescribe buprenorphine, which does not have that many safeguards, is available without a specialist prescription (unlike other opioids), does not seem to require a licence for its prescription (Whatever happened to the NDPS act!!) but remains prohibitively expensive, there is a need to take a re-look at limiting fentanyl prescription. Apart from the fact that the similarly priced buprenorphine patch is less potent (commonly prescribed patches are equivalent to between 12-24 mg of daily oral morphine only), there is also the necessary fact about the difficulty in reversing its effect.

There seems to be a systems level fallacy which is being perpetuated which advises against the prescription of transdermal fentanyl, even when indicated, due to its so-called prohibitive cost which might prove to be a drain on miniscule resources made available to palliative care.

Examiners during the fellowship exit exam have also advised yours truly to focus on the doctrine of double effect in justifying the prescription of opioids in the advanced cancer setting (which might not be applicable to the prescription of say tramadol in liver failure) and head of the departments have boasted about using 700 mg of oral morphine equivalents as a badge of honor (and allegiance with palliative principles). It is easy to see the lack of rationale behind both these arguments and their lack of applicability to this setting.

Denying Fentanyl to a patient with malignant bowel obstruction or in the setting of renal failure with delirium or when reversibility of hepatic dysfunction is being sought (and prescribing morphine or even tramadol) and then utilizing the heady concoction of allegiance to an abstract philosophy and lack of resources as an excuse, sounds not just unscientific, but points towards a complete lack of situational awareness.

Would I have been able to justify prescribing Morphine in someone with malignant bowel obstruction, knowing well that the option of indenting fentanyl patches in a registered medial institution, holding a valid license was available? No.

Would I be willing to prescribe it, if I was made aware that the poor family was being made to pay three thousand INR every three days to another private tertiary care centre providing palliative care in the periphery? Would I have prescribed it, knowing well that I wanted to break this vicious circle of harassment (often seen in films demonising the zamindari system and other such social evils)? Let’s be practical and pragmatic, I would be tempted to consider it.

Would I do it to save my professional relationships and keep my job? Hmmm.

Would I be comfortable living with decision? Unequivocally no.

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.

Palliative medicine is a relatively young subspecialty whose intellectual and clinical boundaries continue to evolve. In the absence of definitive texts to address contemporary questions, artificial intelligence tools mainly Anthropic (Claude) have been employed to support deeper conceptual exploration, challenge assumptions, and improve clarity of expression. They do not replace critical scholarship, clinical experience, or editorial judgment. Final responsibility for all interpretations, factual accuracy, originality of synthesis, and the quality of the published material rests entirely with the Founder and Editor.