There is one recent patient death that seems to be occupying centre space in my mind, one that demands a respectful closure. Can my words make up for a family’s permanent loss?

Being witness to the drama that played out following the demise of an admitted patient with advanced hepatobiliary cancer and bilateral percutaneous biliary drains who was admitted to the step-down unit and was being planned for a discharge, has left many questions unanswered and made me question the complicity of my involvement. She who despite being on broad spectrum antibiotics developed a near total shut down of the kidneys with normal creatinine values (were they deceptively low in sarcopenia of advanced stage cancer?). The shutdown in the absence of an elevation in baseline creatinine was taken as an indication of the beginning of phase of irreversible terminal decline, and soon enough, she developed cold peripheries and passed away. The well calibrated display of emotion by her family which seemed overtly serialized, while I was in full view, made me introspect further on my position within the narrative.

Had I missed infection (blood culture did turn out to positive)?

Should I have sent serum procalcitonin outside?

Should I have been informed that serum procalcitonin was available, earlier?

Why had I not exercised more caution? Was I guilty of being played around by a family for whom, the severe paucity of resources had resulted in having been unable to provide expensive institutionalised care for their patient with multiple medical issues?

And wasnt it enough of a burden on the family that in the absence of medical ICU services, ceiling of care form had been signed prior to admission, that the coercion by absence had already occurred; the deed had been done!

Is being willing to shoulder this kind of blame, an indication that one might have allowed themselves to get carried away by the deep seated sense of injustice being perpetrated on needy, underprivileged patients, in a situation that was beyond one’s own control and where they had done most of all, that was in their hands.

Case in point – ceiling of care was maximal ward-based care only, wouldn’t it have been extremely unlikely for an advanced cancer patient with septic shock to be managed in the ward only, who was to shoulder the blame for the absence of fungal serology or that yours truly was not informed well in time that serum procalcitonin had become available (another reminder!).

In having taken the decision to work alone, had I provided ammunition to those, who were more than willing to blame me, for, having made an accurate estimate of available resources, family preferences and the advanced stage of disease into consideration, while formulating the plan of management (that general medicine services were not available was also a potential mitigating factor)?

The fact that these discussions were held at the patient’s bedside might constitute some evidence for the assumption that the patient, even with her impaired cognition and possible lack of capacity, was aware of the decisions that were being taken on her behalf.

While reflecting upon the sequence of events for an umpteenth time, it is evident that this situation, that of prolonging the admission in the step-down ward (after bile and urine cultures had returned sterile) was brought about by a lack of concordance in the goals of care. While yours truly, had repeatedly reminded the patient and their family that goals of care involved stabilization till the next foreseeable period of deterioration, and that improvement in functional status might not be possible (more so, in the absence of allied health professionals willing to visit the bedside), the patient had commented that she was expecting her functional status to improve (in the possible absence of a disease directed treatment and a reversible cause, barring a blood stream infection by a MDR organism, which she eventually grew, and possibly succumbed to).

Who was to blame for letting the patient cling onto to hope?

Should I have been more forceful in my prognostic disclosure?

Who else, will speak on behalf of the patient?

PS There might be a need to make a much needed investment in the idea of relationality and stop designing systems around the idea of risk and instead make relationship building the foundation of system building.

References

Jay, D. (2024). Relationality. Berkeley, CA: North Atlantic Books.

Suggested reading

Kim, J. H., Yu, J., Lee, W., Jeung, Y. S., Yoo, S. H., Sim, J. A., & Keam, B. (2026). Association between multidrug-resistant organism status and quality of end-of-life care in patients with advanced cancer referred to palliative care: a retrospective cohort study with nationwide data linkage. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 32(5), 822–828. https://doi.org/10.1016/j.cmi.2025.11.032

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.