I have recently written about my experiences that have led to my becoming a palliatrist, in a blog which is expected to be available for public dissemination soon. In it, I write about the gradual change in perspective and a new found respect, upon being given full responsibility of my patient. However, I have not elaborated upon my fears and possible misconceptions, and this might be the right time to talk about it. I have received news that I have been re-invited as an abstract reviewer for podium presentations and poster presentations for the annual assembly of American Association of Hospice and Palliative Care for a second year in a row. I am riding on a high, so this might be the right time for some honest self-reflection.

There has always been the fear of stopping or withholding antibiotics in those with advanced disease who have been admitted under my care. That there exists a certain prickly and tempestuous debate about the initiation and continuation of anti-thrombotics in the admitted patient with advanced cancer is an entirely different discussion. I have mostly initiated anti-thrombotics in those with advanced cancer, who are being admitted (demonstrating allegiance with up-to-date guidance), but have refrained from continuing them after a conscientious trial of treatment has not borne any fruit. But antibiotics have been a different ballgame altogether. In the landscape of limited guidance and even more limited research, I was able to identify only one set of individuals where antibiotics were not initiated, and that was the advanced cancer patient who presented too sick to the hospital, often gasping, with severe metabolic acidosis, in whom a certain advice made some medical sense to me – allow natural death. Such patients were started on anticipatory prescribing (including paracetamol for fever and possibly midazolam for seizures) and intravenous fluids (as per family’s preference) and I did not feel the need for initiating intravenous ceftriaxone in them. In all others, antibiotics seemed like a necessity. That meant that those with delirium at the end of life, investigated for reversibility, those with infections, those with cord compression, those with malignant bowel obstruction were all started, and in most cases, continued on broad spectrum antibiotics, up until the day of their demise. Since this was happening in a hospital where, palliative medicine was the default service to which those with medical issues were referred (in the absence of a functional internal medicine service), this seemed justifiable.

In my present position, where I am attached with a tertiary cancer centre attached to a corporate setting, which also houses a teaching hospital, where more affordable services are being provided, I have somewhat, in an absence of a better way to put it, been shown the real place of palliative medicine. The referrals come from various departments, but the maximum are channelled through medical oncology (radiation oncology is a close second).

This piece concerns an advanced cancer patient, in whose case the temptation to continue antibiotics was averted, thanks to effective communication between the palliative specialist and the medical oncology team. The antithrombotic started at my request, was also discontinued. Furthermore, management of corticosteroid induced hyperglycemia was simplified after intense and frenetic discussions also involving the endocrinology team (though the recurring advice for a diabetic diet did not appear goal-concordant). That there remains more work to be done is clear, and effective communication with other teams remains on the top of my list.

My visits to the ward during the final days of the patient’s life were accompanied by requests for the nursing staff to visit the patient’s bedside, in order to comfort her. Though these might seem unconventional, they acknowledge the unique humane needs of the imminently dying patients and the tremendous strain on the families, where presence equates compassion.  

Families needing palliative admissions often require- longer conversations, repeated counselling, sustained efforts at discharge planning in addition to regular ward work. They also have unique social, financial and intensive nursing needs. Non-pharmacological treatment, time at the bedside, effective communication, effective coordination among teams, nursing support and social support become as essential as medications.

Personally, the shift from equating responsibility and specialization with taking independent decisions and personally rationing every intervention to understanding that responsibility can also mean building enough understanding and trust across specialties that treatments are rationalised when they no longer serve the patient’s goals, became the most important learning point.

Competence has come to faintly, and perhaps unsurprisingly resemble a form of nuanced coordination and specialized care – a form of proportional care and understanding arrived at, through dialogue.

Cite as
Arora, R. D. (2026). Reflections at the bedside (RB9) – From doing everything to helping teams do the right things together – a lesson in contemporary palliation. Zenodo. https://doi.org/10.5281/zenodo.21305835

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, primarily Claude (Anthropic), have been employed to challenge assumptions, support deeper conceptual exploration, 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.

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