A review was sought for a geriatric patient whose infarct had undergone a malignant transformation and whose family had decided to forego surgical decompression and antecedent Neuro ICU stay for a request for admission.

The review proceeded in the following stages:

Discussion with the Neurology resident – understanding poor prognosis and expected course of disease. Malignant transformation on anti-oedema measures with anti-hypertensives and anti-epileptics ongoing. Recognition of herniation as a possible terminal event.

Involving the next of kin – Aware of the prognosis, expresses knowledge of patient preferences – “My mother died from Cancer” he says, “He had told me multiple times that he would not want to be admitted to the hospital”, “We do not know why we brought him here”.
Patient makes a noise – Startling those at the bedside. Can we do anything more? One might be forced to rethink.

Managing expectations from the referral – Doctor, what are you going to do?

“We are going to first ensure that you understand the patient’s current situation”
“We are going to act as an effective bridge between the treating team and the family”
“We are going to document family and patient preferences towards treatment”
“We will provide advice directed at rationalisation of treatment, making it more in line with stated goals”.

Negotiating the appropriate place of care.

Documentation including loss of capacity, present neurological condition (no spontaneous eye opening, incomprehensible sounds), increasing oxygen requirement,
“No relative present during the family meeting dissents to the palliative line of treatment”.

Team decision for DNACPR/DNI noted, patient’s family acquiescence noted and for maximal ward-based management.

Rationalisation of treatment –

Noted that Enoxaparin was already on hold,
Advised de-intensification of ongoing glycemic control, once daily long-acting insulin, once daily evening time monitoring, glycemic goals 6-15 mmol/l,
Continuation of anti-oedema and anti-epileptics, anti-hypertensives, laxatives
Discontinuation of nootropics and atorvastatin.
Recognition of infection as a possible terminal event with initiation of empirical antibiotics (might also contribute towards preventing sepsis and removing a possible contraindication to organ donation).
Recognition of thromboembolism risk and advise intermittent pneumatic compression device (mechanical thromboprophylaxis – I must not hasten death sayeth the WHO definition)
Started antiemetics and laxatives.
Anticipatory prescribing – anti-secretory and anti-epileptics (additional PRN orders in case of breakthrough seizures).
Advised reduction in the number of daily feeds whilst keeping in mind legal caveats and markers of intolerance to feeds (obtundation, gurgling sounds).
Not for frequent investigations, monitoring and change in position.
Documentation of Family preferences.

Informed the medicine team about the plan of management and regular follow-up.

Follow-up – Days 2-4 Counselling about goal of care at the bedside, addressing concerns and detailing expected changes. Request for intensive nursing support and frequent elicitation of family/caregiver preferences prior to planned interventions/intrusions.
Ongoing discussion about transplantation.
Discussion of terminal discharge/ discharge to home with practical discussion pertaining to logistics and consumables.
Ethical deliberation at the bedside – why this does not cross into the realm of overmedicalization?
Day 5 of admission – decreasing urine output, cooler peripheries, persistent obtundation and noisy breathing
Tapering of anti-oedema measures – pre-emptive counselling that the demise might coincide with tapering, and understanding that the taper is not designed to hasten death.
Documentation of clinical reasoning.

Day 6 – Alas, the curtain falls and the end beckons.

Death announces itself with vulgar exsanguination, described in a torrent of emotions by the caregiver, and the Palliatrist realises that it may be time to bid adieu. Sensing the need for privacy, he leaves the four of them together, for one last time.

Arrangements fall into place for the transplant and other noble deeds.

Has the review reached its conclusion, or is there more to come?

An epiphany beckons, another patient awaits!!

Author’s perspective
Highlights the importance of understanding disease status and expected natural history.
Reliance on prognostic understanding in order to rationalise treatment.
Underlines documentation requirements and tries to address the unease between a law-making apparatus that appears to be severely disconnected from practical bedside realities.

Editor’s take

This case highlights the primacy of prognostic understanding in palliative clinical decision-making. An accurate knowledge of disease trajectory — malignant cerebral infarction proceeding to herniation — is the prerequisite for every treatment decision that follows, from glycaemic rationalisation to statin discontinuation to DNACPR documentation. Effective palliation here is not the absence of treatment but its precise calibration to a prognosis that admits no reversal.

The family’s acknowledgement that hospitalisation was inconsistent with the patient’s own expressed wishes is a reminder that the palliatrist’s consultation often functions as the moment when the patient’s prior voice is heard for the first time since the crisis began.

Documentation in cases of this complexity is not only an administrative formality. It is the ethical record of decisions made about capacity, prognosis, family agreement, and treatment goals — a record that justifies the management plan to any subsequent clinician, to the institution, and to the law.

Finally, this case exposes a persistent tension: India’s legal framework for end-of-life decision-making, while evolving, remains structurally misaligned with the practical reality of managing a rapidly deteriorating patient when time for formal legal processes does not exist. The palliatrist navigates this gap daily. It deserves formal acknowledgement — and eventually, legislative resolution.

Cite as

Arora, R. D. (2026). Contemporary Palliatrist Review (CPR2) – Malignant transformation of acute CVA – What’s a Palliatrist got to do with it?. Zenodo. https://doi.org/10.5281/zenodo.21725743

Disclaimer

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

Artificial intelligence tools, primarily Claude (Anthropic), have been employed for evidence synthesis and language refinement. 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.