Despite a mastectomy and aggressive hormonal and chemotherapeutic therapy, she developed extensive metastases to her brain and bones.

Mrs. Harris is a 57-year-old woman who developed breast cancer three years ago. Despite a mastectomy and aggressive hormonal and chemotherapeutic therapy, she developed extensive metastases to her brain and bones. She began to develop severe pain at the sites of her bone metastases, but refused narcotic medications. Although she later went through a period of confusion due to hypercalcemia and brain metastases, she responded well to intravenous (IV) fluids and radiation therapy and regained decision-making capacity. Her physician approached her about the completion of an advance directive, to which she agreed and in which she documented that she wanted to continue to receive treatment that could potentially prolong her life. Her advance directive contained specific information about her desire to receive antibiotics for recurrent infections and IV fluids for dehydration and hypercalcemia. Mrs. Harris’s advance directive also contained information that directed the healthcare team not to introduce tube feeding and not to attempt cardiopulmonary resuscitation (CPR). These latter requests were based on her physician’s opinion that neither of these would be lifeprolonging and that both would impose significant burdens and risks. Finally, Mrs. Harris’s advance directive urged that her healthcare providers aggressively manage all of her symptoms to ensure that her pain and discomfort are minimal at all times. 

1. Are there any situations in which palliative care is not appropriate?

2. Are palliative care and life-prolonging treatments incompatible? 

3. How should physicians document their intentions to provide palliative care?