Dr. Jose Pereira MBChB(SA) DA(SA)
Palliative Care Consultant in the Regional Palliative Care Program, Assistant Professor in the division of Palliative medicine, University of Alberta.

Not infrequently, decisions have to be made regarding the active treatment/non-treatment of various abnormalities that are found in patients with advanced cancer. This often applies to various metabolic or hematologic abnormalities and these decisions may occasionally appear difficult and complex and need to be made within the ethical parameters of beneficence, non-maleficence, justice and respect for the patients autonomy and wishes. It is important to remember that every patient is an individual, with unique needs, wishes, hopes and circumstances. Management protocols therefore need to be individualized.

A balance needs to be achieved between over aggressive management with increased treatment related toxicity, and a failure to use treatments that have useful symptomatic benefits. To individualize the decision-making process, we have found the following steps to be useful.

First, establish the potential problems and adverse effects of the abnormality that may impact on that particular patient’s quality of life (eg. anemia causing severe shortness of breath and lethargy, hypercalcemia causing confusion and thirst, a pathological fracture causing pain and immobility and an infection causing pain, confusion, nausea and rigors). Rank the discomfort associated with a specific problem on the patient’s overall symptom complex.

Secondly, establish the potential problems associated with the correction that may impact on the patient’s quality of life (eg. the inconvenience of transfer to an acute unit for a blood transfusion, peri-operative risks involved with surgery).

Thirdly, balance overall pros and cons of intervention verses no intervention for that individual patient.

And fourthly, develop a consensus with the patient, family and other health care providers about the most appropriate course of action.

Having followed these steps through, it is at times appropriate to treat infections, transfuse patients who are anemic, treat hypercalcemia and surgically stabilize pathological fractures. The focus becomes symptom control and providing comfort rather than prolongation of life.