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Case history

image A 70-year-old man, with a medical history of hypertension only, presented to his GP with a 2 month history of cough, early satiety, abdominal bloating and reduced appetite. A chest X-ray showed bilateral pleural effusions. A subsequent CT scan demonstrated widespread omental and peritoneal disease. Bilateral pulmonary emboli were also present.

He was reviewed in the cancer of unknown primary clinic, where he was commenced on low-molecular-weight heparin and referred for omental biopsy and ascitic drainage. Histopathology and immunohistochemistry confirmed a mucinous adenocarcinoma with positive expression of cytokeratin (CK) 7, patchy expression of homeobox protein CDX2, and negative expression of CK-20, prostate-specific antigen and thyroid transcription factor 1 (TTF-1). Abnormal tumour markers included CA-19.9 of 16,473 and carcinoembryonic antigen (CEA) 11.

An endoscopy found a tumour in the second part of the duodenum (D2), consistent with a primary small bowel cancer. After discussion at the multidisciplinary team (MDT) meeting and review in the gastrointestinal oncology clinic, treatment with oxaliplatin, fluorouracil and folinic acid (OxMdG) chemotherapy with an intermittent approach (treat for a fixed period with planned re-challenge on progression) was offered. The patient completed two programmes of OxMdG; however, during the third he began to deteriorate. He was deemed unsuitable for second line chemotherapy and was referred for the Gold Standards Framework (

The following month he had two admissions with vomiting and aspiration pneumonia. Discussions with the patient in the presence of his wife and son disclosed that his prognosis was in the order of a short number of weeks. He was reviewed by the palliative care team, who documented that he was aware that he was approaching the end of his life. He expressed a strong wish for end-of-life intravenous fluid support and his preferred place of death was the local hospice. He was transferred to the hospice the following week. Soon after arriving, however, he became unhappy with the care he was receiving. He requested administration of intravenous fluids, which resulted in pulmonary oedema and ascites. The patient was not able to recall he had been told that he was approaching the end of his life. The hospice team contacted the oncology team, requesting that he be transferred back to the hospital according to his wishes. Discussions took place between the treating teams and he returned to the hospital.

On his return to hospital he stated that he wanted to be 'actively managed', including total parenteral nutrition, as he felt he was being starved. He was able to tolerate oral fluids, and, after long discussions with him, intravenous fluids were limited to 1 l/day. He sadly died 10 days after returning from the hospice.

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