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What is futile and who decides? The clinician’s dilemma

Fictionalised case study: John’s story

John, a 63-year-old farmer, was admitted to the oncology ward for management of extensive oesophageal cancer with chemotherapy and radiotherapy. He lived alone on the farm, was estranged from his wife and saw his adult children infrequently. John had a history of moderate alcohol use and his nutrition had recently declined because of the extensive cancer. A feeding tube was inserted to assist in maintaining nutrition while he was undergoing treatment.

A few days into the admission, staff noted that John had intermittent episodes of confusion at night, which were attributed to alcohol withdrawal and delirium and were managed with medicines. Psychiatric opinion was sought and revealed no other abnormality, and his symptoms eventually resolved. Several days later, John declined enteral feeding. The treating doctors had the impression that John was able to make decisions about his care. Given inadequate nutritional support, the decision was made to stop chemotherapy but continue radiation for symptom management, although the likelihood of successful control of the cancer would be lower with less extensive treatment.

A few days later, John developed a fever and cough, and…