head and neck cancer; head and neck neoplasms; enteral nutrition; goal-directed care; hospice medicine; hospice care; quality-of-life; palliative care; case report


Bioethics and Medical Ethics | Family Medicine | Geriatrics | Internal Medicine | Oncology | Otolaryngology | Palliative Care



The goal of palliative care is to preserve the quality of life or patient “comfort” in patients with serious diseases. Palliative care providers serve a wide range of patients: from those who seek curative treatment to those who are actively dying. Given this range, palliative care must mirror the dynamic goals of the patient at different stages of life and treatment. Throughout these stages, a goal of the palliative care provider would be to avoid hastening death; however, this often leads to clinical decisions that directly pit the patient’s comfort against the patient’s life span. This is most salient with clinical decisions of withdrawing treatments that prolong life even at the expense of comfort. An example of this dichotomy can be seen when providers use enteral nutrition to treat head and neck cancer patients.

Case Presentation

We describe a patient with stage IV pancreatic cancer with metastases to her head and neck. The patient was experiencing increased morbidity related to her percutaneous endoscopic gastrostomy (PEG) tube feeding. These complications included tube-related concerns such as infection, leakage, and diarrhea but also decreased intended benefits as she lost weight and functionality while maintaining enteral feeding. Despite the patient experiencing a common and expected disease course, she remained unsure and was fearful about considering discontinuation of her enteral feeding. However, the care team who understood the risks, benefits, and harms related to withdrawal provided a foundation of discussion and mitigated patient fears, allowing for the successful removal of her PEG tube and increased quality of life at the end of life.


To care for a patient in their entirety is also to care for them at all stages of disease. Care is not limited to those who might be cured of disease, but should also consider those who continue to live with disease and the downstream effects of medical interventions used to support them. Discontinuing treatments whose harms outweigh the benefits to patients is a moral imperative to providers; yet, how providers approach discontinuing life-prolonging treatment is seen as morally distressing. Our patient did not see the discussion as morally distressing and continued to benefit from active discussions even at the end of her life.