A 45 year old man diagnosed of hepatocellular carcinoma referred to your clinic with loss of appetite, extreme weakness, and

rapid loss of weight over last 3 to 4 weeks. Family is worried about his condition and wishes to have IV fluids. How will you proceed?

Before proceeding to make a decision I have to consider ethical aspects of the patient and views of worried family. As a doctor I have dual responsibility to preserve life and to relieve suffering .But in this case preserving life becomes impossible, importance should be given to provide maximum comfort. Here I would like to apply four cardinal principles of ethics of palliative care. 1. Respect patients autonomy 2. Benefiscence 3. Nonmalfiscence 4. Justice Legally a person is not obliged to accept medical treatment, even if refusal may result in earlier death. I will discuss the advantage and advantages of pareneral administration of IV fluids, with the patient and his opinion will definitely be considered.

Studies show that there is no enough proof that IV fluid in terminally ill patient Interferes with the length of life and comfort. Biochemical parameters show that only 50% 0f parents have any evidence of

dehydration within the final 48 hours .Even then only mild to moderate degree of dehydration. The extensive experience of palliative care clinics Measure suggests that systemic fluids make no difference and may actually contribute to sufferings at the end of life In patient with hepatocellular carcinoma, because of law serum albumin level, fluids may gather in lungs and dependent parts. Respiratory secretions may be worsened. Vomiting may be prolonged. Family members have to spend precious time worrying about drips running out and causing discomfort instead of concentrating on quality time with the patient. The drip may cause physical barrier between the patient and his loved one at this important time. I will explain to the family that the body is gradually shutting down and is unable to handle extra fluid. I should make aware them that patient will not be allowed to suffer from pain or other discomfort. Measures taken to avoid discomfort of the patient will be explained. If family insist on artificial hydration , and I feel extra fluid will not adversely affect comfort, a relatively small amount of fluid to be used subcutaneously or intravenously for short period on the understanding that at any time it would be discontinued if it was thought to be causing distress to the patient.