At the end of a long afternoon case you find a stickynote on the operating room window informing you of a consultation request: “Consult from Staff GI. Room 527. Blair, Robt. Dx: Metastatic ca. of pancreas. Request central line for TPN.” During the walk up you wonder if this is going to be necessary. The chart of this individual yields little history except a scribbled note; “Unfortunate 58 y.o. white male with history of metastatic ca. of pancreas admitted with dehydration and malnutrition. Plan: Hydration/? TPN. Discuss chemorx. options.” The “yes” or “no” box indicating presence of advance directives on the front sheet of the chart is unmarked. On entering Mr. Blair’s room you are greeted from the bed by an alert, sallow-complected, cachectic man who speaks in a whisper and grasps your hand with a surprisingly strong handshake. “I hope you can do something to make me stronger.” His wife, sitting at the bedside, appearing overwhelmed, adds, “I can’t stand to see him like this. He just doesn’t seem to want to eat. He is sleeping all the time and he’s been having nightmares. We both know there’s no cure for this, but at least he shouldn’t starve to death in the meantime! His next chemo appointment is next week. They said they might try something new. I don’t think he can take it unless they put some meat on his bones.” While his wife is speaking you note Mr. Blair gazing in the distance through the window. During the ensuing discussion you learn he had undergone an exploratory laparotomy 2 months previously and had a “double bypass” for his tumor. Subsequently he was treated with what they were told was a fairly new chemotherapy agent with “mild” side effects. Despite the resolution of his jaundice after his operation he continued to lose weight even though he had an initial return of appetite. During the previous 2 weeks, he had shown little interest in food or drink and he seemed to be sleeping more and more of the time. He had been receiving oxycodone (slow release) for his cancer-related back pain, with satisfactory relief and no recent dosage escalations. Earlier that week he had several nightmares about his death. Privately he confided, “I think my wife is more hopeful than I am. I’m just so tired.” After this initial meeting you learn that an abdominal CT done the previous week demonstrated progression in size of his hepatic metastases.