[Clinical thinking and decision making in practice. A severely ill elderly man with icterus].

A 74-year-old man was admitted to hospital because of jaundice and malaise of several weeks' duration. Five years earlier he had sustained a stroke from which he had recovered almost completely. On physical examination he was overweight and had an enlarged liver. Laboratory values were consistent with cholestasis and hepatitis. An abdominal ultrasound showed multiple nodular abnormalities in the liver consistent with a malignancy. Rapidly developing abnormalities in blood coagulation were thought to be a contraindication to hepatic biopsy. The patient deteriorated and sustained a new stroke. The physicians were convinced that he had cancer and could not be cured. They planned further diagnostic studies, but at the same time made an advance directive for non-resuscitation. Three days after admission the patient was found dead; no consent for an autopsy was obtained. If it is suspected that a patient is suffering from a malignant disease, the malignancy should be demonstrated or excluded as quickly as possible in the least uncomfortable way. Also, the patient and his family should be informed of any restriction on the possibilities of treatment.