Approaching patients with advanced cancer requires the clinician to acknowledge that sometimes patient/family preferences not seem aligned with those of the healthcare team For example, the clinician may encounter a patient who is clearly within hours or days of death but who still “wants everything done,” including cancer-directed therapy and aggressive management such as intubation or resuscitation On the other hand, the clinician may instead face a patient with seemingly good functional status and quality of life who declines further diseasedirected treatments Cases may exist anywhere in between these two extremes It is the clinician’s responsibility to provide honest and complete information and elicit the patient’s beliefs and wishes to facilitate decision making that most reflects the wishes of the patient and family Once decisions are made, it is then the duty of the clinician to help carry out those wishes Patients with advanced cancer may have clear preferences regarding admission to the hospital While some patients and families may have adequate services in place to remain in their homes, some will still desire inpatient management as a form of respite Initiation of a management plan intended to reduce symptoms is always an appropriate step The kind of intervention best able to reduce symptoms must be chosen based on the goals of care Patients with advanced cancer have often received large amounts of opioids in the past and may therefore require larger doses of pain medications than routinely administered to children in the ED (see “Pain” section) It is imperative for the clinician to increase the opioid dose until an efficacious dose is reached Opioids may also be carefully titrated to treat shortness of breath or other respiratory symptoms Diagnostic workup and specific management beyond symptom control should be undertaken in a manner consistent with the goals of care If the patient’s focus is only on comfort, then additional testing should be considered only if it will help identify a reasonable strategy to optimize that comfort Consider, for example, a patient who presents for pain management but who is also cachectic and dehydrated The clinician may wonder whether checking serum electrolytes and initiating rehydration are indicated If the stated goals of care are comfort, then these measures should be omitted since electrolyte disturbances rarely cause pain or discomfort and hydration often will prolong the suffering associated with severe pain at the end of life Indeed, hydration could increase edema or secretions that would actually decrease quality of life As an additional example, consider a patient presenting with a malignant pleural effusion causing severe respiratory distress Under other circumstances, the management of a large effusion might be immediate placement of chest tube In this case, the clinician might instead ask, “How will a chest tube help this patient and does it match what he/she wants?” This change in thought process is often extremely hard for healthcare providers whose experience and training not