During the summer months of 2010, our palliative care unit experienced a cancer crisis dealing, not with pain control, constipation, delirium, or with any of the crises that we usually would experience, but with the social media. One of the patients in our ward, a young man in his 30s with three young children, was dying of a brain tumor. In response, his friends had decided to post a Facebook page with pictures of the children, asking for funds to help in their future education. This was a simple, well-intentioned gesture, born of the need to help in a difficult situation. The reaction was unexpected. It was highly inflammatory from several of the patient's family members. The patient's father was incensed. He was suddenly besieged with messages from his son's schoolmates of years ago. Again, they were all well-intentioned, saddened, and shocked by the imminent death of one of their cohort. But the father saw these contacts as highly invasive of his and his son's privacy. Even more, he saw the intrusions into his bedside vigil as disrespectful, demeaning to his son. He rightly pointed out that these young adults were sometimes only casual contacts, having attended the same classes as his son up to 20 years previously. The fact that some had not kept contact over time and were only trying to send messages now because of the dire situation signaled to him the shallowness of the relationship. That the father had no previous experience with the social media, and did not understand the benefits or uses of electronic networks such as MySpace, Twitter, and Facebook only deepened his suspicion of their use over his son's almost comatose body. Other family members rushed to his defense and shared his outrage.

The patient's former wife, on the other hand, used social media networks regularly, and saw the potential benefits of the tool. It does not take a great deal of imagination to see that the family, already deeply divided over many things, now became at odds over this latest Facebook incident. The power of attorney for personal care wisely asked to have the Facebook page removed in deference to the patient's father, and peace was restored. But the whole incident left me with some unanswered questions. What was the role of the social media in this end-of-life crisis? How often do these incidents occur? Is it harder to die in private now that these days of social media tools and the internet have arrived? Are the feelings about social networks determined by the age of family members and familiarality with the tool? And what part does the palliative care team play in preparing patients and families for the potential effects of social media on the dying process? The palliative team members could argue that it is none of our business how a wider social circle responds to the news of a dying patient online. But Facebook may be our business in the same sense that preparing families for visitors, for funeral homes, and for the process of grief is our business. Our social worker prepares families for financial issues such as insurance, payment of funeral bills, and compassionate care funding programs. The team guides families through grief work and its attendant pitfalls and processes. Therefore, it is understandable that warnings about possible sensitivities over social media may become the norm in a palliative setting that aims to give holistic care. Giving families knowledge about hyperlinks that could exist on the World Wide Web years after a patient's death may become yet another piece of knowledge to impart when patients are introduced to palliative care.

These particular family members weren't the only ones divided about social media. The palliative care community also has mixed reactions to the many social networking tools available. Dr. Christian Sinclair, a palliative physician from Kansas, does public lectures with titles such as “How and why to do tweetchat in Palliative Care” and “Hospitals and Social Media”. He emphasizes the positive aspects of the tools, indicating that they are essential to keep current, and that they have roles in such varied aspects of care as frontline care, education, advocacy, fundraising, public relations, customer service, and community outreach. Given the mountains of information now reaching the medical field, quick dissemination of information is essential to first-line care. But the tools that broadcast information may also have harmful consequences to humanity. Social media may be used to raise funds for a dying patient's children, but in the wrong hands they may also be tools for the exploitation of donors touched by the dying process. During the summer of 2010, a young woman named Ashley Kirilow made headlines in Canada. The 23-year-old had pretended to be dying of cancer, and had asked her 5,668 Facebook friends to donate to the charity she had founded “Change for a Cure”. As a result, she awaits fraud charges for the misappropriation of ~ $20,000.

This one unfortunate young woman's actions could make it more difficult to raise funds online for a genuinely dying patient. Her case is the polar opposite of the case we experienced in our palliative care unit. But the father's protestations still echo in our minds. Is there any sense in which the social media can depersonalize humanity or desensitize people to death? Or is this question simply a reactionary stance akin to those who decried the printing press when it was first released?

Author David Kirkpatrick has written a book called The Facebook Effect – The Inside Story of the Company that is Connecting the World. In it he explores the rapid rise of the world's most successful social media tool. “Facebook is founded,” Kirkpatrick explains, “on a radical social premise—that an inevitable enveloping transparency will overtake modern life … Facebook is causing a mass resetting of the boundaries of personal intimacy.” No wonder those who work in palliative care and those whose loved ones are dying are not immune to its effects.

In the end, however, this case signaled to our palliative care team what we had known all along. There are as many ways to die as there are individuals, and each patient, with his or her wider circle of caregivers, represents a unique community to which we must tailor our ministrations. If some choose to die in the social media spotlight, then we facilitate that as much as possible. If others want to die in total seclusion, then that is what we must provide. The tricky part is always the house divided; the relatives and friends who disagree with each other, the hidden background to current and past wounds, the eddies and flows of personalities that engender particular responses and requests. To steer each person through these shoals is both the art of palliative care, and its great reward. In an age of burgeoning social media tools, it may become an even more difficult art.