© Annals of Palliative Medicine. All rights reserved. Malignant bowel obstruction (MBO) occurs in between 3% and 15% of patients with cancer, and portends a poor mean survival of four weeks for patients who are not able to undergo operative intervention. Surgical interventions may be fraught with complications since these patients typically have compromised nutritional status and progressive metastatic disease burden, with tumor type and degree of aggressiveness affecting outcomes. MBO is a dynamic and difficult process to treat, with adequate pain control being limited by unpredictable enteral absorption and need for prolonged parenteral analgesia (given limited enteral access) with its inherent risks. To explore these difficulties, we report the case of a 43-year-old patient who presented with multi-level MBO from metastatic rectal carcinoma, and explore the challenges and successes of symptom management in a non-operative MBO.