Metastatic involvement of the thyroid is extremely rare and can present many years after the primary. Rarely, they cause critical airway obstruction and death as a result. This article describes the case of previously well 68-year-old man, who on presentation with left shoulder pain and mild shortness of breath, was found to have extensive and longstanding left cervical metastatic disease involving the thyroid and left clavicle. With the primary unknown, airway obstruction ensued and the patient died within 5 days of presentation. Several treatment options are available for palliation of airway obstruction, yet it is still a subject that perplexes and divides clinicians. This report aims to inspire debate about end-of-life issues, and emergency management of airway crisis in patients already dying from an aggressive malignant process.