This is a pragmatic article on a difficult and much debated subject. Management of anaplastic thyroid cancer (ATC) can feel like making decisions between a rock and a hard place, and this article suggests one path to help navigate some of the key challenges. Although workup and curative treatment options are discussed, it is the palliative management aspect of this article that I found most interesting. Airway management planning is covered in detail. Tracheostomy is a key contentious issue in these patients; whilst providing potential airway symptom relief on one hand, ATC patients can have a particularly poor experience with tracheostomies, which can be prone to tumour fungation and associated wound care complications. Further, patients can still suffer from airway obstruction in ATC despite tracheostomy. Discussion of palliative care plans is recommended at diagnosis, including airway management, feeding options and end-of-life discussions. Where resection is not possible, it is suggested that surgical debulking may improve survival and/or prevent death from airway obstruction especially if combined with other treatment modalities. If a neck airway cannot be avoided, a cricothyroidotomy may be both more straightforward and less likely to be displaced by enlarging tumour bulk. It is interesting to note that many of the recommendations here are discordant with those of the 2014 BTA guidance.