Palliative Pain Therapy at the End of Life and Forensic Medicine Issues

An 83-year-old woman with a history of Alzheimer’s disease and breast cancer died at home while receiving palliative pain therapy with oral morphine from her family for metastatic breast cancer. Allegations of mistreatment were made, and this case was ultimately referred to the Office of the Chief Medical Examiner, State of Maryland. An autopsy failed to identify any injuries or residual cancer, leaving no anatomic explanation for the pain that had been presumed to be metastatic breast carcinoma involving bone. The blood free morphine concentration was 5200 ng/ml, and the total morphine concentration was 15,000 ng/ml. This case demonstrates the challenges and difficulties in forensic medicine when faced with the interpretation of toxicologic results at the end of life.

[1]  S. Kaasa,et al.  Start of oral morphine to cancer patients: effective serum morphine concentrations and contribution from morphine-6-glucuronide to the analgesia produced by morphine , 2000, European Journal of Clinical Pharmacology.

[2]  A. Caplan,et al.  The Pain Relief Promotion Act of 1999: a serious threat to palliative care. , 2000, JAMA.

[3]  K. A. Stormo,et al.  Self-intoxication with morphine obtained from an infusion pump. , 1999, Journal of analytical toxicology.

[4]  Baldwin,et al.  The Role of the Physician in End-of-Life Care: What More Can We Do? , 1999 .

[5]  A. Somogyi,et al.  Plasma morphine and glucuronide (M3G and M6G) concentrations in hospice inpatients. , 1997, Journal of pain and symptom management.

[6]  R. Moore,et al.  Morphine and morphine-6-glucuronide plasma concentrations and effect in cancer pain. , 1996, Journal of pain and symptom management.

[7]  T. Hedner,et al.  Morphine and morphine metabolite concentrations in cerebrospinal fluid and plasma in cancer pain patients after slow-release oral morphine administration , 1995, Pain.

[8]  D. Gavaghan,et al.  Oral morphine in cancer pain: influences on morphine and metabolite concentration , 1990, Clinical pharmacology and therapeutics.

[9]  V R Spiehler,et al.  Computer-assisted interpretation in forensic toxicology: morphine-involved deaths. , 1989, Journal of forensic sciences.

[10]  Robin Pugsley,et al.  Guidelines on the Termination of Life Sustaining Treatment and Care of the Dying , 1988 .

[11]  K. Worm,et al.  Morphine concentrations in autopsy material from fatal cases after intake of morphine and/or heroin. , 1988, Journal - Forensic Science Society.

[12]  T. Tena,et al.  Concentrations of free and conjugated morphine in blood in twenty cases of heroin-related deaths. , 1987, Journal of chromatography.

[13]  S. Chan,et al.  Distribution of morphine in body fluids and tissues in fatal overdose. , 1986, Journal of forensic sciences.

[14]  R. H. Cravey,et al.  Death from intravenously administered narcotics: a study of 114 cases;. , 1976, Journal of forensic sciences.

[15]  A. Lund,et al.  Morphine concentrations in blood and organs in cases of fatal poisoning. , 1974, Forensic science.