A 44-year-old woman with severe pain at the end of life.

DR PARKER: Mrs L is a 44-year-old woman admitted to a Boston, Mass, teaching hospital with terminal cancer complicated by severe pain. She lives in the greater Boston area with her husband and has managed care insurance. Mrs L experienced a flaccid left arm for 5 days prior to admission—the first manifestation of metastatic lung cancer. She also noted some mild weakness in the left leg accompanied by slurred speech and some drooling. There was no associated headache, change in vision, fever, or weight loss. She complained of mild shortness of breath and back pain. Her medical history is complex and notable for a seizure disorder since age 16 years, polycythemia vera, hemiplegic migraine, carcinoid, colitis, pseudotumor cerebri, and distal pancreatectomy for islet cell tumor. Her medications on admission included phenytoin, 100 mg 4 times per day; primidone, 250 mg 3 times per day; acetazolamide, 250 mg 4 times per day; clonazepam, 0.5 mg 4 times per day; gabapentin, 300 mg 5 times per day; sulfasalazine, 500 mg 4 times per day; salsalate, 750 mg 6 times per day; famotidine, conjugated estrogens, medroxyprogesterone acetate, alendronate sodium, calcium, pyridoxine hydrochloride, and folate. She does not drink alcohol. She has smoked 2 packs of cigarettes per day since adolescence. Family history is notable for her mother dying of parathyroid cancer and colon cancer and her father dying of coronary artery disease. At admission, Mrs L was alert and oriented, with stable vital signs and a temperature of 37.9°C. Chest examination revealed crackles and wheezes on the left side. Her neurologic examination was significant for a flaccid left arm and minimal weakness of the left leg. Initial workup revealed a left upper lobe mass on chest x-ray with left hilar adenopathy and left pleural effusion; computed tomography scan of the head revealed a right frontoparietal lesion with edema and a left occipital parietal lesion with edema and hemorrhage. Computed tomography scan of the chest revealed a 12 3 10 3 9–cm mass in the left upper lung and a 3 3 4–cm lesion in the right apex. Laboratory studies revealed a hematocrit of 0.41, a white blood cell count of 20 3 10/L with a normal differential; an erythrocyte sedimentation rate of 83 mm/h; an aspartate aminotransferase level of 162 U/L; an albumin level of 37 g/L; and arterial blood gas including a pH level of 7.34, partial pressure of carbon dioxide level of 31 mm Hg, oxygen level of 62 mm Hg, and oxygen saturation of 91%. Lung biopsy confirmed primary lung cancer, with presumed brain and spine metastases. Mrs L’s initial pain regimen included salsalate and Percocet, a combination of acetaminophen and oxycodone hydrochloride. She experienced increased difficulty walking. On hospital day 3, Mrs L received dexamethasone, 10 mg 4 times per day, and radiation therapy to the brain was started. A patient-controlled analgesia (PCA) pump with morphine was initiated by the resident physician team with 1-mg doses as needed every 15 minutes, without a basal rate. On day 4, Mrs L stated that Percocet wasn’t helping her back pain and she was given meperidine hydrochloride, 50 mg intramuscularly, without relief. The PCA pump was found to be inoperative at 1:00 AM and she was given an extra dose of morphine. On day 5, Mrs L complained of increased back pain and headache and received a transdermal fentanyl citrate patch. She was receiving ibuprofen, 800 mg 4 times per day, and Percocet and stated, “The pain in my back is killing me.” She also complained that lorazepam made her “loopy.” The hospital pain service was consulted. By day 9, Mrs L complained of progressive loss of vision and difficulty seeing the PCA button. She was started on octreotide, 200 μg every 8 hours, for potential carcinoid tumor suppression. The pain service changed the PCA morphine to fentanyl citrate, with a basal rate of 50 μg/h and 25 μg every 6 minutes as needed. A palliative thoracentesis that removed 1500 mL of pleural fluid relieved her respiratory distress somewhat. Her fentanyl citrate basal rate was increased to 100 μg/h and she was administered ketorolac tromethamine intravenously, and cyclobenzaprine hydrochloride. Sustained-release morphine sulfate, 30 mg every 12 hours, was also started. The pain service described neuropathic and somatic pain. Her fentanyl citrate basal rate was further increased to 150 μg/h plus 25 μg every 6 minutes as needed, and therapy with ketamine hydrochloride, 2 μg/h via continuous intravenous infusion, was started.