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

Levine, Barry Ph.D; King, Theodore M.D; Pestaner, Joseph P. M.D; Smialek, John E. M.D

The American Journal of Forensic Medicine and Pathology: March 2001 - Volume 22 - Issue 1 - p 62-64

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.

From the Office of the Chief Medical Examiner, Baltimore, Maryland.

Manuscript received May 3, 2000; accepted July 15, 2000.

Address correspondence and reprint requests to John E. Smialek, M.D., Office of the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201, U.S.A.

© 2001 Lippincott Williams & Wilkins, Inc.