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 5,200 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.     

Ethical and practical principles underlying the end of life decisions

"I will not relinquish old age, if it leaves my better part intact. But, if it begins to shake my mind, if it destroys its faculties one by one, if it leaves me not life but breath, I will depart from the putrid or tottering edifice. If I must suffer without hope or relief, I will depart, not through fear of the pain itself, but because it prevents all for which I would live." Seneca, the great Roman statesman of 1st century AD, spoke these words 2 millennia before the Netherlands became, on November 28, 2000, the first country in the world to legalize euthanasia. The decisions pertaining to end of life, whether legalized or otherwise, are practiced in many parts of the world but not reported on account of legal implications. Lack of awareness regarding the distinction between different procedures on account of legal status granted to them in some countries is the other area of concern. Debate among the medical practitioners, lawmakers, and the public taking into consideration the cultural, social, and religious ethos will lead to increased awareness, more safeguards, and improvement of medical decisions concerning the end of life.