Epidural analgesia at end of life: facing empirical contraindications.
In a patient with unbearable cancer pain at the end of life, long-lasting analgesia without impairment of consciousness could only be achieved with an epidural infusion of local anesthetics combined with opioids and clonidine. Despite leptomeningeal infection during prolonged treatment, epidural analgesia at the lumbar level provided analgesia using very large doses of local anesthetics combined with clonidine and morphine. Thus, terminal sedation was avoided, allowing the patient's end-of-life planning of an "aware" death surrounded by her family. It may be useful to reconsider institutional pain management standards when unbearable pain occurs in patients with limited life expectancy.


CONCLUSIONS
We report a patient with severe visceral and neurogenic pain from metastatic carcinoma of the colon resistant to multimodal oral analgesic therapy. Although there were empirical contraindications, epidural analgesia was successful, allowing the patient's end-of-life planning of an "aware" death surrounded by the family.
Exner
Hans Juha
HJ
*Keski-Suomen Saivaanhoitopiiri, Anestesiologia ja tehohoito, Jyväskylä, Finland; and †Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany.
Peters
Jürgen
J
Eikermann
Matthias
M
D015746:Abdominal Pain / Q000188:drug therapy; D000316:Adrenergic alpha-Agonists / Q000008:administration & dosage* / Q000627:therapeutic use*; D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000627:therapeutic use*; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000627:therapeutic use; D002045:Bupivacaine / Q000008:administration & dosage / Q000627:therapeutic use; D003000:Clonidine / Q000008:administration & dosage* / Q000627:therapeutic use*; D003110:Colonic Neoplasms / Q000150:complications; D000075202:Contraindications; D003424:Crohn Disease / Q000150:complications; D005260:Female; D006801:Humans; D007239:Infections / Q000209:etiology; D008279:Magnetic Resonance Imaging; D009020:Morphine / Q000008:administration & dosage* / Q000627:therapeutic use*; D010148:Intractable Pain / Q000628:therapy*; D013118:Spinal Cord Diseases / Q000209:etiology
D000316:Adrenergic alpha-Agonists; D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D009020:Morphine; D003000:Clonidine; D002045:Bupivacaine