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The Patient's Story

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Mr X is a 33-year-old man with a 4-year history of metastatic mucinous adenocarcinoma of the appendix. During his illness, Mr X completed several cycles of chemotherapy and had several percutaneous draining ostomies for small-bowel obstruction due to peritoneal carcinomatosis. His most recent admissions were triggered by protracted nausea and vomiting and recurrent small-bowel obstructions associated with increasing abdominal pain.

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In recent months, Mr X's overall care had been managed by his medical oncologist and the anesthesia pain service. In addition, on the admission before this, he had been briefly seen by a palliative care physician. His wife reported that he had been "close to death" on several previous admissions. Mr X and his family were aware of the extent of his disease but wanted aggressive life-prolonging treatment to continue, including cardiopulmonary resuscitation. Mr X's baseline chronic abdominal pain had nociceptive, visceral, and neuropathic features and had been difficult to manage. After a variety of opioid trials, he had finally obtained some analgesia on escalating doses of intravenous (IV) methadone. His methadone dose at home after his last admission was 800 mg administered each 24-hour period (200 mg IV every 6 hours), with his wife giving each 200-mg dose during a 20- to 30-minute period. A visiting nurse service and a home care infusion company oversaw his methadone administration.

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One day before his final hospital admission, Mr X underwent a celiac plexus block in an attempt to improve his pain relief and decrease his opioid requirements. Two hours later he developed fever and severe abdominal pain, self-rated as "15 of 10" on a 0- to 10-point scale. The patient's unrelieved pain and the visiting nurse's concern that the methadone was contraindicated because of the finding of a QTc prolongation on an electrocardiogram (ECG) with the consequent potential for an arrhythmia led to the decision to bring the patient back to the hospital.

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On his arrival at the hospital, the patient's temperature was 40.0°C, his blood pressure was 98/40 mm Hg, his heart rate was 116/min, and his respiratory rate was 34/min. When examined by Dr P, the attending physician on the medicine team, Mr X was sitting up in bed in acute distress. He was cachectic and jaundiced and had severe abdominal pain. His abdominal examination revealed diffuse tenderness to palpation with rebound and guarding. There was pus draining through the skin sites of previous percutaneous draining ostomies.

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The initial impression was that Mr X was in an acute pain crisis superimposed on chronic abdominal pain. The pain exacerbation was thought to be associated with acute peritonitis or bowel perforation due to the progressive metastatic disease or the recent celiac plexus block. The main priority of the medical team was pain crisis management and reestablishing the goals of care in the setting of the rapid worsening of the patient's condition. Despite the severity of his ...

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