Forensic Toxicological and Medico-Legal Evaluation in a Case of Incongruous Drug Administration in Terminal Cancer Patients

Background: In most cases, palliative care is prescribed to adults diagnosed with cancer. The definition of the most suitable therapy for an effective sedation in terminal cancer patients still represents one of the most challenging goals in medical practice. Due to their poor health, the correct dosing of drugs used for deep palliative sedation in terminal cancer patients, often already on polypharmacological therapy, can be extremely complicated, also considering possible drug-to-drug interactions that could lead to an increased risk of overdose and/or incongruous administration with fatal outcomes. The case of a terminal cancer patient is presented, focusing on the “adequacy” of administered therapy. Materials and Methods: A young male, affected by Ewing sarcoma, attending a palliative care at his own home, died soon after midazolam administration. Toxicological and histological analyses were performed on body fluids and organ fragments. Results and Discussion: Morphological reliefs evidenced a neoplastic mass, composed of lobulated tissue with a lardy, pinkish-gray consistency, extending from the pleural surface to the lung parenchyma, also present at the sacrum region (S1–S5), at the anterior mediastinum level, occupying the entire left pleural cavity, and infiltrating the ipsilateral lung. Metastatic lesions diffused to rachis and lumbar structures. The brain presented edema and congestion. Toxicological analyses evidenced blood midazolam concentrations in the range of 0.931–1.690 µg/mL, while morphine was between 0.266 and 0.909 µg/mL. Death was attributed to cardiorespiratory depression because of a synergic action between morphine and midazolam. The pharmacological interaction between midazolam and morphine is discussed considering the clinical situation of the patient. The opportunity to proceed with midazolam administration is discussed starting from guidelines recommendation. Finally, professional liability outlines are highlighted.

Introduction: Late Hammer

This introduction to a dossier of short pieces on Barbara Hammer locates the work of the late filmmaker in the context of feminist film culture and the journal Camera Obscura. It briefly reviews several phases of the artist's career before focusing on the output of the last decade of the filmmaker's life. Diagnosed with terminal cancer, Hammer made work dealing with her body; gave footage she shot over the years to several filmmakers to finish as they wished; set up a grant for lesbian experimental filmmakers; and collaborated with curators, archivists, and her partner, Florrie Burke, to shape her own legacy. Pieces by the collaborators who contributed to this dossier are introduced.

Good death and bereavement in a lung cancer patient following meaning-centered couples psychotherapy by a cancer nursing specialist

Objective There are many terminally ill cancer patients who are struggling with the meaning of life, but it cannot be said that their concerns are being adequately addressed. Method From a series of cancer patients undergoing end-of-life care, the case of a patient, who developed incurable lung cancer and, together with his wife, lost the meaning of life and underwent meaning-centered couples psychotherapy once every two weeks to have them consider the meaning of life together, is presented. Results The patient was a 70-year-old man who had been diagnosed with lung cancer and pleural dissemination 14 months earlier. The meaning-centered psychotherapy (MCP) sessions were conducted with the patient and his 70-year-old wife by a cancer nursing specialist who had received extensive training in MCP and had also received 7-year on-going supervision from a Japanese MCP-enlightened psychologist. At the same time, palliative treatment of physical distress was performed. The patient was able to discover the meaning of life as a result of MCP performed by a cancer nursing specialist for him and his spouse who had lost any notion of the meaning of life after being informed that he had terminal cancer at the time of the initial diagnosis. Significance of results Meaning-centered psychotherapy provided to terminal cancer patients by cancer nurses can help patients and their families express their gratitude, thereby achieving a good death for the bereaved family. Nurses are likely to increasingly perform MCP in the future.

Factors affecting the oral health of inpatients with advanced cancer in palliative care

Purpose Patients with terminal cancer undergoing multidisciplinary palliative care often have oral health problems, but these details are still unclear. This cross-sectional study aimed to elucidate the oral health of patients with terminal-stage cancer who are inpatient recipients of acute-phase palliative care, and to unveil the factors affecting their oral health. Methods Participants were 121 patients with terminal-stage cancer (68 males, 53 females, mean age: 73.6 ± 11.1 years) and oral health complaints. They received palliative care at Tokyo Medical and Dental University Medical Hospital between April 2017 and August 2019. Their demographic and medical details were extracted, retrospectively, from their medical records, and their oral health status, such as the number of natural teeth, removable denture usage, Oral Health Assessment Tool (OHAT), and Dysphagia Severity Scale, were evaluated. All outcomes were assessed by a dentist from the palliative care team. Results The problems with soft tissue, saliva, and oral cleanliness were observed. The absence of posterior occlusal support was common, and the use of removable dentures was often inadequate. In contrast, swallowing function was relatively well-conserved and 46.3% of the participants were capable of nutrition intake solely by mouth. Multiple regression analysis revealed a significant association between total OHAT score and age, consciousness level, prognostic level, and method of nutritional intake. Conclusion The results revealed that the oral health of terminal cancer patients under palliative care declined despite receiving routine oral care from nurses, and suggest the importance of including dental professionals in multidisciplinary palliative care.