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.

Real-World Data on Home End-Of-Life Care for Elderly Cancer Patients: A Yokohama Original Medical Database-Based Retrospective Analysis

Background Cancer incidence is expected to increase with population aging, making the availability of places for treating terminal cancer patients a pressing issue. Thus, home medical care is expected to play a crucial role. However, real-world big data on the actual state of home end-of-life care in Japan are limited. We aimed to clarify the real-world state of home end-of-life care for elderly cancer patients using data from an administrative database. Methods We analyzed the Yokohama Original Medical Database, which included 2,486,834 people and 29,411,895 medical invoices in 2014 and 2015. Data of target patients were extracted based on three criteria: age ≥ 65 years, malignant neoplasm diagnosis, and having a billing code of home end-of-life care. Medical fee points, including data related to home medical care, emergent admission, and survival time at home, were also analyzed. Results Overall, 1,323 people (554 and 769 aged < 80 and ≥ 80 years, respectively; males, 59.2%) had planned to receive home end-of-life care. The < 80-year group had more frequent emergent home visits than the ≥ 80-year group (p < 0.001), but the number of monthly home visits was similar between the two groups (p = 0.267). The average overall survival time at home was 3.9 ± 4.4 months, with the < 80-year group having a shorter survival time than the ≥ 80-year group (p < 0.001). Conclusions Terminal cancer patients aged ≥ 80 years were less dependent on home medical care and had better prognosis at home than terminal cancer patients aged < 80 years did. Our results can provide the basis for providing home medical care through a community-based integrated care system and for evidence-based policymaking.