A 68-year-old man with metastatic small-cell lung cancer has excruciating bone pain and was near death. He initially responded to a combination of radiation and chemotherapy and had a three-year remission. When his disease recurred four months ago, he chose a palliative approach. His pain from extensive bony metastases was initially well controlled with high-dose, around-the-clock opioids supplemented by radiation and nerve blocks. He prepared for death through talks with his family and clergy and he felt that he had no remaining "unfinished business." At that time, he weighed 80 pounds, he was bed-bound, and his pain averaged eight points on a ten-point scale. He did not want to die but was willing to accept the risk for earlier death that might come from further increasing doses of opioids. After a palliative care consultation, his physician increased his total opioid doses by 25 percent per day until the pain was adequately controlled, or, if sedated, he appeared comfortable.
On the third day, the patient became very sleepy but arousable and appeared relatively free of pain. The physician shifted an equianalgesic amount of opioids from oral to transcutaneous administration because the patient was unable to reliably swallow. The patient became unresponsive but appeared comfortable, and he remained in that state until he died two days later. (Source: Unknown).