Palliative pain therapy at the end of life and forensic medicine issues

An 83-year-old woman with a history of Alzheimer's disease and breast cance r died at home while receiving palliative pain therapy with oral morphine f rom her family for metastatic breast cancer. Allegations of mistreatment we re made, and this case was ultimately referred to the Office of the Chief M edical Examiner, State of Maryland. An autopsy failed to identify any injur ies Or residual cancer, leaving no anatomic explanation for the pain that h ad been presumed to be metastatic breast carcinoma involving bone. The bloo d free morphine concentration Was 5200 ng/ml, and the total morphine concen tration was 15,000 ng/ml. This case demonstrates the challenges and difficu lties in forensic medicine when faced with the interpretation of toxicologi c results at the end of life.