Synergic action of high midazolam doses and morphine in terminal cancer patient: indications, criticality and liability

Introduction and Aims Palliative care were introduced in Italy in 2010, while in 2007 the Italian Society Palliative Care (S.I.C.S.) published recommendation on terminal/palliative sedation, defining the taxionomic, pharmacological and therapeutic aspects. However, the definition of the most suitable therapy for an effective sedation still represents one of the most challenging goals in medical practice. 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 Toxicological analyses evidenced blood midazolam concentrations in the range 0,931-1,690µg/mL, while morphine was between 0,266-0,909µg/mL. Morphological reliefs evidenced a mammellon tissue, of lardous consistency and greyish-pink color, in the sacrum region (S1-S5), at the anterior mediastinum level, the entire left pleural cavity, infiltrating the ipsilateral lung. Metastatic lesions diffused to rachis and lumbar structures. Brain presented edema and congestion. The pharmacological interaction between midazolam and morphine are reviewed, considering the clinical situation of the patient, the amount and specific way of administration of the benzodiazepine. The opportunity to proceed with midazolam administration is discussed starting from S.I.C.S. recommendation. Finally, professional responsibility outlines are highlighted.