She had a total hip replacement following a full discussion of the enhanced risks of surgery. Within a week she had complete relief from her left hip pain and regained full mobility following rehabilitation. This enabled her to spend most of her final year of life living independently. Del Fabbro et al [27] discussed an unusually complex case of a woman in her sixties with lung cancer with limited metastatic disease and a history of osteoporosis, OA, and chronic back pain. She was admitted to

the palliative care unit with intractable pain that was poorly controlled using intravenous (IV) opioids (oral morphine equivalence Inhibitors,research,lifescience,medical of up to of 1600mgs daily). The main focus of the paper is on the temporary palliative sedation that was used to control delirium and enable assessment Inhibitors,research,lifescience,medical of symptom

severity whilst rotating opioids to maximise analgesic affect with minimum side effects, enabling discharge home for a period of weeks before death. This case highlighted how the treatment of long term chronic musculoskeletal pain may have inadvertently and adversely affected the care needs as death approached. The woman had been receiving muscle relaxants and opioid analgesia for chronic back pain since the death of her husband. The possibility that she had somatised her grief and selleck products depression during her bereavement is discussed. It is suggested that this maladaptive coping mechanism of requesting opioids for existential distress Inhibitors,research,lifescience,medical as well as physical pain, contributed to the rapid escalation of opioids that led to delirium and the necessity of temporary sedation [27]. Greenstreet [21] focused on ‘Hannah’: a woman in her early 50s with colon cancer, metastatic lung disease and a pulmonary embolism (PE). She had a history of OA and Inhibitors,research,lifescience,medical bilateral knee

arthroplasty. The main physical symptom was pain in the left knee due to osteomyelitis. Hannah was not fit for surgery and non-steroidal anti-inflammatory medication was inappropriate due to the risk of haemorrhage as she was prescribed anticoagulant medication following her PE. Corticosteroids and a course of intravenous Inhibitors,research,lifescience,medical antibiotics were prescribed with the aim of reducing the inflammation, and associated pain, caused by the osteomyelitis. Analgesia was given in accordance with the WHO Cancer Pain Ladder [28] and a strong opioid (morphine) was gradually titrated until a good analgesic effect was achieved at rest. This was realised with 460 mg slow Resminostat release morphine twice daily. Breakthrough pain, commonly provoked through movement remained. Non pharmacological measures to reduce these episodes of breakthrough pain included a brace to immobilise the knee joint, crutches to minimise weight bearing, and ensuring the leg was elevated when Hannah was sitting. Psychological support, massage and aromatherapy were also used to reduce pain perception. Epidemiological papers Smith et al [29] considered the epidemiology of pain during the last two years of life.