Palliative Care Emergency: A Rare Etiology of Acute Pain

Patients with serious or life-threatening illnesses are typically referred to palliative care to discuss goals of care, advance care planning, and to seek control of their cancer-related pain. Physicians who care for patients near the end of life quite often attribute worsening pain to advancing disease. We present a case of a patient with metastatic gallbladder adenocarcinoma who presented to a palliative care clinic with complaints of worsening chest and back pain, uncontrolled with her established opioid pain regimen. Findings on physical examination prompted the search for other etiologies of this patient's worsening pain. An initial review of her recent investigations revealed a suspicious positron emission tomography (PET) scan obtained prior to her clinic appointment, which showed a large right-sided pneumothorax with tension physiology. The patient was urgently sent to the emergency room for emergent placement of a chest tube. This case attempts to bring awareness to the potential bias physicians may have regarding the pain experienced by patients with advanced disease and who are near the end of life. The performance of a thorough physical examination can be neglected in a developed, resource-rich country where imaging is easily accessible. Although the adoption of a stepwise ladder in pain management for patients at the end of life is frequently implemented, forgoing a thorough history and physical examination can have detrimental effects. Consideration of other etiologies of acute pain remains imperative when treating patients at the end of life.