Palliation of Intractable Cancer-Related Pain With Low-Dose Epidural Bupivacaine

Patients with advanced cancer nearing end of life often present with complex multifactorial pain. Although epidural analgesia is routinely used in inpatient hospital settings for targeted pain control, there is scant description in the literature of the use of low-dose epidural analgesia for relief of cancer-related pain at end of life. In this study, we present a case of difficult to control cancer-related rectal and pelvic pain in a patient who responded well in her last days of life to a low-dose bupivacaine epidural. A 66-year-old woman presented for inpatient hospital admission for pain control from home hospice with intractable cancer-related pain from metastatic colorectal adenocarcinoma marked by extensive erosive lesions extending from the anterior perineum to the posterior rectum, with rectovaginal fistula. The patient reported poor tolerance of medications and described spiritual beliefs (based in Buddhism) that caused her and her family to prioritize maintaining a lucid, clear mind above nearly all else while seeking symptom management. The patient was so debilitated by pain at the time of presentation that she was bedbound in a quadruped position. After 2 weeks of poor pain control in the hospital with multiple failed attempts at palliation-including bilateral pudendal block, as well as opioids and other routine, but potentially sedating or deliriogenic, medications to treat her pain-the patient permitted administration of a low-dose bupivacaine epidural that significantly reduced her pain and allowed the patient to remain clear-headed up until the time of her death. Twenty-three days after admission, and 5 days after initiation of low-dose bupivacaine epidural for pain control, the patient died peacefully in the hospital. Low-dose epidural analgesia for cancer-related pain at end of life from malignancy involving the pelvis-perineum, rectum, or vagina-may be a viable option for patients, particularly those who wish to avoid the risk of somnolence or confusion from systemic opioids and other analgesics.