Continuous subcutaneous infusions offer a safe, simple, effective alternative to intravenous or intramuscular injections when oral medications cannot be used. They are extremely useful for cancer patients suffering from pain, vomiting, seizures, and other symptoms. Hydromorphone or morphine may be combined with metoclopramide, methotrimeprazine, or haloperidol (in D5W only), in the same pump to control both pain and nausea. Seizures can be controlled by subcutaneous infusion of phenobarbital or midazolam. If proper doses are prescribed and skin irritation is watched for, they can be used safely in the patient's home.

Accurate estimation of survival time in terminal cancer patients is difficult yet may provide useful information. A historical prospective study on 172 patients admitted to a home based hospice service was performed to determine which variables were best correlated with survival time. Mean and median survival were 48 and 22 days, respectively, representing a highly skewed distribution of life span in this sample. As age increased, survival time decreased. All Activities of Daily Living (ADLs) recorded (Bathing, Continence, Dressing and Transfer) as well as other measures of performance (mobility and pulse) and nutrition (appetite and nourishment) were each strongly associated with survival. Multivariate analysis limited significant variables to dressing ability, pulse rate, level of appetite and transferring ability. Outliers (survival greater than 180 days) were differentiated from the remainder of the sample by significant differences in all ADLs recorded as well as the level of appetite. These findings establish the importance of assessing ADLs, a measure of functional status, and reinforce the importance of performance and nutrition measures when estimating length of survival in terminal cancer patients.

Methadone has been found to be useful in pain uncontrolled by large doses of conventional opioids such as hydromorphone and morphine. While the subcutaneous route is effective and may afford cost-savings over the intravenous route in patients unable to take oral medication, its utility for the administration of methadone may be hampered by local toxicity, specifically erythema and induration. To examine the issue of limiting toxicity, we analyzed our inpatient hospice experience in six consecutive patients who received subcutaneous methadone for severe cancer pain. We confirm the high incidence of local toxicity, but note that the severity is subject to considerable individual variation. Furthermore, toxicity is uniformly manageable by site rotation and the use of dexamethasone infused concurrently with the methadone. We recommend that the infusion of subcutaneous methadone should be considered in the appropriate patients who can be closely monitored.

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