Joe Stevens is a 77-year-old man diagnosed with prostate cancer that has metastasized to his lumbar vertebrae. After being treated initially with chemotherapy, he developed significant side effects and chose to stop after five courses of treatment.

Mr. Stevens now gets goserelin (Zoladex) injections every three months, which are holding his cancer at bay. His bone metastases cause significant pain, and his physician has worked extensively with him to develop an effective pain management regimen, including trying various drug combinations. Mr. Stevens turned down palliative radiation, because he wants to avoid the severe fatigue he experienced during earlier radiation therapy.

Currently, he takes the long-acting opiate OxyContin and uses a Fentanyl patch. When he takes enough pain medicine to decrease his pain to a tolerable level, Mr. Stevens feels confused and sleepy and can't interact well with his family. In addition, his pain medicines cause nausea and vomiting. He tried metoclopramide (Reglan) and then ondansetron (Zofran), but neither helped much.

Mr. Stevens also experiences anxiety and has gone to the emergency room twice in recent months with panic attacks and hyperventilation. At his last visit, three weeks ago, he was prescribed lorazepam (Ativan), as needed.

To date, he and his wife have declined referral to hospice, stating they prefer to manage on their own as long as possible.