First, take a look at how the attending answered Task 3.
The following description explains how the real case unfolded. However, using the principles of pain managment discussed and in working with this patient, several alternative pathways might have been equally effective.
At the office visit the following occurred:
Naproxen 500 mg bid with meals was started along with misoprostol 100mcg bid. D/C percocet. D/C fentanyl patch.
Start morphine sulfate long acting in equal analgesic doses to:
25mcg duragesic equals 15mg morphine sulfate long acting bid
60mg of oxycodone daily equals 30mg morphine sulfate long acting bid
for a total of 45mg of morphine LA q 12hrs.
30 mg of morphine IR q 4 hrs prn ‘break through’ pain.
Wendy was instructed to call immediately if any problems arose.
Two days after the office visit the physician calls Wendy and she reports her pain had decreased from an average of 9-10/10 to 6-7/10.
She used on average 4 doses of breakthrough morphine IR per day. I increased her morphine LA by dividing 120mg (4 doses of breakthrough medicine at 30mg/dose = 120mg) between her q12 hour doses so she is now takes 100mg of morphine LA q 12 hours and continues to take 30 mg of morphine IR q4 hrs for ‘break through’ pain.
Two days later I called Wendy again. She reports her pain had decreased further to 4-5/10 on average and she takes two break through doses of immediate release morphine on average per day. She complains of mild sleepiness and some constipation.
What did I do at this point?
After I reassured Wendy that her sleepiness was temporary and would improve over the next week, and that her constipation could be controlled with the use of senna, one tablet for every 15 mg of morphine she agreed to increase her morphine further. I increased her morphine LA to 130mg bid and maintain her on the 30mg of morphine IR q 4 hours prn.
When I called her back two days later she was grateful. Her pain was averaging 3/10 or less with her 130mg of morphine sulfate LA q12 hours and she was using her breakthrough morphine IR on average less than once/day. Her sleepiness improved and her bowels were moving well. In fact she found it hard to believe that she still had cancer. After all these months of uncontrolled pain she has equated her pain with her cancer. Now that the pain was controlled she found it hard to accept that her cancer still persisted. This radical change in Wendy’s life occurred within 9 days of her first office visit.
Conclusion
Conducting a thorough pain assessment, using the information obtained to formulate an understanding of the underlying etiology of the pain, and using this understanding to develop a sound pharmacologic treatment plan based on the WHO analgesic ladder produced excellent pain management in Wendy as it will in cancer patients more than 85% of the time with minimal side effects. More importantly you have freed Wendy from the suffering of uncontrolled nociceptive pain. Freedom from pain will allow Wendy to concentrate her energies upon the many opportunities for dealing with the significant emotional and spiritual challenges she faces at the end of her life.
What happened to Wendy and her family?
While listening to Wendy’s story you feel a deep sense of emotion as you remember your own father’s death and what it has meant to you. You also remind yourself to spend some special time with your own children when you get home. You let Wendy know that you will assist her in her efforts to support Oscar and her children during this difficult time. You give her some reading material on grief in general and grief in children in particular. You also give her the Web site for the National Hospice Organization and refer her to the hospice bereavement coordinator who enrolls the entire family in a bereavement program for children and their parents. Wendy makes it clear she wishes medical care that promotes comfort and quality of life. She wishes the least invasive care that will allow her to
stay home with the support of her family. Oscar is not as willing to suspend aggressive curative therapies. He insists Wendy continue to seek experimental chemotherapy. He is certain God will not let her die and a miracle will save her no matter what the odds. Oscar’s perspective creates significant stress for Wendy. She struggles with what to do. In the end she doesn’t want to put her future in the hands of medical treatments and miracle cures. Her limited time is too precious to spend in this manner.
You meet with both Oscar and Wendy. You ask Oscar his greatest fear. While he doesn’t cry his voice wavers as he says, “I can’t imagine a future without Wendy as my partner.” When you ask him what he hopes for he replies in a determined voice, “I know if I pray hard enough God will cure her.” You ask Wendy her hope. She looks Oscar in the eyes and softly says, “To spend the time I have left with Oscar and my daughters in our home sharing each moment to its fullest. I too believe in God and the power of miracles. I am expecting a miracle but do not want to achieve it through painful medical treatments that will keep me in the hospital. Being isolated in the hospital is my greatest fear.” Oscar’s body noticeably softens. He
unwillingly agrees with Wendy to consider a Hospice referral.
You refer Wendy and her family to Hospice. Over the next 4 months, Wendy accomplishes the following goals and rituals to assist herself and her family deal with their mutual bereavement and loss: She has frank and open discussions with her daughters and Oscar, exploring together their concerns, fears, and grief. Wendy’s mother and sister visit. Past grievances are forgiven and their love for each other is affirmed. She leaves written letters for her daughters in Oscar’s keeping to be opened on their sixteenth birthday, graduation from high school, 21st birthday, wedding day (should they marry), and the birth of their first child (should they have children). As her love and connection with Oscar deepens, they marry and he adopts Alicia and Sarah. Together, Oscar and Wendy buy a home in which
the new family can live and where they celebrate a poignant final Christmas. As Wendy declines Oscar continually asks treatments be considered which will prolong her life. Initially he wants a feeding tube placed as Wendy’s weight declines. Later he wants IV fluids started as she nears death. Throughout he suggests a consultation at the University Medical Center to see if some new therapy would help. Both Wendy and you patiently hear him out. You both gently remind him of Wendy’s goal of staying at home with Oscar and her daughters, enjoying each moment fully. Wendy asks Oscar to pray with her for God’s healing power. This reassures Oscar that Wendy has not given up and he is willing to continue a hospice/palliative approach. In fact Oscar’s actions speak louder than his words. He never wavers in his devotion and care to Wendy and their children.
Finally, even Oscar with tremendous difficulty, acknowledges that Wendy is near death. She asks that the family come together on the anniversary of her death to sing her favorite hymn, which she and her father often sang together. When Wendy dies peacefully at home, the family grieves deeply. Yet over the months and years the grief lessens and the legacy she leaves behind allows her to remain a continuing member of her strong and growing family. You, as well, feel enriched and transformed by your involvement in this experience and always feel Wendy’s presence when you provide care to Oscar and his children.
Remember: The Clinic closes on Friday.
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