August 1997
Volume 61 |
Number 8
|
| |
|
| Pain Management
From the Other Side of the Mountain |
Kay L. Miller
Introduction
This article was written by Kay Miller after
the death of her husband John Miller, M.D., who was Chair of the
Department of Anesthesiology at the University of South Alabama
College of Medicine. She wrote it from observations and notes
that both of them collected during John's last months of life.
I had the opportunity to suggest that they do this and was overwhelmed
by the sincerity, depth and implications of their writings. It
is offered as both a source of education and encouragement for
all ASA members. The issues of pain and dying are of concern to
all of us in our professional and personal lives. As Kay has stated,
John's intent "was not to lecture from the grave, but to
offer considerations and provoke thought."
Gale E. Thompson, M.D., Chair
Committee on Pain Management
 In
October of 1995, John had a right upper lobectomy to remove a
poorly differentiated adenocarcinoma. Eighteen months later, he
began experiencing severe pain, and an MRI scan of the spine revealed
destructive changes involving the L2 vertebral body and sacrum.
John was referred to a radiation oncologist for palliative radiation
therapy of his bone lesions. The severity of his pain was markedly
diminished by the end of the five-week series of treatments. During
this time, John was taking oral morphine and ocycodone/acetaminophen
as needed for breakthrough pain, with occasional short-term use
of steroids. He also took gabapentin and later amitriptyline for
the tingling nerve pain in his legs. In mid-August, he began experiencing
severe back pain and received intravenous Strontium-89 therapy,
which he tolerated well and once again experienced good pain relief.
Several days later, John noticed that he was becoming very short
of breath. A thoracentesis confirmed that it was a malignant effusion,
and a talc pleurodesis was performed to control it. During this
time, John began to deteriorate markedly. He continued to experience
severe right chest pain and breathlessness. He was started on
a combination of morphine sulfate sustained release with morphine
sulfate immediate release for breakthrough pain and dexamethasone.
John responded to this therapy and began to experience an improved
but limited quality of life. In early September, he retired from
the University and all academic pursuits.
Pain Control
John ultimately concluded that the management of his cancer pain
involved less technology than he had expected and some concepts
of pain management that were previously unknown to him. Except
for the radiation therapy and the strontium injection, most of
his pain control was managed by varying the medium and frequency
of morphine. He also realized that anxiety plays a significant
role in pain management. He wished to address two specific aspects
of his pain treatment.
1. Nebulized Morphine
At home, after the exhausting pleurodesis, the chronic chest
wall pain and the breathlessness became his primary irritants
and the focus of our concern. The discomfort was constant and
draining. We knew they would wear him out and hasten his death.
But these problems were relieved almost immediately when his doctor
and the hospice respiratory therapist recommended a trial of nebulized
morphine therapy.
Nebulized morphine was simple to administer. We placed a 10 mg
morphine tablet in 3 cc of sodium chloride in the nebulizer. It
dissolved in a few seconds. John then inhaled the solution and,
within a few minutes, his breathlessness was relieved and he experienced
a dramatic reduction in the chest pain. John could regulate the
frequency of the treatments based on his perceived need, but usually
they were no more than four hours apart.
John also had discretion in the dose of morphine, doubling the
amount as his condition worsened. This control was an important
secondary benefit to him. The nebulized morphine contributed to
a sense of well-being and comfort. My family appreciated the simplicity
of the technique and did not fear committing a technical error
during a time when our concentration as caregivers was compromised.
2. Anxiety
John was not afraid of dying. In fact, many people remarked on
his courage as he faced death. He attributed this to having had
polio at 7 years old. John had worked through feelings of anger
and self-pity when he was bedridden as a child and during the
subsequent years of pain and disfigurement. John achieved spiritual
peace with his impending death very early in the cancer's course,
accepting death as the natural outcome of living. For these reasons,
he rejected treatment with cytotoxic chemotherapy and sought only
palliative care.
During John's illness, the most frequent question I was asked
was whether or not he was in pain. Due to the combination of therapies,
his pain was actually quite well-relieved, and I could answer
"no." To those who knew instead to ask whether or not
he was suffering, I often had to respond in the affirmative. The
suffering resulted primarily from anxiety caused by the breathlessness
and chest pain.
John's experience led him to conclude that generally not enough
attention is paid to the importance of recognizing and controlling
anxiety, especially early in a patient's course of treatment.
John knew he would experience increasingly severe pain with his
death, but he was not prepared for the level of anxiety that he
would experience. Though he was prepared to die, he was not prepared
to die alone, gasping and suffocating ignominiously to death in
the middle of the night in his hospital room.
During this time, none of his surgeons prescribed anti-anxiety
medications. It was only upon the suggestion of a visiting physician
friend that this medication was provided John. From that time
forth, John willingly accepted prescriptions for lorazepam. This
reduced his anxiety and helped him achieve psychological comfort
and relief from the "horrors" he experienced from the
fear of suffocating and the lung complications he envisioned as
a respiratory physiologist and anesthesiologist. As the dyspnea
worsened considerably a few days before his death, his oncologist
prescribed chlorpromazine, saying that it would also help by enhancing
the morphine.
Upon reflection of his personal experience, John recalled a number
of cases he had witnessed in the hospital when the apparent failure
of the physician to recognize the role of anxiety in the acute
phase of a patient's postsurgical treatment contributed to the
patient's irrational behavior. John wondered how frequently ICU
psychosis is just a case of severe anxiety. This reinforced to
him the role of a multidisciplinary critical care team, with a
member experienced in the psychological needs and treatment of
acutely ill patients to recognize when pain stops and suffering
begins. He surmised this would expedite the patient's ultimate
recovery and might reduce the use of more high-tech, costly treatments
for symptoms that may be solely manifestations of fear.
Pain Management Specialists
By the time of his death, John had arrived at some conclusions
about the field of pain management. It was a shock to John, as
a Board-certified pain management physician, to discover the gaps
in his knowledge. He, like every other anesthesiologist with whom
he spoke, had been unfamiliar with the concept and use of nebulized
morphine. He wondered how he and others could be called effective
pain management specialists when all were unaware of a very effective
way of relieving chest wall pain. He said that as a physician
he was used to dealing with postoperative pain control involving
the musculoskeletal component of chest wall pain, but not visceral
pain.
He felt that anesthesiologists, as specialists in acute pain
management, had to transition beyond the acute pain situation
to also become effective as managers of the chronic, background
pain that may be overlooked or exaggerated by the acute pain.
His desire was that anesthesiologists become aware of and involved
in the full scope of pain management, not just a limited number
of techniques practiced in traditional settings. He felt there
was a whole world of opportunities yet to be created for pain
specialists.
John would also suggest that physicians who are involved in the
treatment of dying patients ask them what it is that they fear.
Even before he experienced anxiety, due to dyspnea, John often
worried about being ordered more aggressive treatments than he
wanted or of enduring a high technology, drawn-out death. John
appreciated that his oncologist did not assume what his concerns
were, but pointedly asked about them.
In summary, John would recommend physicians have more cross communication
among all those specialties treating the patient, and he would
recommend more direct communication with patients about fear and
anxiety issues associated with dying.
Personal Thoughts
I am grateful that John received a combination of therapies that
substantially relieved his pain and anxiety and that contributed
to a relatively comfortable, stable quality of life. He was able
to continue working, and we had four invaluable months of very
good companionship. It also permitted him the symptom-free, dignified
death at home that he originally sought.
I am also grateful that John could articulate his fears and wants
to a sensitive physician who listened to his desire for good pain
control, but who knew that John's greater issues in dying were
comfort, control and a sense of well-being. His oncologist continued
to ask and listen to what John wanted over the four months that
John was his patient. Only at the very end did he disagree with
John's inquiry about whether therapy to reduce the fluid accumulation
in his abdomen would be helpful. The oncologist later told me
that dying patients will often renegotiate with themselves and,
if their physician has had open and frank conversations with them
about their desires and fears, the physician is better able to
ensure that a patient's final dignity is preserved. In John's
case, his physician intervened when he knew John would not be
"kind to himself." John respected him enormously for
this final reminder of their original agreement.
But John told his oncologist's nurse that dying is hard. He said
that as a cancer patient, your days have a different value than
those of your physician's. An hour or so lost while waiting for
a response to his page for help was infinitely frustrating. He
felt it was his life that they were consuming by their tardiness.
It never ceased to amaze him how evasive other physicians were
about dealing with his cancer and death. We laughed over the card
from a fellow anesthesiologist who sent condolences about John's
"medical misfortune," but we also felt great sorrow
at how these evasions choked their relationship.
Dying was hard because John put into it the emotional and intellectual
insight to understand that his previous definitions of what constituted
a good quality of life could change. I knew the day he willingly
agreed to go shopping at Circuit City in a wheelchair that he
was beginning to appreciate life on a level previously abhorrent
to him.
From that day forth, I gave up thinking I knew what was best
for him, or any dying person, and let him show me exactly where
he was on his journey toward death. Fortunately, in October, when
he was ready, the act of dying was not hard. Again, thanks to
the morphine and the chlorpromazine, by that time being administered
intravenously, his pain and anxiety control was such that he died
peacefully.
Gale E. Thompson, M.D., is Staff Anesthesiologist
at the Mason Clinic, Seattle, Washington.
Kay L. Miller is Director of Corporate
Compliance, Governmental Relations and Risk Management for a large
Alabama health maintenance organization.
return to top
|