Tuesday, March 9, 2010


Today I spent the day in a hospice setting. It was a difficult day. I really only saw one patient throughout the course of my day, she is dying from cervical cancer (don't get me started on getting paps in a timely fashion, that's for another post). Advanced cancer is painful, and this woman is in pain. Her family does not want her to receive pain meds because they've "seen other hospice patients and they are all out of it." They want her to only receive pain medications when she asks for them, or in med lingo, prn.

Here's the difficulty with end of life pain meds. Pain is difficult to control, particularly in patients who have a lot of it for a long time. And once the patient is feeling the pain and asking for meds, it is harder to keep it at bay than it is if we "stay ahead of the pain". By staying ahead of the pain this does not mean snowing people so they are completely incoherent. It means giving a monitored dose of long acting pain medication in a scheduled fashion so that people are less likely to need the short acting, heavy hitting "breakthrough" meds. In addition to the benefit of less pain, the patients are often less agitated and better able to handle their surroundings and are less likely to become delirious secondary to pain and anxiety.

It's also important for patients and families to understand that addiction to pain medications in this setting is almost never an issue. Addiction implies an illness defined by the patient actively seeking out a drug. Pain medications for chronic pain almost never fit this category. Dependence on the pain meds often does happen. The patient will grow to require higher doses, but often this stems from advancing disease processes rather than the patient getting used to a certain dose of meds. The patients may withdraw if they are removed from the pain meds, and this is also not a sign of addiction. In fact, withdrawal can occur even from antidepressants, a class of drugs which is not addictive in nature.

It's important to me that patients become informed about what palliative care and hospice really mean. It is not simply a place to die. In fact, hospice is not a place at all, but a philosophy of care. Hospice often happens at home. Currently the average patient is in hospice care for a median of 15 days. 15 days until they pass away. This is most often because both physicians and patients are not informed about when a patient may receive hospice and what kinds of services they may be eligible for when they do. If you feel a loved one may need Hospice care, or would like to find out more about what Hospice entails, please visit www.hospicenet.org.

The people who work with Hospice are about as caring and giving as it gets. I truly believe if more people understood hospice and what they do, more people would take advantage of this amazing benefit at the end of life. Check them out.

And as one last note from my soapbox - talk with your loved ones about your wishes long before you reach an end of life situation. It can make all the difference in the world.


medicine girl said...

Thanks for a great post! I'm a hospice volunteer and currently on a 2-week Palliative Medicine rotation. Hospice has a special place in my heart.

It saddens me to hear that some patients and families avoid the pain meds based on the myths you've addressed. Another advantage of pain medication is that it helps the patient to devote a lot less energy to fighting her pain. This can give her more mental energy to interact with family and better address any end-of-life emotional or spiritual needs.

P.S. I love the baby updates and look forward to reading more!

L.G. said...

Thanks! It was an intense day, and though we only get one day in a hospice setting, it was enough for me to really appreciate those who take up the mantle for their patients.

I hope all is going well and that you are keeping yourself busy as the match approaches. I will be a nervous wreck at this point next year I'm sure. Keep us posted on how it works out!

medicine girl said...

I am absolutely keeping busy and am looking forward to attending my favorite conference next week!

While I may have approached nervous wreck status during interview season at times (tho' never during the interviews themselves, haha), I decided it doesn't pay to be nervous after the rank order list deadline. If for some reason it doesn't work out for me, then well, I'll deal with it as it comes!

Tho' I don't have your full CV, it's clear that come residency interview season you'll be a strong candidate in a field you love. I trust you'll be just fine this time next year!