Opioids and Control

Given Rose's diagnosis of cancer and widespread metastasis to the bone I knew pain would eventually become an issue for her. But one of the fundamental needs was to maintain control. It was the predominant value she clung to for all the time I knew her. If we look at Godfather Death from the standpoint of the king we need to pull from alchemical imagery to understand what is happening. The king represents the status quo, the predominant world view. In the fairy tale the king is expected to die. Death has proclaimed it. Our world view is forever destined for extinction as it gives way to a new way of approaching the world, a new stance, a new attitude toward the world.

Rose's world view was no longer useful for her and was destined to give way to something else. Her world view included the need to maintain control at all cost. Most of us have this view, this need. In Rose's case it kept her from taking medication that would manager her pain but for her there was a cost she was not willing to pay;there was a perception that the medication would limit her control. Let me clarify here that opioids such as morphine are used very successfully for pain management and there are side effects that can cause sedation and some cognitive changes that are temporary until the body develops a tolerance. So initiation of opioid therapy involves confronting these side effects, most of which will go away, and which patients experience to lesser or great degree. Despite my attempts to educate Rose, she continued to hold on to the belief that she was going to go through this dying process in as much control as possible.

I supported her in this belief system knowing it would eventually collapse as all heroic approaches must but I did not anticiapte my role in augmenting its collapse.

Rose had started a more rapid decline the few weeks before she died. Her appetite faded, she seemed to be in more pain, more often and getting her out of bed was becoming more painful as her bones became more brittle. I was called by her physician and was told Rose would not let her put her in hospice or start her on appropriate analgesics which in Rose's would include opioids. On top of that the doctor had her sent to the hospital when Rose's pain was out of control one night. The doctor wanted her back radiated because she suspected spinal cord compression due to the cancer. I was angry the doctor had not consulted with Rose. When Rose got to the emergency room she threw a fit and demanded to be sent back to the nursing home. The doctor accused me of enabling Rose to maintian this heroic stance and the time now was for her to let go and let us do our job. The doctor's accusation hit me hard and made me think. I told the doctor I would talk with her.

When I saw Rose she was weak but glad to see me. She told me she was angry with the doctor, but I did not see the fire in her eyes I had seen in past discussions about doctors and control issues. I told Rose the doctor had called me and told me her pain was worse and will be gtting worse. I reminded Rose of all our discussions about opioids and when the time was right and Rose letting go. I then told Rose, "that time is now Rose, now is the time to let go and let hospice in and let the doctor order opioids for your pain" and then I said, "I need you to do this Rose. I need you you to accept hospice now and let them take care of your pain. You can relax now." I did not know where those words came from, " I need you...". It was not my clinical personae which respected her decision to make choices and respected her need to remain in control. The part of me that told Rose I needed her to let go was that part of me that cared for Rose. Rose amazingly agreed. "You're right" she said and she almost started crying, " ...let hosice come and do what they need to; I will let them."

After all that time it was our relationship that helped move Rose from the heroic pathway to acceptance and letting go. After all that it was not my clinical role, or clinical education; it was my caring about her. Perhaps she just needed a nudge and was already at the precipice of abandoning the heroic stance. I don't know.

When I think about the hard decisions patients and families make and the role of the clinician I am thinking the primary physician has an important role in helping the patient/family abandon the heroic pathway at the right moment and maybe it is not their clinical approach, the medical options they offer and the manner in which they offer them, maybe it is simply our caring that can nudge them in that direction and it is in the context of that sacred and very ancient relationship that these decisions are made not in some waiting room where the family is simply told their options.