Pain was simply the biggest discomfort he had during those last few days I cared for him. I had just transitioned onto the inpatient wards service, taking over the patient list from one of my colleagues. I received sign-out from her saying a patient had been in the hospital for over a month, battling recurrent pain episodes from his metastatic renal cell carcinoma. Initially, the patient came in for severe pain from worsening tumor burden, weight loss and low appetite, and deconditioning to the extent where he was no longer able to care for himself. Because of these factors, his cancer treatment had been put on hold, invariably worsening his tumor spread. During my time with him, the patient would only find relief from IV pain medication. He required it on an almost bi-hourly basis to be able to sleep and be at peace in his own body. And every attempt to decrease the frequency of the IV pain medication or to transition him to an oral pain regimen, it would be of no avail. He would groan in pain, turn side-to-side constantly on his bed and look uncomfortable with his furrowed brows and creased forehead. So, with consultation with his oncologist and palliative care physician, the plan was to give him a cycle of chemotherapy to see if it would help his tumor burden and, ultimately, to assuage his pain. Unfortunately, the chemotherapy worsened his liver markers and kidney function without showing any sign of tumor shrinkage. He became weaker, more nauseous, causing less oral intake, and his pain even more profound. When his labs continued trending in the wrong direction and his frailty even more apparent, the topic of comfort care was broached. The patient was estranged from his immediate family members and requested that the care teams not reach out to them. He only wanted his fiancée and her parents to be made aware of his condition. Upon a discussion with the patient, his oncologist and palliative care team, his primary inpatient provider and his fiancée, the patient thought it was time to pursue comfort care best. He no longer wanted to live in agony and wanted to feel relief for more than just a fleeting moment. He did not want to prolong his suffering any further. After that point, we started a PCA pump to give him continuous pain relief moving forward. But for the first few days after starting the PCA pump, every time I visited him, I would always still see him groaning in bed, shouting he was in torture and wanting it all to disappear. His fiancée at bedside, caressing his face and asking if there’s anything we can do for him so that he can actually get some sleep. He was in such discomfort that he wouldn’t answer any other questions I had, just shaking his head and saying he was in “so much pain.” Therefore, I worked with his palliative care team and nursing staff closely multiple times throughout the day to adjust his PCA pump. We tweaked numerous times with his basal rate and demand dose settings to optimize his regimen. I would check up on him multiple times throughout the day just to make sure if other changes needed to be made. After all these adjustments, it was then at one particular conversation I had with the patient that made me realize he had finally found relief. One evening before I left the hospital, I came to visit him. It was the first time I’ve ever seen him lying in bed calmly. He had no visitors there at the time. He was just staring at the ceiling, not groaning in pain, not shuffling around in his bed, not panting for relief and his face not contorted from pain. “Are you feeling better?” I asked. “Yeah,” he stated. “Great. I’m really glad to hear that. Please let us know if this regimen is not working anymore or if you’re in pain again, and we can always make any modifications as necessary to make sure you’re as comfortable as possible. I want to make sure that’s a priority.” “OK.” I stood there for a few seconds making sure if he needed anything else. And as I was about to turn and head out the door, he spoke up. “Thank you for talking to everyone today to get my pain medication right,” he said. “I feel a lot better.” “No trouble at all, I was happy to do so. I’m sorry it took so long to get it right for you, but I’m glad it’s working now. I really do want to make sure you’re finding relief from everything we’re giving you. So please, let us know if you need something else.” “Thanks.” I then came to the edge of his bed and sat down. Our eyes met as I said, “We’re here if you need anything.” The patient didn’t speak afterward. He resumed looking back at the ceiling as I sat at the edge of his bed, observing him and making sure he was comfortable. The next minute, the patient closed his eyes and fell asleep. I slowly stood up and walked out of his room, praying he’ll be able to sleep through the night. Nghia Pham is a family medicine physician. Source
