A Bad Case of Pink Elephants

Pink Elephants

There is a huge problem in trying to manage pain in a profoundly demented and deaf patient.  I had seen a functional decline in Dad within the couple of weeks before the diagnosis of cancer.  With the addition of pain medications the functional decline was even worse.  Bone Cancer is unbelievably painful.  Dad has always been pain tough, but clearly the bone cancer is tougher.  He has gone from taking no pain meds to taking ms oxycodone, liquid hydrocodone, and liquid fast acting morphine for break through pain.   Dad occasionally  took a little Advil or Tylenol for a thumb that got a little sore when he went bowling.  At 81 he was hiking Hadrian's Wall with Jon and me in Northumberland.  He was never infirm or arthritis ridden.  Now he is cancer ridden and taking the big boys of pain management.

Hadrian's Wall

Which brings us to a bad case of Pink Elephants.  I was called to the facility night before last at 10:30 pm "because your dad is in pain and I think you need to give him some morphine".  Because the morphine is liquid and has to be given in the mouth by syringe either a nurse or a family member must give it;  a Med Tech can't.  Nurses in the facility are only available by day.  A hospice nurse could have come out to administer the medication, but I live a minute away and the hospice nurse was probably one to two hours out from arriving.  So I went.

Dad was sitting in a wheelchair with an attendant.  He was wearing nothing but a pair of depends with a thin white blanket over his lap which I watched him pull off a few moments later.  He doesn't recognize me and the attendant says he is clearly delusional and keeps talking about having to go to the basement or up two flights of stairs.  It takes me only a moment to see that for myself.  So I go and put on gloves (this particular morphine will go right through your skin, which might be fun under other circumstances) and draw up .25ml and walk back down the hall to dad.  But this isn't feeling or looking like pain to me.  He won't tolerate anything on his skin, neither the very light blanket or the hospital gown they tried to drape him with.  He is not reaching for his shoulder and his hands and skin are hot to the touch, but it doesn't seem to be fever induced.   I decide this isn't a need for more pain meds, this is a case of too much medication.  Back to the medication room and a call to Hospice to consult.

Dad received no more pain meds that night, was watched carefully and tended to compassionately while his system cleared the drugs from his system.  Tomorrow would be a new day and a new consultation to try and find a protocol that would manage the pain without a bad case of Pink Elephants.  No one said midwifing the dying was easy.

The Game Has Changed

As you may already know my dad has dementia and since October of last year has been living in a Memory Care Facility when it became difficult to care for him in his own home and actually dangerous since he had begun to wander at night.

Last Wednesday evening I found myself in the ER with my dad who was complaining of shoulder pain.  Well, actually it was more like this:

Me:  "Dad does your shoulder hurt?"

Dad:  "I don't know where she went."

Then a grimace, reach for his shoulder and exclamation of  "Oh Shit".

I call that complaining of shoulder pain.  His shoulder was also beginning to show signs of swelling.  It did not appear to be a dislocation and because he can't remember anything there was no point in asking if he had fallen.  So off to the ER we went for an X-ray and evaluation.

The result was a diagnosis of a cancer lesion that had eaten through most of the left clavicle and created a "pathological fracture".  The cancer lesion could also be seen to have moved up into the soft tissue.  This lesion is probably a secondary cancer.  In other words he has a probably primary cancer which has metastasized from some other location.  Did I want to Order tests to find out what kind of cancer this was?  No I didn't.  I didn't feel there was any reason to order a lot of extremely invasive tests, think needle into the bone to get a biopsy, which were not going to provide any information that would change the care plan.

My dad is 90.
Profoundly deaf
Has severe dementia
Went from continent to generally urinary incontinent in a week and a half
Has a waistline that went from 38 to unable to close or zip his pants in a week and half.
Cannot communicate his needs for food, water, or level of pain.

It was time for Hospice.  We were discharged with a prescription for liquid hydrocodone and an ambulance ride back to the facility.  Technically called a "gurney transport".

Thursday by 9:30 pm he was admitted to Hospice.