In order to take care of cancer patients, one must understand how to measure pain. It is not like blood pressure, scaled by cuff. It is not cholesterol, counted by machine, nor even a lung mass whose metric mass is weighed by X-ray. There is no modern marvel to tabulate suffering. If you want to take the measure of pain, look in the eyes.
6:25 am; status-post first cup of coffee. In the pre-dawn silence of the Solid Tumor Unit the occasional tone of an alarm or a distant closing door echo down deserted halls. Morning rounds.
Room 7; Ms. Wilsney, 72 year-old female with breast cancer metastatic to bone, admitted for dehydration. The nurse’s notes in the chart show a quiet night. Good urine output, hemoglobin stable, no fever. Physical therapy was able to get her to stand next to the bed. She received only one extra narcotic dose the last 24 hours. No complaints of pain.
Her private room is full of shadow, lit by faint glow of bathroom light and the television, which runs the unchanging, unwatched scene of an empty chapel. Despite the hour, she is awake, lying on her side. Blanket and sheet clutched to her chest, legs and feet uncovered, pillow eschew. Not yet washed or brushed, the musty smell of sweat and foul breath greet my exam. The IV light blinks to mark drips progress. Grandchildren observe from pictures covering one wall. I bring down the bed rail, and sit by her side.
“Morning Jean, how are you doing?”
“Good, good,” she responds with short words, spoken almost as tiny gasps. “Can I go home today?”
“I don’t know yet. Are you feeling any stronger?”
“Yes, I’m good.”
“Have you been able to eat or drink?”
“I think I drank the whole pitcher.”
“How is your stomach? Did the nausea go away? Did you move your bowels?”
“I’m OK. I’m good. Can I go home?”
Jean looks stronger and more responsive; the dehydration has past. Nonetheless, something is wrong. She speaks without moving, staying immobile on her side. Her words are close, short. More than anything else, there is something in her eyes. The corners squeeze, the borders pull tight, and the lids fall heavy and tired. She does not relax or really look at me. She is trying to control the moment, to over come agony, seeking desperately to go home. Suffering of body and soul radiate from her eyes.
“Jean, you are in pain.”
“Maybe a little … but I can handle it. Its OK.”
“Pain is not OK. Is it your back?”
“It’s just this hospital bed …it will be better at home.”
“Is it a new pain?”
“It’s the old pain … just worse from this bed. I think I pulled it when I moved from the stretcher. The aide was not very gentle.”
“Did you tell the night nurse?”
“No, it wasn’t bad and they were busy. They have sick people to take care of.”
“Why didn’t you ask for extra pain medicine?”
“I don’t want to get addicted.”
“You can never get addicted to medicine you take for your pain. The pain itself is bad for you. If you cannot move you might get a blood clot or pneumonia, plus you get weaker just lying in the bed. How can I get you home if you are in so much pain you can’t even get out the door?”
Back at the station, I talk to the nurse. We discuss that Ms. Wilsney is not likely to ask for pain meds and will have to be carefully checked to assure she is comfortable. I order a now dose of a fast acting pain medicine and increase the long acting pain medicine Ms Wilsney is already receiving. I decrease the time that she will have to wait for extra, as needed, breakthrough pain medicine. I check her scans, see no evidence of new disease, and decide it is just that she has been receiving inadequate doses of pain medicine and, has not asked for more.
4:45pm. Fourth cup of coffee. At the busy, too noisy nursing station, doing charts. Ms. Wilsney walks by slowly, talking to her daughter. Her movements are slightly stiff, but much more fluid. Her IV is gone. She gives me a smile. I complete prescriptions for home pain medication. I write a discharge order.
Ms Wilsney leaves the floor, holding her daughter’s arm. Her eyes are open, relaxed and clear. She is happy to be going home. Her vision now filled with comfort and hope.