Mysteriously Effective Pain Medication

For some reason, Helen was the palliative care attending at County Hospital two weeks in a row, which was fantastic. During the day, it occurred to me that I felt utterly happy just following this wonderful physician around the hospital. In general, I really enjoy the company of doctors: they’re so smart. Jack the fellow was also still there.

Megan, the palliative care RN, was back from vacation, and again explained a lot of interesting things, including the reason a patient is prohibited from having a code status of DNAR / DNI for 30 days following surgery: if the patient dies within 30 days after surgery, that is a black mark for the surgeon, so the patient has to be kept alive no matter what. It can also happen that tons of care team members will rush to attend to a patient who is in crisis after surgery so that the patient will live long enough to die in the ICU instead of the operating room.

We visited seven patients that day, including an elderly man who was brutally attacked as he walked in a park. He was left for dead, choking on his own blood. Fortunately, the person who did this horrendous thing was taken into custody.

In the afternoon, we had a “pre-meeting” with an absolutely darling young doctor who reported that he was trying to clarify goals of care for his patient, but the relationship had ruptured: “He hates me. He won’t talk to me anymore.” After we heard more details, Jack said that on the spectrum from saying to a patient, “What do you want to do?” and, at the other end, being paternalistic and telling the patient what is going to happen, maybe it was time to aim for being more directive. I offered to skip the meeting, in case having a whole herd of people go in at once would make things worse, but the doctor said the patient didn’t seem to mind having groups visit, so we all went in and sat down around the patient’s bed.

While the patient was clearly frustrated and several times announced he had nothing more to say, even making the lip-zipping motion with his fingers, he didn’t actually seem to mind talking to us, including to his young doctor. However, the conversation seemed to be doubling back on itself a bit, so finally Jack took over and clarified that what was bothering the patient most was a stabbing pain in his arm. There was a bit of discussion about where the patient would go from the hospital, but Jack mainly said, “Let’s treat your pain, and then we’ll take it from there. Is there any pain medication that seems to work for you?”

“Yes!”

“What is that?”

“Tylenol!” shrieked the patient.

When we came out of the room, I said to the young doctor, “How do you feel?” I thought he was going to say, “Great! My patient doesn’t hate me, after all, and the path forward is clear.”

But instead he said, “I feel like a failure: I didn’t manage his pain.”

I said, “You know what you did right? He clearly feels how much you care about him.”

Jack and Helen also reassured the doctor, whose arms were crossed in front of him. Jack said that not an hour earlier, he had felt like he’d blown it in a family meeting, and Helen said not a week goes by that she doesn’t wish a family meeting had gone a different way. (After the earlier family meeting, Helen had reassured Jack, and also given him suggestions for the future. Her main suggestion was to use the pre-meeting to gain clarity on the purpose of the meeting.)

The doctor said he tries to do goals of care discussions himself and not bug the palliative care team, but Helen firmly said, “Things will go better for you and your patients if you rely on your team.” Jack said he agreed with my observation that the patient feels his doctor’s love and care. (I nearly swooned hearing a doctor use the word “love.”)

So, another reason it’s important to have a chaplain on a palliative care team: besides offering support and love to patients and family members, the chaplain may have occasion to nurture other team members.

At the end of the day, Jack said his palliative care rotation at County Hospital was ending, so he would not be seeing me again. He shook my hand and he told me that when he went to a weekly palliative care meeting that practitioners from several hospitals attend, he shared about how powerful he thought my prayer the previous week had been!