Helpless as a Patient Passes

I felt helpless, because I was. I sat at the bedside of a woman I had known for 20 years and watched her die. It was surreal, as she had seemed indestructible. She was the rock of her extended family, a supportive wife, mother and grandmother. She was a tough and strong woman, qualities I had seen her display through many physical difficulties. I had seen her sick but I had never seen her weak until the cancer came.

The cancer came fast and hard. The diagnosis had come just 2 months earlier, bringing with it severe, unrelenting pain and stealing her appetite. Just before Christmas came a severe infection that sapped her already limited strength and trapped her in her bed most of the time. She went home on hospice Christmas Eve, determined to be with her family. Remarkably she was able to sit up for a few hours and hug her grandchildren as they thanked her for their gifts, as if she was determined to not let the cancer take away Christmas.

Even though I knew she was dying I was not emotionally prepared for the moment when it came. I should have been, as I had visited her at home the day before and observed the decline. It was clear the end was approaching fast. My medical mind knew it was only a matter of days. My heart wanted to believe otherwise. When her husband called the next evening to tell me she was having trouble breathing I didn’t want to go, didn’t want to accept that she was actually going.

When I arrived a few minutes later my fears were confirmed. She was breathing as those who are about to die breathe. I struggled to stay in “doctor mode”, tamping down my emotions so I could be a source of strength for the family. I made sure she was not suffering and made sure the family knew it. It was all I had left to give. When the moment finally came my heart broke as grief flooded the room. I felt helpless again, not knowing what to say. She was loved so much and had so much love left to give.

Afterwards I felt awkward as family members hugged me and thanked me for being there. How could I not be? I had known her for over 20 years. It was the least I could do.

This weekend the family is gathering to say good-bye and to celebrate her life. I am planning on being there, to love, pray, celebrate and mourn with them, as their doctor and as a friend. She deserves it.

Bart

As you read this, please say a prayer for the family. 

Dying in Pain

The overuse of narcotic medications has become a national problem. Current estimates are that over 2 million Americans either abuse or are dependent on prescription opiates. Recent data reveals that15,000 Americans die as a result of an overdose or narcotic pain medications every year. More Americans die from prescription narcotic overdose each year than die from being shot. It is a national crisis.

In response to the crisis the Center for Disease Control (CDC) has issued new guidelines to aid physicians in the appropriate use of narcotic medications in the treatment of chronic pain. The guidelines are desperately needed, as chronic pain is incredibly common. 43% of American adults have been diagnosed with a chronic musculoskeletal condition and over 11% of American adults have pain every single day of their lives. In this context it is not surprising that in 2012 physicians wrote over 259 million prescriptions for pain medications.

The CDC guidelines set definitive limits on acceptable daily doses of these drugs. The limits were set based on evidence that higher doses dramatically increase the risk of overdose without evidence of significant improvement in pain or function. The maximum recommended total daily doses are the equivalent of 50 mg of morphine in most circumstances (which is approximately10 Vicodin pills, or 5 Norco), and 90 mg of daily morphine for the rare case when higher doses are indicated. The consensus is that the higher doses should typically be prescribed by pain management specialists.

Based on these guidelines I was understandably concerned by a patient I saw a few months ago in the office. His daily pain regimen included the maximum dose of an addictive muscle relaxant along with regular doses of oxycodone and methadone. After reviewing narcotic conversion charts I calculated his daily narcotic dose to be the equivalent of over 500 mg of morphine a day, 10 times the recommended daily dose. Remarkably, he was alert and seemingly unimpaired. Sadly, he was also still in severe pain.

I knew from personal research and discussions with pain specialists that he was likely suffering from “opioid induced hyperalgesia” a condition in which high doses of pain medications actually increase the patient’s pain. He needed to get off of the narcotics. While this conclusion was easily reached it was not easily implemented. He had a complex medical history and he needed an expert to aid in the weaning process.

I called several physicians on his behalf, including three different pain doctors and a specialist in addiction. All of them agreed that he needed to go through detoxification but none of them were interested in supervising the process. Even the weaning doses were higher than they felt comfortable prescribing. It took dozens of phone calls and hours of work before I was able to arrange a hospital admission to begin the detoxification process.

This patient reminded me of how and why patients become dependent on pain medications. His pain began with a neck injury and neck surgery that failed to relive his pain. While comprehensive pain programs that include physical therapy, cognitive behavioral therapy (a type of counseling), behavioral modification and now-narcotic medications have been proven to be most effective in managing pain, such programs are expensive, labor intensive and not widely available. His previous doctor did what most doctors do. He prescribed pain medications. When his pain persisted, out of compassion, poor judgment or both the doctor increased the dose again and again.

The patient illustrates the challenges faced in dealing with narcotic addiction. Our current health system and payment models make it easy to do the wrong thing and difficult to give patients the help they need. We desperately need to decrease our reliance on narcotics, but if we do not also work to provide better comprehensive pain care we will be abandoning millions to a life of suffering.

Bart

Update- The patient's wife informed me that he had successfully weaned off of narcotics. Amazingly, his pain levels had not increased. Sadly, they had not improved either. He has a long way to go.

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America Lost in 2016

A friend told me today that he had not spoken to his brother in 2 months. The reason- Donald Trump won the election. My friend did not vote for Trump, so that was not the reason for the loss of relationship. He was cut off from his brother because he did not share the view that everyone who voted for Trump was a racist, bigoted, misogynist. My friend had the audacity to suggest that some Trump voters had purer motives and that crossed a line. There was apparently no room in his brother’s life for someone who did not share his perspective.

My friend is not alone. Online stories and personal conversations over the last few months relate similar experiences. I recently read a blog post on the liberal website dailykos in which the author proudly stated that he cancelled his holiday party rather than entertain the possibility that Trump voters might attend.

As I read and hear these stories I find myself asking, “Why is there so much hate over an election?”

I suspect no single answer can explain every response but one thing seems clear. We have become a nation that focuses on the things that divide us instead of the things that unite us. We have lost sight of the truth that every man and woman is created in the image of God and is beloved by him. We have instead made people out to be less, to be nothing more than their political opinions, sexual orientation, or social class.

Unless we return to the original American ideal that our value is inherent and God given and that men are defined by the content of their hearts and the condition of their souls we will continue to see people end relationships and isolate ourselves from others for frivolous and judgmental reasons.  The ultimate result of such actions is we will stop being Americans.

Bart

Suffering for Christmas

I have seen a lot of suffering lately.

The week before Christmas a patient I had known for over 15 years was sent home from the hospital on hospice. His bone marrow cancer had left his bones and attacked his liver. It was too late for the bone marrow transplant he had been waiting for and too advanced for any hope of a response to any treatments. Within 24 hours of going home he was confused and difficult to arouse. He died less than a day later.

I had another patient go home on hospice Christmas eve. The combination of metastatic cancer and heart disease had left her too weak to fight. As it was possible this Christmas would be her last she chose to spend it at home. She still holds out hope that she might regain enough strength to resume curative treatments but there are no guarantees. Hers was a sick Christmas.

On December 23rd I made a house call on a third hospice patient. This patient has an incurable lung infection. We thought it would have taken her life months ago but she has hung on, her body refusing to give up on the unwinnable fight even though her mind did long ago. Walking across the room can be an ordeal for her. The disease has destroyed so much lung tissue she has no respiratory reserves remaining.

All three of the patients and all of their families suffered this Christmas. The emotional and physical pains were real and intense. In addition to their hospice status they had something else in common, the lingering question, “Where is God in all of this?”

Modern society, and at times the Christian church within it, seems to have the view that suffering has no rightful place in this world, that its presence is evidence that God either does not exist, does not care, or is weaker than is claimed. The thought that a good God could allow suffering, or worse, ordain it, makes no sense to us.

When Christians do talk about suffering it is usually discussed as a temporary stop on the journey to a positive destination. This is often true. My own life is evidence of this reality as my struggles with chronic pain and anxiety have helped soften and mold me into a more patient and caring man. What is seldom discussed or acknowledged in the Christian faith is the suffering that endures, the pain that never fades and is a permanent part of someone’s life.

It is seldom discussed but it is readily evident in the world around us. Whether it be from conditions such as fibromyalgia or Lou Gehrig’s disease or oppression under hateful governments there are millions of people around the world who wake up each morning in the same state or worse than they were the day before, with no end in sight and no hope for better days. What is God’s purpose for these people? Why do they continue to suffer when there seem to be no further lessons to learn? Why does not God rescue them from their pain, allow them to go on the next life now?

These questions returned to my mind this week as I was reading through the book of 1 Peter. Peter was writing to Christians in Asia who had experienced severe persecution under the Roman emperor Nero. Many Christians had been killed or tortured and the ones that remained lived in fear of the same. Peter wrote to educate and encourage these people in the truths of God.

The most astonishing aspect of Peter’s letter was his attitude about suffering. Peter wrote that, for these people at least, suffering was not something to be temporarily endured but rather a calling to be accepted. Peter told the people of the eternal nature of their call, of the profound blessings that awaited them in the next life and the certainty of them receiving them. He reminded them that Jesus was called to suffer on their behalf and that they were called to suffer as well. He then made the remarkable point that the manner in which people endure prolonged suffering is a powerful testimony to others.

As I read his words I realized that they are in profound contrast to what many Christians seem to believe. When suffering comes we spend our days praying for relief, looking for a lesson or hoping for a way out. Peter’s words remind us that none of those options may apply in this lifetime. At times the only purpose for our suffering is that God be glorified by the manner in which we endure it.

Not a truth I particularly like, but a truth I need to accept.

Bart

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Peace on Earth in a World Filled with Conflict

The words are repeated every year at Christmas in word and song, “Peace on Earth, Good will to men.” It is a beautiful sentiment, but as with many Christmas proclamations for some its meaning has been lost after centuries of repetition. God gave the angels these words to describe the good news of the Savior’s birth so it seems they are important enough to reflect upon at Christmas.

In considering these words the first thought that comes to mind is that they do not appear to be entirely true. For most of human history there has not been anything close to “Peace on Earth.” War is a perpetual reality. A review of history reveals that at any given point in time there is at least one group of people trying to kill or conquer another group of people. One is left to wonder, “Where is this peace promised by the angels?”

Clues to the answer can be found in the source of the proclamation, the angels who appeared to the shepherds on Christmas night. Their nature and identity shed light around the shepherds then and shed light for us now.

Luke, in his gospel, describes the angels in this way-

“And suddenly there was with the angel a multitude of the heavenly host praising God and saying, Glory to God in the highest, and on earth peace among those with whom he is pleased!"

 “A multitude of the heavenly host” appeared.  A clearer description of these individuals is found in Wuest’s expanded New Testament, where he translates the phrase, “a multitude of the army of heaven.” Wuest was on to something. It was not a choir that appeared. The word “host” is a military term used to describe the soldiers of an army. Standing on the hillside that first Christmas night was no angelic choir. It was the army of the Living God. They were there for a reason. It was not by accident that God sent his army to proclaim “Peace on Earth.” Their presence on the scene has tremendous meaning.

The army of God is described in a number of places in scripture. In the Old Testament it appears on the scene to defend the prophet Elisha from the Assyrian army. (2 Kings 6) In the New Testament, this army returns at the end of the world to carry out God’s judgment. It is this last job description that is most significant with regards to the Christmas message. The message of peace was proclaimed by those who will one be the agents of God’s wrath. At the end of the age God will send His armies to wage war against not only the devil, but against all of disobedient mankind. The battle into which this army will be sent is God’s battle against sinful man.

The presence of the Army of God reminds us of the conflict addressed by the birth of the Savior. Since the fall of man, the original sin, Mankind has been at war with God. The universal peace lacked by all was peace with God. Unless something happened to restore this peace the wrath of God would fall on all people.

On that first Christmas night the solution to the conflict was proclaimed. The one who would resolve the conflict had been born, the Prince of Peace. The army of God arrived on the scene and with their presence reminded all of the wrath that was coming and that was deserved. In their words they proclaimed the reality of how the wrathful hand of God would be stayed. In response to the birth of Jesus they laid their weapons down and proclaimed, “Peace on Earth, goodwill to men.”

This is the message of Christmas. Our world is sinful and fallen, deserving of destruction at the hands of a holy God. As deserving as we are of such punishment, we need not experience it. For on that day, in the city of Bethelehem, was born a Savior. The One who would one day take the wrath of God upon himself and open the door to everlasting peace.

Merry Christmas

-          Bart