REFLECTING ON WHAT is it to be an empathic clinician, I recalled a patient who touched my heart when I saw her as a consultation with one of the nurse practitioners on our team. Ms. R was a single woman in her early 30s who had progressive metastatic rectal cancer complicated by a large pelvic fluid collection, a malfunctioning pelvic drain, and poorly controlled pain despite the use of high doses of opioids. Adding to the complexity of her situation, she had survived three cardiac arrests over the past few weeks. Before meeting Ms. R, my colleague and I discussed her at length, during which time the nurse practitioner presented a comprehensive data review that included results of the Edmonton Symptom Assessment Scale, the Memorial Delirium Assessment Scale, the patient's family structure and job history, pain medication history, morphine equivalent daily dose, physical findings, and imaging results. She also described how our team had rotated the patient's opioid regimen multiple times, never finding a regimen that provided Ms. R with adequate relief. The nurse practitioner did an excellent job of collecting and presenting objective data for us to consider as we developed a treatment plan.
PAIN PERCEPTION IS COMPLEX
Among our concerns was that this young woman seemed to require higher doses of opioids every day, particularly in the intravenous form, than we expected based on imaging findings, physical exam, and our subjective assessment of her comfort and function. She appeared to be comfortable taking a few steps in her room or walking short distances around the nursing unit; however, she often became very demonstrative about her pain in our team's presence. Considering the patient's pelvic collection to be the source of her pain, the nurse practitioner suggested that we ask interventional radiology to reposition the malfunctioning drain, potentially a much more effective intervention than increasing opioids if the undrained tumor abscess was the source of her pain. However, the longer we discussed the situation, the more it became clear to me that we would have to do much more than reposition the drain to address this woman's pain. Going through her chart more thoroughly, I learned that she had a past psychiatric history that related to unspecified teenage trauma, with the possibility that earlier emotional, physical, and/or sexual abuse could be contributing to her current pain experience. This woman's pain was not just bodily pain, but rather a deeper suffering that opioids and other medications could not fully relieve.
Thinking about Ms. R, I realize that we clinicians are often under excruciating time pressure, and consequently become focused on completing our assessments and checking off our to-do lists rather than stepping back, reflecting on the information coming at us in real time, and looking at the patient as a person. I like to refer to this reflective process as “synthesizing” ...