Who are you, and what have you done with my husband?

Narcotics are nasty..."There is a reason they call it dope."

Watching the personality of your patient change is difficult, even when you know the reason.

It wore off.

When narcotics wear off, and pain reenters the picture, the voice coming out of the body is physical pain. Along with physical pain are myriad emotions associated with the pain.

• Frustration: The inability to control the situation of the disease and pain.
• Grief: The inability to do mundane daily activities, which, in retrospect, were not so horrid chores.
• Anger: The combination of grief and frustration.
• Self-Pity: The confusion caused when control over one's own body is lost.
• Shame: Loss of pride at admitting someone else must care for even the most basic of needs.
• Denial: The desire to be in another circumstance.
• Blame: The confusion leading the patient to believe the condition is the fault of the caregiver.

Pain is a way of life.

Sometimes the cure is worse than the disease. Poking and prodding and invasive maneuvers to get information can make your patient (and you) believe the treatment has an evil intent all its own which is equal to or greater than the disease's intent to kill.

To quote Disney's Genie from Aladdin: You would be amazed what you can live through.

Pain is a way of life for a cancer patient. Unfortunately, the narcotics in smaller doses only diminish the pain to a "bearable" level. Equally unfortunate: In higher doses, the narcotics remove the patient from reality.

Maybe that is not so bad?

Many people would run away if it were possible. They would manage their pain to the point of barely being conscious of their surroundings. This is an informed choice to be made by the patient with the consent of the doctor. Despite what the caregiver may desire, this is not a choice she can make.

What are the drawbacks?

For the patient, truly few...pneumonia is the largest threat, followed distantly by bedsores. Poor appetite can potentially cause other problems.

Cancer is not only a physical disease. The mental drawbacks are mighty. Let's look into a few:

1. Loss of long term memory
2. Failure to produce short term memory
3. Lethargy, lack of desire
4. Poor attitude
5. Poor impulse control
6. Inappropriate or flat affect
7. Mild dementia-like symptoms
8. Overstimulated REM sleep

Don't some of those have an upside?

To say they do not would be a lie.

1. This is more a problem for the family than the patient. As life comes to a close, family wants to rekindle memories of bygone happiness. Your patient may not remember enough to actively participate in such reminiscence.
2. This is a problem for the part time caregiver. Your patient will not remember activities of the day and self-report erroneously. This patient should not have access to medications or poisons. For all intents and purposes, this patient must be treated as a child for all important matters.
3. Lethargy can lead to surrendering the will to live. Caregivers need to be particularly cognizant of the depth of the lethargy. At all times, engage the patient in your own activities with him. Be aware of all activities with which you could interest your patient.
4. This understandable drawback is associated with the disease as much as the treatment. Do not wear your feelings on your sleeve. Take insults and apparent swipes with a grain of salt. Rarely are they intentional, but they are a needed release of anger.
5. Reduced inhibitions are a side effect of narcotics, but they are also a side effect of anger and frustration. Take particular care your patient does not put himself in harm's way in activities he may feel he can successfully attempt.
6. Engage your patient in conversation about something within his sight. Trigger any emotion which would allow for a change in his affect. Whether or not you are successful, report this to the doctor. This is an end-stage symptom.
7. Memory loss in short or long term will produce dementia symptoms. If your patient begins a conversation about a time period in which he has never lived, play along. Do report this to his physician.
8. REM sleep often extends for a short period into wakefulness. It is another manifestation of the poor impulse control during wakefulness. If your patient talks to you from REM sleep, talk back in a non-committal manner. Do not steer the dream in a certain direction. This is his mind coping.

The mental aspects of extended narcotic use are more difficult for the caregiver than the patient since the patient is not cognizant of the side effects as they occur. Seek help for yourself as routine to discuss your feelings about losing the personality of your patient.

Chin up,
Ann Marie

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