I have been struggling to put in words what is most important to teach in palliative care. It is important to teach facts, such as 30 mg of morphine by mouth is equal to 10 mg of morphine IV.  This is a useful fact that makes it possible to convert one form of medication to another.

Developing good clinical judgement is another important teachable skill.  This allows us to recognize that the elderly gentleman before us is no longer able to take his pills for pain from the cancer that is sucking his life away.  This is where that fact about the relationship of oral to IV morphine will become important.

Critical thinking will lead us to notice that his lips look parched and his adult depends, now on for 6 hours, is still dry.  He probably isn’t eating or drinking much now and his renal function has declined.  We should take that into account when ordering his pain medicine. I lean down to speak to him, to ask “How are you?  Are you in pain?”  He opens his eyes and reaches out catching my stethoscope.  We are now linked, bonded together like two molecules. He says quietly, “My son…. He’s coming”.

I regain my composure and my stethoscope.  His nurse, who has followed me into the room, “I just talked with his son. He will be here is two hours. He is hoping that he will be able to talk with his Dad.”  I nod as I help her pull him up in the bed and put his oxygen on.  On leaving the room we talk.  “How can we make sure that he is comfortable but awake and able to talk with his son?” Together we decide to start with a very low dose of morphine 1mg IV but to have higher doses in reserve if he should need them. Also, the nursing aide will give him a bath and help him sip some water he has been asking for so he will be ready for his son.

It is several days before I saw his nurse again. I know that he died in the morning after we had admitted him to our unit.  I asked the nurse “How did it go? Did he get to talk with his son?”  “Yes” she replied “he was awake and talked with his son.  They were so happy.  We had to give him several doses of morphine for pain in the hour before his son came but during the visit he was comfortable.  We checked in several times during the evening.  I advised the son to stay if he could and we set up the couch for him.  Around 11 pm the son came out and said that his father needed more pain medication.  He said his Dad asked for the bigger shot. I guess his Dad had heard our conversation. The nurse that came on for the night shift said he had rested quietly as did the son.  He died peacefully”.

Clinical wisdom – Coloring outside the lines

Clinical wisdom. That is what I want to teach. Know how to convert morphine from oral to IV, taking into consideration the dosing when the renal clearance is low. Decide that it would be Ok to “color outside the lines” and start with this very low dose of pain medication to control pain but enable these final hours with his son. It took the wisdom of the team.