Morphine in palliative care

The best way to treat pain is assessing the pain. Knowing the root cause of the pain will help the doctor to prescribe the best type of medication.The medication can rage from a combination of different pain killers and their dosages.

Generally morphine is given to patients, when end is mostly obvious and there is no hope. For most of the patients- who are given morphine, It is generally not the stage of the cancer, but the degree of the pain endured by the patient.  The pain is constant and continuous.

Assessing Pain

To treat the pain, It is extremely important that it is analyzed properly with careful observation. The best way to assess the pain is to get the patient to talk, be involved in the treatment. Apart from this the family of the patient can monitor the patient( at least once a day) taking into consideration the following factors. 

• Physical effects 
• Practical Impact
• Emotional factors. 
• Spiritual needs

Route(s) to administer Morphine

• Oral 
• Rectal
• Sublingual
• Subcutaneous
• Intramuscular
• Intravenous. 
• Transdermal (The most common used nowadays)

Towards the end, pain becomes stubborn and responds poorly to opioids. No drugs or most of the drugs fail to provide relief from pain. However, morphine- one of the oldest drug is still used extensively in palliative care for the patients with fast approaching end.

Intolerance to Morphine

The patient tolerance to morphine can be attributed to the following factors

• Exposure to opioids in the past. 
• Hereditary
• Opioids providing no relief
• Rate of dose titration. 
• Additional treatment being given. 
• Disease related 
• Kidney and liver function.

The best way to improve  morphine intolerance is to start with a low initial dosage and gradually titrate upwards. Despite of best efforts, if things don’t change then consider substituting the opioid. 

If the condition still persist, try changing the route in which the opioid is administered. If still there is no change in the condition, then probably the pain was not assessed properly, look for other causes of pain. Besides, it is important to manage the side effects with additional medication.

I love you, Papa!

Opioids for CANCER pain

In my previous post I have talked about “PAIN” relief in cancer. In this post, I will be talking about about opioids- drugs which are used to provide some relief from the constant "difficult" pain.

With each passing day, cancer becoming more aggressive, pain becomes a 'constant' part of life. The pain is not only acute but is chronic and with time, it tends to become more uncontrollable. At this stage doctors prescribe OPIOIDS.

What are opioids?

Opioids are medicines that are used to provide relief from moderate to  severe pain( usually in cancer) .These medicines work on the principle of "reducing the intensity" of the pain signals being sent to the brain and affect those areas controlling these senses, and thereby considerably minimising the effects of the painful signals.

Opioids act much like endorphins-  natural substances created by the body to restrict or limit pain. Some of them work better than others in terms of providing  relief from terrible pain. 

Opioids were once formulated from the opium poppy( plant), but today many pharmaceutical companies are creating these drugs synthetically in laboratory, though addiction to these drugs still remains a critical issue .

Types of Opioids

Severe Pain

• Morphine 
• Buprenorphine
• Fentanyl and Alfentanil  
• Hydromorphone 
• Diamorphine
• Methadone
• Oxycodone 

Moderate to mild pain 

• Tramadol
• Codeine 

All  of the above mentioned drugs are available at drugs store strictly on prescription. 

Side effects

Most of the people taking these drugs over a period of time develop a kind of tolerance to these drugs. Therefore, the doctor has to prescribe higher dosage to provide relief from pain  or the other reason can be  increase in pain due to the advancement of the disease. 

A little  increases in the dosage or a change in the type of medicine will help in relieving the pain.

Common Side-effects

• Hallucinations
• Confusion
• Vivid dreams 
• Myoclonic jerks.
• Sedation
• Nausea and vomiting 
• Constipation
• Dry mouth 
• Itchy Skin 
• Coughing,wheezing, and shortness of breath
• Difficulty in passing urine
• Blurred vision

All these symptoms are common, and usually the treating doctors provide medicine to help overcome these effects. 

Im my personal view these symptoms never actually go away. Though the doctor’s do prescribe some medications to control these symptoms, but they prove to be of little or no help. Eventually all the symptoms emerge. ( In case of my father, where I tried my level best to read about the symptoms before hand, so that I could "prevent" them from emerging. With absolutely no result, my father went away!)

Towards the end, when pain becomes “difficult", the body has become resistant to opioids and nothing helps- the focus should be on making life easy- good palliative care.

Because you love them, tell them, show them- be with them. They need you, for the last time!

I love you papa!

Cancer- Dealing with pain

As CANCER advances, pain only increases. Treatment is almost over. Nothing much can be done now medically, only efforts to reduce the pain can be done ( Palliative Care).  Around 2/3 of the patients suffering from cancer experience acute pain. The pain is almost unbearable for the patient and is equally painful for you to see your loved one in pain. 

For treating pain, Doctors use all sorts of medicines - from simple drugs like Paracetamol (Analgesics) to Morphine (Opioids). Honestly nothing helps, but if the medicines are given timely  and in proper dosage, then they are of some help. The patient do experience some relief, if the pain has been analyzed properly and timely.

A study conducted by doctors in UK, says that Tolerance to pain can be Increased in the following ways

• Rest 
• Diversion
• Physiotherapy 
• Relaxation therapy
• Empathy 
• Support from family
• Listening to Music
• Expressing emotionally

Tolerance to pain is reduced by

• Anxiety
• Sadness
• Introvert Attitude
• Insomnia
• Socially Cut-off
• Fear
• Fatigue
• Anger
• Mental Separation
• Depression

Pain can be described as physical expression of social, spiritual and psychological isolation. To feel pain, one need not suffer. Dealing with pain, a lot of effort is required that too in a very organized and a sensitive way.

• Proper Medication
• Counseling
• Other Therapies
• Spiritual Support

Apart from all  of the mentioned above, support from family plays a pivotal role in making life easy for your loved ones. Talk to them, make them express, listen to them-After all you love them and this is the least you can do for them.

I love you Papa!

A year....

A year of pain....

A year of agony...

A year of loss...

A year of loneliness...

A year without you papa....

LOST BUT NOT FORGOTTEN

(5th October 1942 - Forever.....)

Neither fire nor wind, Neither birth nor death

can erase the goodness you spread....

Missed by

Beti, Chutki beti

Motabhai, Chotubhai

and Ma

Papa and the web

The next morning , the doctors came. I had spoken to her about a node behind papa’s ear. It looked like swelling but papa said it was painful. 

The doctor pricked the needle once, twice, thrice.... Papa screamed in pain. My very strong father was screaming " to stop". My mom could see no more. So she asked to stop.

The doctor said, aunty if we won't check how will we prescribe the medicine. I believe the doctors know before  us- the time has arrived. Then prescribing medicine to a person who is.....

I took my father not for some research. I knew nothing will help. I knew he was going. I just wanted some pain-less moments.

I am sorry papa.

Love you PAPA!

Pain in my veins

Papa always said, it is important to forget your past and move ahead. That ways you not only give your best efforts but also make beautiful memories to look back. Had, he been here...he would have been absolutely disappointed to see me..

I am mad. I am angry. I am sad. I feel guilty. My so called friends never came . I feel betrayed. My world has fallen apart. 

Its almost a year, jus 20 days short from his departure. For me,  It was only yesterday when he was here...! I have to close my eyes and their he is...smiling, asking, scolding, playing, writing and reciting his poems( the best was RAMAYANA, I love it!). 

Even after 11 months,  I am still - where I started. Hours into days. Days into weeks.Weeks into months. Months into years. But my pain never seems to calm down.

Life hurts more then death!

Love you PAPA!

My Grief, My Partner

Today, its been 11months since papa left us!

Dealing with loss can be difficult,  It becomes more difficult when you are with your loved one all through. I have always been very close to my father. But the bond we felt, while papa was undergoing treatment was different. There was a different kind of unity. We became each other’s support system. We just knew what to say to make  each other feel good. 

For months, my routine was same-  6:15a.m Wake up, call papa,and ask if he had any new problem(s) and pain(s). And then the fight to deal with that pain would start. Call doctors, visit doctor, arrange medicine. managing papa’s dosage…for hours, i used to be on phone. The day would end and then  would start again….

For me loosing my father was like, a plant uprooted from the ground. It is no rocket science to understand what happens when you loose your ground, how it feels. The day came, papa travelled to a place where he would be free of pain and sufferings…I should have been happy but I am not.

26, October 2013, the day is etched in my memory as the black day of my life. This date,  changed my views for life forever. I have stopped taking life for granted. I value life and people around me more. But I am yet to overcome my grief, my loss. My days still are a combination of pain, shock, anger, bargain, fear, depression...

Pain: Moments after papa left, I was numb. I could not feel. I was just expecting, papa to get up and talk to me. But he didn't ....he was gone!

Shock : Initial 3 days after papa went, I couldn’t cry. My heart  refused to accept that it has happened to me. I was shocked…from the day when papa was detected with cancer…to hours before he left, I maintained this feeling that a miracle will happen and papa will be fine. 

Anger: I am still angry at myself. Why din’t I pay attention to papa’s  declining weight. Why didn’t I push him hard to visit a good hospital. I was his most loved child. I betrayed my father. And he had to pay the price by his life.

Bargain: For months, I would pray to god, that I will do anything If he returns my father. My days are still spent in believing that one day he will return to me…

Fear: I suffer panic attacks. I constantly live under fear, as regarding my own life,  health  of people I love and my responsibilities . 

Depression: 30, November, 2012, 10:30am, when doctor came out of the Operation Theatre, and declared that, papa cannot be operated because the cancer has spread to other body parts….It hit me hard…I cried …and I cried till papa left us. Papa left us, after three days I cried again, and I am still crying…..nothing excites me anymore, day are passing, but they are not so bright as they used to be…I am a part of them, but I am not living.

I am yet to find “something" that will help me to deal with papa’s going away. Though, I will never overcome my father’s fade out but some day I will learn to believe that, he is not physically with me but always around me….

Love you, Papa

In my faith, Keep trying

Today I am restless…very restless, but then i have been restless for months now. What is that bothering me…why am i sad? Why sadness has become a part of my routine? whenever, I am alone, tears just make their way, irrespective of what i am doing… walking, driving, waiting …or watching a show... I haven’t laughed for months now…and it has been months since i have slept peacefully. 

The  question remains same, why did PAPA leave us…he was only 71yrs ( and 70 when detected with CANCER). He could have lived for more few years.he was a healthy and fit person…And I know..he would have easily made it for at least 10 more years. Had it not been CANCER…

I keep on looking for answers..but after 21months… i am still searching answers... searching for peace...I am not sure, If i will ever find answers, but I am trying to....at least be at peace

Yesterday, my husband said..and not only him ..but many others have come up to me and said...…I should not have gone ahead with “chemotherapy”?…I only increased his( papa's) pain…and suffering! Have I?

Have I, I have asked myself? ..a thousand times...May be …May be, I have! But then…What if, chemotherapy would have worked….recently i came across a documentary, which says.. only in 3% of the cases, chemotherapy works. What if,  Papa- was one of those 3% fortunate people. He would have been a survivor!. 

A survivor, how good it feels even to think about it. In retrospect, if not trying, what should I have done, see him suffering or waited for "yama" to come and take papa... even without trying! and live with the guilt of not even doing "that" something, he deserved, that gave me a hope, gave him a hope ....you can call me selfish, but I could have no way let papa go... just like that. He was the person, who told me the story of the spider, who fell 7 times, but still kept trying until she succeeded in climbing.

On the other hand, haven't we heard, God helps only those who help themselves.We should have faith in god.... but how will god help, if I just sit and wait...this is not the age of miracles ...no magic is happening, lord shiva is not coming on earth and take away the sufferings....I have to help myself...help papa to overcome the demon( cancer). My faith is my karma..

Now, for all those who feel, against my decision of taking papa to the hospital for treatment, my question is? Do we stop our children from learning to walk, because they may get hurt? or don't we hurt each other by saying terrible things and are still together. Or, for fear of loss, should we stop trying? Do we not teach our children, keep trying!. Is the word “try(ing)" only meant for our convenience, use it whenever we want and discard, because it may cause pain. Are we not responsible for teaching our children, the most valuable lesson of life…..”keep trying until you succeed”….when Pythagorus, La-places’s theorem will not help…trying will help, having faith in your karma will help!

To summarize, I am quoting Buddha

"Better than a thousand hollow words, is one word that brings peace

And for me that word is at least I “TRY(ied). Keeping alive in my faith, Trying is the first step of winning, I will keep TRYING, after that……..may be "I am at peace"

Love you PAPA!

Chapter 6- The time has arrived....

It was  6th August,2012. I had an appointment with the doctor. Since the past few days, papa was unable to sit by himself and had been complaining of acute pain in the shoulders. Therefore, i decided to visit the doctor and discuss the problem. In 1945, 6th August, 8:16am, Atomic bomb was dropped on Hiroshima( JAPAN) killing thousands of people. And today another bomb was dropped....that changed my life for worse....  

At 9:00 am, i reached my parent's house, dropped my daughter, collected all the necessary reports and left for the hospital. Papa couldn’t come because of the pain and his inability to sit. 

I reached the hospital around 9:45am, i still had 30min, before i meet the doctor. I decided to have a cup of coffee. While I sipped my coffee,  my gaze fell on a middle aged man, who was crying. I felt bad, but we had something in common - one of our loved was suffering.  We both were in pain, and when pain is the common factor, it becomes so much easier to talk even to the strangers.

What I heard was unbelievable, he told, he was 47 years old, his mother passed away, soon after giving birth to him. His father never married again. He din’t have any sister. He doesn’t have a daughter. The only woman in his life is his wife, whom he loves very much, and will do anything to save her. He further added that, she is the one who has stood by him all these years, gave him a family, gave him a sense of being loved, she gave him 2 sons,  and looked after his father. She has loved him selflessly and today the doctor says, she has no time left….she is going!( Sorry,Uncle for sharing your story)

I was saddened the way my day has started, but then it was same…as it had been for past 7 months. My name was called, i gulped my coffee and  went inside…the doctor looked and re-looked at papa’s reports and with a sigh, he said, the cancer has spread in the bones( and the whole body) and ….and….and... now ..NOTHING CAN BE DONE!

The time has come, was my first thought. I asked the doctor, how time papa has got, he said…may be a week or a month. Somebody just stabbed me in the heart…papa don’t go!. 

I composed my self, and asked, Can we do something to make papa’s remaining journey less painful. I pleaded, can we continue with chemotherapy, that ways papa will have hope?

The doctor said, No, that is not possible but you can take radiation therapy session, but that too won’t help papa because of his old age. I pleaded again, I will do anything - just anything  to maintain papa’s hope, even if means nothing or is not helping him anyways. 

Since, i was not  ready do give up, he said, you can take opinion from other doctors ( that was his way of making me understand, through other doctors telling me- be prepared, time is near). I was so desperate, that I could have done anything to save my father, whom i was about to loose. I visited all the major hospitals of Delhi, while my brother visited a re-known hospital in Mumbai. But nothing changed -the answer remained  same.

The rains set in, and the candle burned out!

Love you papa!

Chapter 5 - Palliative Care

In words of Buddha…

No matter how hard the past is, we can always start afresh

It has been more then 10months, I am still trying to come terms with my loss. Had it been that easy, then everyone around me would have been happy. Such a perfect place to live, this world would have been. But none of us is happy ( Don't go by what i say, but introspect, you will find the answers). I come across a lot of people everyday but i haven’t found one such person…who is happy enough to not complain.

I understand that starting afresh is my only option. But the time i will  take to start, only time will tell. Moving from past to present, today i want to talk about the most difficult phase of life...when with every passing moment papa was suffering more. I knew time was running out but .... I became a spectator, He could not be saved.

In my last post i talked about the doctor telling me in my first visit of making my father nearing end…”easier” as NOTHING can be done now. What he meant was they will try to lessen his pain by medicines, care and counseling. This process of “trying” to make life comfortable is known as palliative care or support care or comfort care.

Papa, received palliative care from day 1 of his treatment,  and it continued till the day when he took his last breath. We were trying, but  nothing was coming out. I was loosing hope, I was scared as a result, i  spent most of my day in thinking or reading about other forms of treatment and pain relievers. Papa was trying hard. He just wouldn’t let go. Every time the palliative care team visited papa, at least papa spoke. Papa would plan his queries and ask me to write on paper, this gave me immense peace- though momentarily. As a result i started looking forward to visit from the team, That meant so much to me. 

CARE or NO CARE, i knew the result from the very first day. Nothing helped him. Neither medicines nor our prayers. And now, all i know is my father has left me. In his life, after cancer  the only thing that gave him some relief were the pain killers. Starting form 2 tablets a day to  a day arrived, when papa was just  having  the pain killers - absolutely no food, no juice, no water. We would moisten his lips with cotton dipped in water or may be put few drop of water by a spoon. How helpless CANCER made my father.  This continued for 4 months..But he held on. And then...

Even after taking precaution(s) and trying in vain. All the symptoms came along. one by one and i could do nothing.

He went away right in front of eyes….

Love you papa!

A little more about PALLIATIVE CARE

What is palliative care?

Palliative care is usually given to patients with  life threatening or serious illness such as cancer. The aim of this kind of care, is basically to handle or treat  the symptoms or side effects of the disease  as soon as they appear. The aim is to cure as prevention is not possible. Palliative care is also known as support care, symptom management or comfort care

When to start palliative care?

Palliative care, especially in diseases like cancer starts right from the diagnosis and continues throughout the treatment.

Who gives palliative care?

Usually the treating oncologist, but other people like the pain specialist, dietician, counsellor play an important role. The aim of palliative care is to  make life comfortable. 

Rose Bud

For me writing has been always my passion....it is a medium that i vent out my feelings .good or bad..feeling happy and light without having to say a word!

This blog is not just a blog, its like i am painter and this blog is a canvas on which  i am painting my masterpiece...sometimes i will use bright color as red and some time pastels to show my state of mind. With patience and determination, i will create a piece of art- which will be a motivation to those around me and those who are away from me.

My father, always wanted me to write, and i always said...i will write papa...the day you become free of this daemon...and walk away as a "SURVIVOR", But nothing like this happened and the daemon took papa away, he left me behind on 26th October2013 and became a star- the brightest star - My PAPA!

I am writing for my father- who believed in me ( he always said - believe in yourself and things will be in your favor). He believed my lies, just like truths. He listened to my stories, just like a friend. 

He gave me choices, just  like a father would have. He gave me everything that i laid my hands on. With him around ..my hands were always full!

That one moment ( 1:20am, Saturday, 26October, 2013) - i felt i could not breathe. I wanted to hold my papa so tightly that i will never let him go. He was going ....he din't want to, I din't want him to...helpless and shattered, i stood there and he want away.

He din't deserve this. I always wanted his sufferings  to end! But...

And they did, he faded - moments after he was gone, i looked at his face-  it was so bright and calm as if nothing has ever happened. The scars, the bruises, swollen nerves left behind by months of chemotherapy and various tests just disappeared. He looked so peaceful as if he was fast asleep after a long tiring day and will just wake up! and call me"Beti".

My father was a very disciplined  and organized person especially when it came to health. Even after his retirement he maintained his disciplined routine. He was always a very happy and a contended man,  leading a very fulfilling life with his wife and his children and grandchild. Until tragedy struck and life came to a halt!  I lost my papa to CANCER( Gall Bladders cancer to be precise). 

I am not sharing all this because, I want to vent out the pain inside me. It will be there forever.  But i don't want anyone else to suffer like me. The pain, the anguish never goes but i am hoping things will be better.

In one of the finest CANCER hospital of India, where papa was treated, I saw this written 

                                          "If detected early, CANCER, can be cured"

I can never believe this, but in the hope that it will be true for someone. I want to use this blog as a medium to make people aware, so they don't go thorough the pain of loosing their loved one.
Miracles do happen, don't they ?

Be Aware, Be Careful and Stay Happy Always!