Question

Styles Examination of the perineum reveals inflamed excoriated tissue from the labia to the rectum. Stool appears to extrude from the vagina. The excoriation is cleared and the pain is under control with 10mg of morphine q4 hours (6 doses a day). She uses approximately 3 additional doses of 10mg of morphine for breakthrough pain per day. Thus she is using approximately 9 doses / 24 hours. Unfortunately, she awakens at night in pain. She describes no adverse effects to the medications The patient is being prepared for discharge to hospice at home when she expresses some concern regarding her son who has a history of substance abuse. She is afraid he might use her medications. Prior to her discharge to home on hospice the patient admits to the nurse that she is very afraid to die. When questioned further she describes concerns regarding her children's care as well as her own guilt for having a child prior to marriage. The patient is well cared for by her family at home. Her condition deteriorates Ond she becomes weaker, unable to swallow. She does not have a venous access device and her home hospice team decides that subcutaneous morphine might be useful. Her current analgesic regimen is 100mg long acting morphine every 12 hours with 3 doses of 30mg immediate release morphine each day. She died a few days later, comfortably in her home. 1.Does the patient fear the unknown or is she primarily worried about her children's care after her death? 2.Is there additional work that might help the patient prepare for her death?

Answer 1

1. The patient in this scenario is very much worried for her children's care after her death. As she is dying her thoughts and feelings revolve around her family and self. She expresses her grief in front of the nurse and also accepts that she is going to die and this would affect her children. She is in anticipatory grief where she also feares the unknown by being afraid that her medication can be misused by her son who has a histroy of substance abuse. Moreover, she is mainly undergoing the stages of dying explained by Kubler Ross, where she negotiates and is depressed regarding her situation and worried for forecoming situations.

2. The additional work here might help the patient prepare for her death. Hospice care is mainly concerned with providing releif from symptoms and sufferings without altering the natural course of death. As the patient is undergoing anticipatory grief she can be helped here by mental health counselling and motivational counselling. The psychological impact of diagnosis and illness has led her to undergo depression and this can be rectified with help of therapy and better social and family support. Moreover, her worries related to care of her children can be reduced by referring her children to social services and providing proper care provisions for them while she is alive.