“You matter because of who you are. You matter to the last moment of your life, and we will do all we can , not only to help you die peacefully, but also to live until you die.” –Dame Cicely Saunders
The Hospice doctor that called to see and evaluate Vic was a tall, slim young woman. She has a gentle voice and long fingers with short nails. She drives a Jeep and keeps large dogs. She looks like a naturalist.
“I am Dr Sue Walters from Hospice. The Pain Clinic asked us to see you. Is it okay for me to examine you?” she asked Vic in her gentle voice.
Vic’s abdomen was severely distended and very tender. She was running a fever and her resting heart rate of 103 indicating severe pain despite the fact that she had already taken her pain medication. Vicky’s vitals were poor.
Sue administered a strong morphine injection.
“Vicky, you appear to have an abscess on the right-hand side of your abdomen. The skin is hot to the touch and distended. I think you have a partial obstruction.” Dr Sue said to Vic.
“I am here to see if Hospice can help you. Do you realize that you are very ill my love?” Dr Sue asked Vic.
“Hospice will not hasten your death my love. It would be our aim and purpose to provide you with pain relief and quality of life. We will treat you and not the disease. It is exclusively your decision whether you want us to help you and how you want us to help you.” She explained to Vic
Hospice is a philosophy of care. The hospice philosophy or viewpoint accepts death as the final stage of life. The goal of hospice is to help patients live their last days as alert and pain-free as possible. Hospice care tries to manage symptoms so that a person’s last days may be spent with dignity and quality, surrounded by their loved ones. Hospice affirms life and neither hastens nor postpones death. Hospice care treats the person rather than the disease; it focuses on quality rather than length of life. Hospice care is family-centered — it includes the patient and the family in making decisions. http://www.cancer.org/Treatment/FindingandPayingforTreatment/ChoosingYourTreatmentTeam/HospiceCare/hospice-care-what-is-hospice-care
Vic was in so much pain that she was barely able to speak. Tears welled up in her eyes and she softly said “Please doctor”.
“My love, you need to tell us how you want us to treat your symptoms such as obstructions?” Dr Sue asked
“I want no life extending treatment. I am so tired doctor” Vic whispered. “I can’t do this anymore…..”
“That’s fine my love. We will try and relieve your pain and give you some quality of life.”
“Mommy I thought I had more time…” Vic said with tears silently running down her cheeks…… Then the injection kicked in and she drifted off to sleep.
Dr Sue said that the responsible sister would collect the morphine from the Hospice pharmacy and she would set up a subcutaneous morphine syringe system by that afternoon. Hospice would arrange for counseling for the boys.
She hugged me and left. All of a sudden I felt so alone again!
Subcutaneous, or under-the-skin, injections use a needle to deliver medications into tissue just under the skin. An infusion of morphine, anti-nausea medication and Dormicum is now administered 24/7.
The first couple of days Vic slept a lot. She was tired but there was immediate pain relief.
The nausea subsided and the partial obstruction cleared two days later!
The first infusion site was in her leg. Within a day and a half the area “tissued”. A common side effect associated with subcutaneous injections is injection-site reaction such as swelling, redness, and pain. We phoned Hospice and the Nurse promptly came and the needle was reinserted into the arm. Within two hours the needle came out again and the morphine was running onto the skin. It was too late for the Hospice Nurse to return and to re-insert the needle so Vic went to the doctor and he relocated the needle into the abdominal area.
Last night the tissue in the abdominal area had tissued again. It was also bloody and the morphine was running onto the skin and not into the tissue. Vic was nauseous with pain. I had no option but to remove the needle and re-inserting it into a different site.
“I think we should put it into the other side of your tummy” I said
“Mommy, I will insert the needle if you help me…” Vic replied
“No sweetie” I said. “I will do it”
My heart was in my throat. I removed the needle and cleaned the injection site. I disinfected the new site that I had identified. I took the needle in my hand and lifted the skin. I pushed the needle against the skin. I assumed that the needle would just slide in… It did not just slide in! There was resistance!! I let go of the skin and changed my position. I could hear and feel my heart pounding in my ears! I again took my child’s skin between my fingers and pulled it upward.
“Maybe I should relax my hold onto the skin…maybe the skin must more relaxed?…..” I thought.
I exerted pressure on the needle and it slid in… Sweet success!!!!
“Oh Mommy you are such a star! Thank you. That did not hurt at all!” Vic gushed.
I do not believe her. I had felt her little body tense up as the needle went in. It hurt!
My entire body shook. The bile rose in my throat and I slowly let out my breath.
We have all come such a far way. Until last night I could not watch anyone stick a needle into my child. Now I have stuck a needle into my child’s flesh. I fear that Vicky’s tissue is too poor for us to continue on the subcutaneous route…… If we do I will have to do this many more times in my life.
The good news is that I was actually able to work the whole week. It was the annual African Air and Defense Show and we exhibited. Normally I would be absolutely frantic about Vic. But I was okay with the fact that she is relatively pain free and the nursing sister visits every two days.
Vic is far more active. She is truly so much better. The partial obstruction appears to have cleared! She spends time chatting to the boys. On Saturday she took Jared shopping for a new shirt and shoes!
On Sunday morning Jared lit candles “For those we have loved and lost but will forever be in our memories♥..Gramps, Oupa Tienie, Ouma, Nan and Oupes♡” Vic handed him his baptism candle that she received 15.5 years ago at his christening. He lit his candle as he took responsibility for his own walk with God. Vic and I laid hands on him and prayed for him. It was so touching.
Vic attended Jared’s confirmation service. I have never seen a more radiant and proud mother in my entire life.
Vic has reached another milestone in her life.
Today, having a loved one live with a terminal diagnosis for an extended period of time is fast replacing sudden and unexpected death as the norm. Ultimately, many will reach a point where medical technology may be able to keep them alive but can neither restore their health nor even improve their condition. In actual fact they are merely kept breathing…. More treatment will only prolong their dying.
It is at this point that patients and families face difﬁcult choices about the kind of care they want….
I have seen studies that clearly show that patients who access Hospice, earlier in the disease process, actually live longer than expected. Ironically it seems that Hospice, with its emphasis on quality of life, actually keeps people going. When people who are ill have good pain and symptom control and their caregivers are well supported, they don’t want to give up; they want to live longer.
Vic has reached a stage in her life where she wants to die. She has absolutely no quality of life and is growing weaker by the day. Everyday Vic loses a little more of her independence and dignity. Vic needs help with almost all her day-to-day activities.
Opinion polls decisively show that most people would prefer to die at home, free from pain and surrounded by their loved ones. Sadly people often die alone in hospitals or nursing homes, attached to life support machines they do not want. It is also a fact thatmany terminally ill people die excruciating painful deaths because, even in death, their doctors suffer from Opiophobia…
“Opiophobia is the syndrome of failure to administer adequate opioid analgesics because of the fear of producing addiction or toxicity. The etiology of opiophobia is multifactorial: Peer pressure (provider and patient), regulatory agency pressure (real or perceived), and lack of education on opioids and the fundamentals of pain management all contribute to its persistence…. All of these factors contribute to the underuse of these relatively simple and very effective medications, due to no fault of the patients. ” University of Wisconsin textbook on pain medicine, Bonica’s Management of Pain, 3rd edition:
I promised Vic no more surgery and no more hospitals. https://tersiaburger.com/2012/06/01/1-6-2012 The only humane option left is Hospice. I have been fighting for Hospice to get involved with Vic’s palliative care not to hasten her death but to enhance her quality of life!
WHAT IS PALLIATIVE CARE
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:
WHAT TO EXPECT
Should the patient be accepted onto a hospice programme, the Hospice team together with the patient will develop a tailor-made plan care plan. Usually patients are visited by the hospice staff in their own homes. The care and support of the hospice team will help the patient and family as they navigate their way through the challenges of living with a life-limiting condition.
The main things hospice can help with are:
The challenges that we as a family must face with Vic’s terminal diagnosis is complex. It includes evolving new structures and dynamics as the person we love very, very slowly slips away.
Last night and again tonight, Vic said to me “Mommy, I know you think I will live forever but you must prepare yourself because I know how my body feels…”
As a family we have learnt to cope with setbacks, Vic’s health steadily deteriorating and periods of seeming remission. This “extended grief”, wears us down and leads to the horrible realization that we sometimes find ourselves wishing that the process would end…. I have often said “Sometimes I am scared Vic will never die…” I do not want my child to die. I merely want her suffering to END!
As a family we have moved into a phase where the stress of the situation can no longer be ignored. It is making all of us ill.
This week has been an emotional roller coaster! On Tuesday I cried in front of a strange doctor. Wednesday I felt that I was losing the plot. I was unable to function on a professional level. My mind was absolutely fogged over. Thursday an angel named Christa evaluated Vic and I went from absolute despair to exuberance when I heard that Hospice’s Doctor would evaluate Vic on Monday morning…
Today when Jared and I were waiting to see the doctor after his CT scan we had a long chat…
He said “Oumie I can see when you are stressed. You zone out… You have been very stressed this week….”
“Yeah” I said. “I have been a little stressed this week.”
“Since you starting writing your blog you no longer wear a mask Oumie…You handled the stress better before! You always smiled.”
OMG. What am I doing to the boys? I realized today that I have to be more careful. The mask has to go back on. I scare them when I show my stress. Imagine what it would do to them if they read my blog….. Thank God they don’t!
I left the best for last though – no immediate lymph biopsy will be done on Jared. The lymph nodes are definitely enlarged but there has been no adverse change in the past two and a half weeks. We will give his kidney some time to heal and the CT scan will be repeated again in two months time.
I am feeling so positive!
There is a God and I thank him for Jared’s outcome, Hospice intervention, Baby Isak and my wonderful, loving family. I pray that He will enfold Vic and the boys in His Mercy and Grace. I pray for my mask!
Just seconds ago I was thinking “What a glorious wonderful day…” when the thought crossed my mind “Hang on a minute…. It is a glorious day because Hospice have agreed to evaluate my sick child????”
Hello!!! How sick is that that our lives has degenerated into a hellhole where Hospice is good news!!
This morning Christa, an internationally acclaimed pain expert, came to evaluate Vic at home. She spent a lot of time with Danie and me to build up a case history on Vic. Christa works for Janssen Pharmaceutical Company as a “Medical Scientific Liaison: Pain”… Part of her responsibilities is to liaise and advise the Pain Clinic and Hospice as an expert!
It was as if a floodgate opened. I rambled on about Vic’s (health) background, history, symptoms, operations, treatment and decisions. I showed X-Rays and photo’s of Vic abdomen at different stages of Vic’s 10 year journey. She was shocked to hear that Vic spends 95% of her life in bed. That she is too tired to even read.
Christa told me that Prof Froehlich had phoned her the previous day and told her that “Mrs Bruce’s mom is in trouble…” https://tersiaburger.com/2012/09/12/pain-clinic-11-9
I should have cried earlier. I have been fighting for months to achieve this! Then when I give up my fear, exhaustion, stress and defeat obviously showed… Maybe it is the new doctor who has not been desensitized to the suffering of the patients… Maybe there is a God of Mercy after all.
After chatting to us and taking copious notes, we got into Vic’s pain medication regime. I told her about this wonder drug, Jurnista. She just smiled and told me that Janssen’s manufacture Jurnista! I am amazed that she consults for the Pain Clinic and Hospice and they don’t have the budget to supply Jurnista!
I eventually took her to meet Vic. (Shame poor soul got such a fright when I woke her). She examined Vic briefly, spoke some and made wonderful sympathetic sounds. I introduced her to Jared who was in bed as he was in too much pain to go to school.
She explained to Jared that she was here to evaluate his mom and would be making a recommendation that Vic be accepted into the Hospice program. She also told him we, as a family, needed to have some counselling. The psychiatrist would come to our home…. Jared told her that his pastor’s wife was coming to see him in the afternoon…. I smiled. I know the boys so well. They automatically put up barriers when they hear the word “counselling”…. (It was really the truth – Mrs Pastor did visit. First visit in 4 years from Vic’s church…)
Christa wished Vic well, hugged me and said “Vicky clearly qualifies for palliative care. I will talk to the Hospice Palliative Care doctor and recommend that they accept Vicky into the program. I will phone you this afternoon”
At 5 pm this afternoon Christa phoned to confirm that the Hospice doctor will evaluate Vic on Monday morning at 7 am! I read somewhere that terminally ill people often feel that upon entering the Hospice program they go from “dying from….” to “living with….” It is my heartfelt prayer that this will be the case with Vic.
Tomorrow morning at 9 o’clock my beautiful Jared will go for his CT scan. At 12 O clock we will see the surgeon.
I have stopped thinking and researching Lymphoma. My heart has stopped beating. It is pounding.
Why do you weep, my child?
How long have you been sitting here, trembling
beneath these glossy-green leaves of the Banyan,
heavy laden with delicious figs?
Why are you frightened so?
The world is no bigger than you can handle
in any given moment, and you are not alone!
Why do you moan, my precious one?
Have I not taught you the melodies
of your father’s father?
Shall I sing for you the soothing songs of your village
where you played “Mboo-bay Mboo-bay”
with your brothers and sisters?
Why such silence, my dear?
Do you not know that the sound of your voice
is as a thousand angels laughing and giggling
beside the cool riverbed.
Why do you hide from me?
Have I not held you warmly in my embrace
and rocked you to and fro
when you were frightened by the lions roar?
You know me, sweetness.
I rule the world with a benevolent hand
as I dry your tears, carry your burdens,
sing your songs, play your games
and hold you close.
Come, offer me your hand and rule with me.
Let us spin the earth like a child’s toy
as we munch on afternoon clouds
and drink oceans from a silver cup.
To your feet, my child.
We have other children
beneath other Banyans
that need our love and reassurance.
Wednesday a specialist surgeon came to see Jared. He said CT findings, such as indicated in Jared’s scan, is nonspecific and are generally “not recommended to rule out the presence of a neoplastic process such as lymphoma. A surgically obtained biopsy is required to confirm the diagnosis of lymphoma.”
Jared asked the doctor exactly what he meant. The doctor tried to avoid answering Jared.
Jared repeated his question: “What do you mean doctor?”
“We have to eliminate lymph cancer.” the doctor said.
He continued to explain to Jared that due to the position of the para-aortic lymph nodes the surgical biopsy is major surgery. A large incision has to be made to allow access to the lymph nodes situated near the aorta, right in front of several lumbar vertebrae. Jared said “Doctor I had major surgery with my Nissen Repair and it was keyhole surgery…Now you want to make a large cut for a biopsy?”
I thought it was a rather intelligent and rational question and even in the scary moment I was proud of my grandson.
The surgeon said Jared would go to theater on Thursday morning for the biopsy. He asked me to be there by 6 am so we could have a further discussion before Jared went into theater.
Jared’s eyes, when he registered what the doctor said, will haunt me until my dying day. He simply said “Oumie can we phone Mom?”
Vic’s first reaction was “Mommy I am just too sick…..” I told her Jared wanted to see her and that her dad would bring her to the hospital.
I took Vic aside and broke the news to her first. Then we spoke as a family. We went to the cafeteria and had a cup of tea. Nobody had an appetite.
Wednesday night I Googled the results of Jared’s CT scan and found the following: “The paraaortic lymph node is lymph tissue located near the aorta, right in front of several lumbar vertebrae. Another term for the paraaortic lymph node is periaortic lymph node. As part of the lymphatic system, a paraaortic lymph node helps drain dead cells and immune system-neutralized foreign bodies. In particular, a paraaortic lymph node helps drain the organs in the pelvis and the lower part of the digestive system.” http://www.wisegeek.com/what-is-a-paraaortic-lymph-node.htm
Five broad etiologic categories lead to lymph node enlargement, as follows:
From Wikipedia, the free encyclopedia
We left home at 5.30am on Thursday morning. It was raining and freezing cold.
At the hospital the surgeon spent a lot of time talking to us. He discussed the results of the CT scan and said that the most common reason for lymph nodes to enlarge is infection. The blood tests, done on Monday and repeated on Wednesday, however showed no infection levels. The CRP levels were perfectly normal. The problem with Lymphoma is that bio-markers are not enough evidence for a diagnosis…
The surgeon was concerned that he had a very long theater list and that Jared had already had four anesthetics this year. It was a long procedure…. Furthermore he had to go back to theatre in two weeks time for the removal of the stent. We agreed that the biopsy would be delayed for two weeks…
Jared came home on Thursday. He is on very strong antibiotics. His kidney is still sore. He is scared.
We are all scared.
Babies are emotional beings right from birth. As parents we know that babies respond to emotional expressions such as smiling within the first few weeks of life. Within three months babies can react to and express joy, interest, anger, sadness and disgust.
Babies and young children express their emotions without reservation. In time, they however learn to control and even conceal some of their feelings, especially when they are sad, frightened, or angry.
As adults we lose our ability to communicate spontaneously. We become guarded. Many of us may still be comfortable expressing positive emotions, such as joy, pride and happiness, but will refrain from sharing feelings that we fear may make others uncomfortable.
The grieving process that walks hand in hand with terminal illness however catapults the bravest of us into a whirlpool of emotions ranging from fear, sadness and anger to irrational hope.
We are what we are. If you are naturally an introvert it will be very difficult to reach out to others when we or a loved one battles a serious or terminal illness. This makes the grieving process difficult for us. People who are comfortable in expressing their emotions are usually more able to reach out to others for the support and reassurance that they need.
When I am scared or angry I withdraw within my safe place where no one is welcome or allowed. In fear I will push people away from me. Anger is different – I will lash out and go for the jugular. Fear for my family will bring out the most primal instincts in me. I will do anything to protect them.
To maintain control I hold tightly onto my emotions– I know that if I allow myself to falter even a little, I may collapse into a whimpering heap of tears. It has taken superhuman efforts to allow Vic to see some of my pain. Well, I fool myself that she only sees some of it. Vic knows so well how my life will screech to an end the day her life ends… We have spoken about absolutely anything and everything. She knows my heart.
Tomorrow morning Jared will have a lymphoma biopsy.
Today, when I saw the tears of fear form in Vic’s eyes, I said “Stop! We never cry in front of the children”
Tomorrow I will smile, support and encourage.
Tonight I will weep for my beautiful grandson, his mother and his little brother……..I will weep for his grandfather and everyone who loves and admires him.
When I wipe my last tears I will retreat to my safe place….. Tomorrow I will smile, support and encourage.