Aunt w/ Bone CA - care totally mismanaged

[canadian_RN]

Hello all,

I'm an RN here in Canada (gee, did my name give it away? :chuckle ). A couple of weeks ago I found out that my Aunt (mid 50s) who lives in a very small rural town in a couple of provinces over, has bone cancer. Now the details of whether this is mets or whether it's primary bone CA, I don't know. I am in contact w/ my cousins (her sons) and they are understandably upset because this has all been very sudden and I'm trying not to push them too much for details or come across as a "know it all nurse."

From what I can gather, she'd been hospitalized 2 months ago, briefly, for a bout w/ kidney stones. It was during that stay that they did an ultrasound and found nodules on her liver - but this wasn't further investigated (don't even ask me why). She began having generalized pain and a CT scan was done of the lungs showing some type of mass. Due to some gong-show type mix-up, she never had a biopsy of this. She ended up having a bone scan which, from what I gather, revealed cancer to arm, leg bones and spine. They did a CT of brain but nothing abnormal there.

I would suspect, due to the fact that primary bone CA is so very rare, that she's got cancer somewhere and it spread to the bones.....but nevertheless, she's in a lot of pain.

Her small town doc, who likely has little to no experience dealing w/ cancer, has given the family a prognosis of her having only a 2% chance of survival.....yet, they're giving her regular transfusions (packed cells, I believe) and they're still planning to send the poor woman by ambulance to the city 5 hrs away this week, for a lung biopsy. She's undergoing NO treatment of any kind but there is a possibility that they'd send her for radiation but the doc says there's no point doing that until they "know what kind of cells they're dealing with." I don't get this because it's proven she has cancer in her bones and it's proven that radiation can help to decrease the destruction of bone caused by cancer cells, which can thereby help to decrease the pain. Well, there's a lot I don't understand about her case.

I used to work with a lot of palliative patients and we were meticulous and thorough when it came to adequate pain management....but in my aunt's case, she's in agony 24/7. She's getting 10mg of Morphine via subcu buttefly, every 2 hours. It's snowing her pretty good but it's not managing the pain well. This is heartbreaking to me - I know that bone cancer is very painful but this isn't the 1800s......there's better pain management regimes available.

The comment my cousin made today is that they don't want to up her morphine because it would be too much for her (she's not a large woman) - I suggested they give her a bolus and then give less every hour instead of more every 2 hrs. Keep in mind, this is a small hospital and their palliative area is just new.

I've asked him to talk to the Doc about trying Dilaudid or even a Fentanyl patch. She's too groggy to swallow adequately so po meds are not an option. She's receiving nothing but the morphine.

It's been several years since I worked acute/palliative so might be out of the loop in terms of the more common pain med protocols but does anyone have any basic suggestions? I've begged my cousin to have the family doc consult with a pain specialist but I think cousin and family are afraid to offend the family doc. It's a bad situation but my poor aunt is suffering immensely.

Do you think some IV steroids would help? Or any other injectable or IV med that would complement the use of narcotics? I've tried to tell my cousin that each person is different and for some, Morphine might work well but for others it might not, it just varies and the doc should be finding what works for HER.

When my cousins try to speak up on her behalf, the nurses (from what I'm told) just look at them blankly and make comments like, "She's terminal, there's nothing else we can do." But to me this is just a crock. Okay, so they can't obviously cure her.......but surely they can manage her pain BETTER. She is constantly moaning and the family is beside themself, watching her suffer.

She's so doped up on morphine but it's obviously not helping a lot......she's too groggy to even take a sip of water or talk. Would some IV steroids help any? It's been 10 yrs since I cared for palliative patients and I'm sure pain management has improved a lot over that time, so I'm not sure what to advise them. I feel helpless - if there was something I could suggest they talk to the doctor about.......NOBODY should have to suffer, nobody.

[SusanJean]

I'm very sorry to hear about your aunt. Is she being referred to an oncologist??

Yes, I'm sure there is much more that can be done to manage her pain, but I am doubtful that nsaids would be of any benefit. With the severe type of pain she has, she needs major managment. Addictionn should not even be a concern for this woman.

If the family does not want to ask for fear of "offending" the local doc, would they give you permission to act (via phone) on her behalf?

I'm hopeful someone else can tell you some recommended pain managment for CA pts.

You might want to do a web search on Pain management advocate groups. They are taking off in USA and might be able to provide some info, too.

My thoughts and prayers are w/ you and your family.

SJ