Aunt w/ Bone Cancer - pathetic pain management regime

[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.

Thanks in advance for your input.

Lisa

[avahsmiles]

I am so sorry to hear about your aunt. Unfortunately as you know, the prognosis for bone Ca is always very poor and very little can be done. Sadly, the best her DR. can do is to make her as 'comfortable' as possible. My grandmother died of brain Ca in 1998 and she was on morphine right up until the end, and she was still in some pain. I'm sorry that i don't have any advice for you, just wanted to let you know that i am praying for you & your aunt & family.

Take care.

[jer_sd]

I am not sure how the canadian system is set up, but she may benifit from either external beam tadiation therapy for bone pain or administration of Strontium 89 which is also effective for metastatic bone pain of cancer. Strontium is often provided my nuclear medicine departments, or occasionaly radiation therapy departments.

Hope this may help,

Jeremy

I am so sorry to hear about your aunt. Unfortunately as you know, the prognosis for bone Ca is always very poor and very little can be done. Sadly, the best her DR. can do is to make her as 'comfortable' as possible. My grandmother died of brain Ca in 1998 and she was on morphine right up until the end, and she was still in some pain. I'm sorry that i don't have any advice for you, just wanted to let you know that i am praying for you & your aunt & family.

Take care.

[Traveler]

Duragesic patches are very good. I don't know how expensive they are and how medications are approved there for insurance purposes. It makes some people a little loopy and they can't tolerate it but works well for many. There are also Fentanyl lollipops called Actiq for breakthrough pain that come in varying strengths that are also supposed to be very good. She needs to be on some type of round the clock meds as well as something for breakthrough. There is an immediate release oxycodone called Oxyfast which works well for this. Of course there is also Oxycontin which works very well for many people but many docs are afraid to rx it. I am so sorry about your aunt. It is hard as a nurse to see a loved one suffer knowing that there are good options out there. Let your voice be heard.

[leslie :-D]

i agree with traveler:

if the ms04 isn't helping her, try duragesic patch 25 mcg to start with prns for breakthrough, such as oxyfast (which i've had great success with), moreso than oxycontin. and oxyfast can be given sl. if she's getting breakthrough pain with the prns then definitely schedule atc, or you might even have to increase the duragesic....you definitely need someone that knows pain mgmt.

and i'm truly sorry.

leslie

[aimeee, BSN, RN]

Are they perhaps not doing the radiation because the cancer is so widespread? My first thought with bone pain is to add an NSAID to the regimen and if that isn't enough, add a steroid as well. Topical NSAID gel, such as ketoprofen, applied to particularly painful areas is another option. Opioids alone just don't do very well at relief of bone pain. You have to relieve the inflammation to achieve good pain control.

[leslie :-D]

you're right aimee, and that's a key element is to ensure that an nsaid/anti-inflammatory is a key part of her regimen....very key.

leslie