I have been the hospice and palliative medicine fellow for 10 weeks now. I have so much left to learn and so little time left to learn it all. I have a research and an education project. Surprisingly, one of the areas of interest to me is determining how to best care for patients on hospice who have concomitant substance use disorder. I did not think this would be an area of interest. I thought I would spend my life trying to fend off individuals with chronic pain or substance use issues. There is this mentality that they are headache patients, difficult to care for, and uncooperative. I can imagine when practicing outside of hospice, it is hard because the data points against the use of opioid medications for chronic pain. Many doctor shop for the ones that will give them what they want. It is not always an easy group. But there is still the possibility that these people will end up with a terminal disease or cancer and potentially getting referred to hospice. Right now, there is little data and even less infrastructure in place to address the best way of caring for this population on hospice. Here we find ourselves in a situation where the best treatments for pain are narcotics, and the likelihood for developing pain is high. Hand-in-hand with caring for a patient with addiction is the concern for family or friends diverting medications from the hospice patient. How do we make sure undue suffering does not occur at the end of life? How do we best address the issue compassionately and safely for all involved? While the numbers of patients we will see that fall into this category are low, they don't deserve to suffer anymore than anyone else. There is a lot of information that outside of the fleeting euphoria that comes with using, most of the time is spent feeling alone, depressed, and craving the drug of choice. It is not a happy or peaceful life and compounds the suffering of dying.
I have to admit that I was jaded by my residency. Many of the people I saw with addiction were not in treatment. They were angry at the world, and more specifically me, because I was the one who was refusing to feed into their addiction. I modeled those I worked with who typically took the strong stand of not prescribing any opioids. Harsh words and curses from the patient were met with the strength of the offensive line in football. Neither side would give and no one was happy with the situation. It will harden and embitter anyone. My hope is that with new training in compassionate communication, I can at least bridge the gap, show empathy, but still be firm in the limitations we define for the care plan. My goal is to not let someone suffer in their last days, but at the same time finding safe ways to provide them appropriate treatment for their end of life symptoms. I don't think this is something I am going to figure out in the first five years of my career. I hope I don't become jaded again. Addiction is a disease not a choice someone makes on a whim. Most don't have control over themselves. It needs the same steadfastness and care as any disease we can tangibly see or test. I hope I continue to remember that when faced with the devastation of the wake from the disease.
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