The Cover of the Book

Two patients were on the same hospital unit recently receiving treatment for their cancers. Luke was a 22-year-old young man with acute leukemia. He had a “gothic” look to him with his hair bleached dark black and his baggy clothing and tattoos. He had previously undergone a stem cell transplant, but recently found out that his cancer had recurred, and learned that it had metastasized to his testicle. After going through an orchiectomy, he started new cycles of chemotherapy. Luke complained of persistent nausea and abdominal pain. He was on 120mg of oxycontin twice a day and had an order for hydromorphone 3mg IV every three hours as needed for breakthrough pain, in addition to several antiemetics ordered as needed—ODT ondansetron, IV ondansetron, IV prochlorperazine, and IV lorazepam. Luke requested the hydromorphone consistently every three hours and stated that the ondansetron really did not do much to relieve his nausea and requested the lorazepam instead. He admitted to smoking marijuana while away from the hospital to “help relieve his nausea.” His room remained dark most of the time, and he had few visitors other than a few friends whose appearances were similar to his.

MaryAnn was being treated for lung cancer. She was an 82-year-old female who was currently receiving her chemotherapy treatments. MaryAnn complained of persistent nausea and had orders for the same antiemetics as the previous patient. She complained of shortness of breath for which she received oxygen therapy and immediate release morphine every two hours as needed. Every 72 hours, MaryAnn received 200mcg of topical fentanyl to help with pain, and had a much needed dose of hydromorphone 2mg IV every two hours for breakthrough pain. She requested morphine every 2-3 hours for shortness of breath and took the hydromorphone every two hours for pain. MaryAnn’s nausea was only controlled with the prochlorperazine, which was requested every 4-6 hours. She was a typical 82-year-old with her husband at her bedside, pictures of her children and grandchildren in her room, and many visitors from her volunteer group and her church.

MaryAnn and Luke are typical patients that we see every day but our reactions to them are often quite different. I have heard too often the description of Luke as being able to “set your watch” by when he asks for pain medication. How many times have you heard that a patient like Luke is difficult because he watches the clock and asks for his pain medication as soon as it is available? Or that he has a problem because he says that only lorazepam works for his nausea? How often have you heard a nurse say that you should hold out as long as you can to administer his medications and watch him closely, especially while his friends are visiting? After all, we’re not sure what it is that they’re bringing to him, and many people have suggested that he’s most likely taking medications other than what we are administering. He’s always angry and demanding.

On the other hand, MaryAnn’s story is so “sad,” yet her family is very supportive and she’s doing what she can to just get through. She’s so brave through her treatment, and it’s nice that her family and friends are always there for her. They are also supportive of the nursing staff, bringing in cookies and candy and always being so grateful for what we do.

How often have nurses placed these labels on patients without looking further? We make judgments about people based on how they look, how they react to us, or what we see on the surface of their actions. The truth is one of these patients was indeed misusing their medication. If I asked you to predict which one, most people would say Luke. It was so obvious, but it would be the wrong answer. Luke took his pain medication only when he had pain and his nausea medication only when his nausea would not go away. MaryAnn, on the other hand, often asked for the medications because she liked the way they made her feel. That way she didn’t have to think about her situation and could escape to another place.

It’s natural that we respond to people and make judgments about them based on what we believe to be true, but how often do we go beyond what we think to be true and really look at what is happening with our patients? I was talking to a psychiatric nurse who told me that she tried to be a medical nurse, but just didn’t care about tubes and drains. She wanted to know who the people were who visited and those who did not visit and why. She wanted to know what was going on with the person, not their tubes. Maybe we need to think that way a little more often. Of course we have to be concerned about the technical aspects of care for our patients, which often takes up the majority of our time, but I believe that we need to find the time. We need to go beyond. We need to treat the person and not what they appear to be to us. Not an easy task, but certainly one worth the effort.