How many speed bumps?
- The Story of Pain: From Prayer to Painkillers by Joanna Bourke
Oxford, 396 pp, £20.00, June 2014, ISBN 978 0 19 968942 2
I had just seen a man about his headaches and was about to call someone about her backache when the receptionist beckoned me over. ‘Mrs Lagnari is on the phone,’ she mouthed in a stage whisper. ‘Her husband is in terrible pain. Will you go and see him?’
During their training physicians are urged not to jump to conclusions. They’re supposed to wait until they’ve worked through a battery of questions and prodded the patient all over before they draw up a list of potential diagnoses. Even so, I couldn’t help wondering why Mr Lagnari’s pain was worse. He had advanced pancreatic cancer, which had spread to the liver. His tumour might have lurched in size, I thought, pressing on and infiltrating the nerves around the pancreas. The metastases growing in his liver could have begun stretching the liver’s capsule; ‘capsular pain’ can be frustratingly difficult to control. I’d seen him only the week before and increased the dose of his opiate medication; he might have developed resistance to the new dose already. Perhaps a deep vein thrombosis had formed in his legs – a well-known complication of a tumour like his. Or his pain might be existential: Mr Lagnari knew that he was dying.
His wife and son opened the door before I had a chance to ring the bell. They made way for me in the tiny vestibule, their faces pinched with worry. ‘He’s more settled now,’ the son whispered, anxious that his father might overhear, ‘but he thinks his number’s up.’ I nodded: his impressions might be more useful than whatever Mr Lagnari would tell me.
He was leaning forward in bed, propped up on a few pillows, his face more withered and pale than it had been the week before. He winced at the smallest movement, and held his hands over the pit of his stomach as if protecting it. The room was just wider than his double bed. He raised one arm to greet me, and with the other switched off the television.
‘I took some of that stuff you gave me,’ he said, ‘and it’s a bit better. No need to fuss.’ But he was gritting his teeth. He was wearing Fentanyl patches, which soaked an opiate through his skin directly into the bloodstream, but I’d also given him a bottle of liquid morphine to use in the moments when the patches weren’t enough.
‘What does it feel like?’
‘Like a burning, horrible pain, coming up from here’ – he bunched his fingers over his solar plexus – ‘and into here’: he spread the fingers out wide and grazed them over his sternum and the right side of his chest.
‘Is it worse if you breathe in?’ I asked.
‘A bit,’ he said.
‘Any pain or swelling in your legs?’ He shook his head, and I lifted up the duvet to check his calves: they too were withered and pale, no sign of thrombosis.
I sat down on the edge of the bed. ‘Anything you can do to make it go away?’
‘If I keep on sitting forward it’s a bit better.’
I examined his belly, pushing tentatively down over his stomach, then pressed my hand into the hollow beneath his right rib-cage while he breathed deeply in and out. His liver didn’t feel any larger or more tender than when I’d last examined him a couple of weeks earlier.
‘So what do you think?’ he asked, holding my gaze. He had been straining to keep things light, as if we were bantering about the weather. But now he looked down, smoothing the duvet between his leg and the depression in the mattress where I sat, and asked: ‘Am I dying?’
I’m not afraid of discussing death; what I worry about is misjudging the readiness of patients to hear an honest opinion. ‘Well it’s getting closer,’ I said. ‘It’s spreading in your liver … but I really can’t give you a time. It could be days, it could be weeks.’
‘But not months?’
‘I wish I could tell you … We could send you back to the hospital for a scan,’ I said, deliberately trailing off, watching his face to see whether he’d clutch at the chance, any chance at all, to delay what was happening to him. He knew what I was hinting at. There was silence for a few moments. ‘No, I’m finished with all that,’ he said. ‘I’ll stay here.’
‘We could switch your medication from the patches to injections,’ I said. ‘They are more effective in many ways, though they might make you more sleepy.’
‘That sounds good,’ he said, relieved we were back to talking about managing his pain, and not his death.
I went back to the clinic. There were six or seven more patients to see, an hour’s worth of paperwork, then more housecalls. Afterwards, I went to check on Mr Lagnari. A nurse had set him up with a drip of morphine, mild sedatives and anti-sickness medication, and he was asleep. ‘The priest was in for an hour,’ his daughter said, ‘and he seems much more settled now.’
That was Tuesday evening; by Thursday morning he was dead.
The priest and I cover much the same patch of Edinburgh and many of my patients are also his parishioners. He avoids giving advice on medication. But even as late as the second half of the 20th century some Roman Catholic theologians would have denied Mr Lagnari morphine for pain, because he seemed so close to death. In New Problems in Medical Ethics (1956), Peter Flood, a Benedictine, stated that Christians in pain should accept suffering ‘as permitted by God for our betterment’. Pain was a ‘privilege, in union with the redemptive sufferings of Christ’. It was essential that a physician tell people they might be close to death, even if they weren’t sure, so that the patient’s opportunity for repentance wasn’t squandered and their admission to heaven put at risk. Pain relief might be administered in small doses, except to those such as lapsed Catholics – the fear being that even small doses might prevent them from returning to the religion of their baptism. In the same volume Eugene Tesson, a Jesuit, sanctioned physicians to administer pain relief only to the dying who had ‘made an act of submission to the Divine’ and those ‘in danger of falling into despair and blaspheming the goodness of God’.
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