In a word, Erin McMenamin looks effective. With her stethoscope draped around her neck where it needs to be, her chrome halo of hair, and her straight unsmiling lips, her aura does not betray much else than,”I can take care of you and you know damn well to do what I say.”
Nevertheless, she runs into the common problem of people not doing what she says. Specifically, her oncology patients suffer from a tendency to not take their pain medications. This is a curious phenomenon. Why does it happen?
According to Erin, the top reasons are not wanting to become addicted and not wanting to “be a zombie.” In reality, she assured me, these things are rare, particularly rare in the oncology population. Yet they continue to take place. Patients have complicated relationships to their medications. A lot of us resist the need to depend on something “artificial” to live well. Plus, there’s the fear being harmed by addiction.
Here’s the deal: Your pain medication “shouldn’t make you overly sleepy, it shouldn’t make you unable to do anything that requires cognitive skills, you should be able to do more activities, you should have less fatigue, and appetite is generally improved.” Straight from the mouth of a pro.
What happens if that isn’t the case? Tell your doctor. Tell your Erin if you have one. Tell somebody. They can give you other options; they can change your dose; they can do a lot of things. Got it? Good. The point is to make you better and that is what your healthcare providers will aim to do.
Clean-cut solutions aside, anybody who knows as much about pain as Erin does (she has years of experience in palliative care) has seen the anomalies. The second video is of her talking about what to do in the event that someone feels so much pain that he or she requires sedation. In the layman, this raises red flags.”Isn’t that just legal assisted suicide?” I asked her.
Her defense of palliative sedation was quite brilliant (so good, in fact, that I couldn’t help but speculate that she’d be able to write a better defense of the Affordable Care Act than, “It’s a tax, guys.”) You can see it for yourself, but it goes something like this:
There are two ways we can look at it. The first one, astutely invoked by Erin, is the principle of double effect. It’s an Aquinas thing. In the principle of double effect, it is assumed that an act is permissible if the intended effect was a good one, even if it produced a second effect that was bad. So the administration of opioid drugs, intended to lessen pain by sedation, is good because it lessens pain, even if it produces death by respiratory depression.
But guess what? (This is the second way to look at it.) There’s actually no evidence that opioids, even when the dose is escalated continually, bring about death by respiratory depression. Erin cited”a study in England” that proved that patients who received palliative sedation actually lived longer on average than the ones who didn’t. The people who did this study, Nigel Sykes and Andrew Thorns of St. Christopher’s Hospice in London, actually concluded that the slippery principle of double effect is not even needed to justify palliative sedation. It doesn’t conclusively lead to death. In fact, it does the opposite.
Like a good Supreme Court Justice, Erin was able to cover ground from a moral angle and a pragmatic angle, the latter being backed by data and punching even harder than the justification she had just given. Take that, John Roberts.
But it doesn’t mean she always gives the go-ahead to pump everybody full of morphine until they’re so snowed they can’t see anything. End-of-life care is rife with ethical quandaries. “I can tell you the first time I escalated a patient’s dose as a very young nurse, I went home thinking that I had basically killed the patient.” That’s something that everybody struggles with—the first time, the second time, every time.
But in territories where Aquinas won’t tread, and where Sykes and Thorns haven’t conducted experiments, there is a solution to be found if you’re looking with the light of common sense. “Is it more humane to let them suffer?” asked Erin, “or is it more humane to treat their symptoms?”
The no-nonsense answer to the question was, “After 20-something years of being a nurse, I think I feel more comfortable knowing someone was more comfortable.”
Sometimes, that’s all you need.