This patient was supposed to be cured. But the cancer came back, setting up residence in her spine and reminding her with each step that it had returned. Like many patients, she thought taking pain medication was surrendering to the cancer. So she resisted taking anything, certain on some level that this meant her cancer was not as bad as it really was.
She needed the meds, however. If she wanted to do anything more than stay on her couch while she hoped the pain lessened, or even to come in for XRT, she needed pain meds. But she refused. Convincing her wasn’t going to be easy. She had her “reasons”—that was what she told me. I wanted to tell her that cancer pain didn’t listen to reasons, it listened to medication, but I knew I needed a different approach for her. First, though, I needed to hear her reasons. She needed me to hear them.
“Vicodin makes me loopy.”
“Okay, no Vicodin,” I said.
“Morphine made me sick.”
“Tell me what happened when you took it.”
I listened, actively listened, knowing how vital listening is to good communication. I nodded my head—not dismissively, but as a way of letting her know I was engaged. We couldn’t move on to what medications might work until I heard what hadn’t worked. It would be easier if I could skip to the chase, interrupt her, and tell her why the morphine she took before would have been fine if she hadn’t already been nauseated. I could interrupt and tell her how we could manage the side effects, like constipation, if we addressed those issues up front instead of waiting until she was backed up for 4 days and uncomfortable. But I waited to say those things, waited until she had a chance to tell her story. I couldn’t edit the story if I didn’t hear it first.
Her “reasons” included her family situation. She had kids in high school. She didn’t want them to see her in pain, but she also didn’t want them to see her “hooked” on pain meds. She didn’t think there was a middle ground.
“Okay,” I said. “This will be tricky, but we can do it.” She needed me to validate that her struggle was legitimate. It was.
THE STRATEGY: USING METAPHOR
I like to use metaphors to teach patients. From the standpoint of learning theories, the use of metaphor is closely aligned with the constructivist theory of learning, the idea of taking past experiences and building onto them to understand new experiences. I tell my patients that I use metaphors as a way of making sense of things in a new situation.
There were two metaphors I used for this patient. The first one I call choosing the right jacket. “Your kids want to play outside in the snow. You open their closet, and inside are three choices. One is a flannel shirt, one is a lightweight jacket, and the third is a wool coat. Which one do you think you would choose?” Almost everyone I ask this question of tells me that, of course, they will pick the warm coat. Helping her to understand what was appropriate for the situation was important. I made the metaphor about something she understood, deliberately making it about her children, hoping she could then apply it to her situation: This is what I would do for my children; this is what I should do for myself. Taking the right dose and strength of a pain medication was like picking the right jacket.
The second metaphor was the one I call the Goldilocks metaphor. In the fairy tale, Goldilocks went to the house of the three bears. She tried the bowls of porridge. One was too hot, one was too cold, one was just right. She tried out the different beds. One was too soft, one was too hard, one was just right. I told my patient that managing her pain with pain meds was like being Goldilocks. Sometimes we had to try different things to get to what was “just right.” This metaphor let her know there were different things to try, that we were seeking a personalized approach, and that we’d keep trying to get it right.
My message was that we wanted to find the medication that was appropriate for her, that would make her as functional as possible, and adding the Goldilocks story let her know we might have to adjust and change our strategies. So often patients tell me that a certain medication did not work for them, yet with a little discussion, I find out that the “reason” it didn’t work was because they took it the wrong way, didn’t take enough of it, or didn’t know how to manage some of the side effects it produced. Overcoming this type of preset notion provides an additional challenge.
I would have preferred to treat this patient’s pain more aggressively, but she needed time to process the information I presented. She agreed to 1,000 mg of acetaminophen every 6 hours as a first step to managing her pain. She reassured me by saying, “I’ll feel better starting with the light jacket.” I knew then that at least she understood my point. With the likely progression of her disease, there would be time to revisit this issue. I have other metaphors to roll out for her. Other medication strategies to try. We’ll keep on trying together, trying to get it just right. Goldilocks would be pleased. ONA
Ann Brady is Symptom Management Care Coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.