by Andrew Thurston
Ms. S.T. is a 26-year-old woman with metastatic colorectal carcinoma who is admitted to the hospital with worsening abdominal pain. Imaging of the abdomen and pelvis demonstrates further progression of her cancer despite second line palliative chemotherapy. In addition to abdominal pain, she reports decreased appetite and nausea. No family is at bedside.
Despite aggressive titration of IV dilaudid via a PCA, she continues to report excruciating pain and frequently asks the nurses for higher doses of opioids. On evaluation, she spends the first few minutes describing her pain in great detail, but the subject quickly changes to other forms of distress. She spends a lot of time talking about her fear of dying, about how her cancer has taken over her life. She describes her dream to be the first person in her family to graduate from college, and her hopes to provide a better life for her family. She speaks passionately of her desire to help others, and her distress at not being able to help herself. She is angry at her cancer, at her doctors for not catching it sooner, and at God for “abandoning” her. Her parents are deeply religious and tell her that “things are in God’s hands,” but hearing this only makes her more upset. When discussing her concerns and general distress, her pain seems to fade into the background, and she only pushes her PCA once in the hour visit.