PALL CARE

high level of nurse expertise in pain and symptom management to markedly improve end-of-life quality: She needed to be on TPN because they still hoped she would be getting better and that her fistula would heal. She had a lot of shortness of breath and rales. She had edema from head to toe. Her legs were like planks. They were doing periodic paracentesis for the ascites. It was obvious to me that she was getting too much fluid. So, I called the doctor and we reduced the dextrose and lipids and the total volume she received. She lost 15 pounds in a week and a half, and her lungs cleared. This man had been on increasing doses of MS Contin and was on sublingual morphine for breakthrough pain and finding no relief from an intractable left shoulder pain that appeared to me to be likely due to bony mets. He also had a nerve component with sharp, shooting pain that went down his fingertips, and at times left him without function of his left side. It incapacitated him completely, left him grumpy and distanced from his family. We started him on Trilisate 750 mg every 12 hours. We use Trilisate as our NSAID for pain because it doesn’t affect platelet aggregation. Twenty-four hours after starting the Trilisate, he was having side  effects from the morphine: somnolence, constricted pupils, respiratory depression. So we backed off on the morphine and let the Trilisate work. He remained comfortable for several weeks until he started having sharp, shooting pains. We put him on Tegretol, and he started getting out of bed. This man had been in bed for months