He's gone

Calmer nights, busier days

"Turn that off. I don't think I can handle this and Barbra Streisand." BR's mother, Dede had arrived with tears in her eyes, followed by her sister, Beth.

BR has slept peacefully now for two nights in a row. At the first sign of restlessness, I have been calling the nurse for breakthrough pain medication, but I've only had to call once at night. I'm very happy with the progress keeping his pain down.

We are now in full visitor mode here at Christopher House. In addition to Dede and Beth, our neighbors Cindy, Damaris, and Suzy have made and delivered dinners. BR's brother John, niece Chandler, and John's associate pastor Todd drove down from Keller for the day. Scot, Cathy, and Sharon are here from Dallas. Chad and David have flown in from Colorado, and Jay from Miami. Their presence is a great comfort. There's nothing like laughing with family and friends to take the edge off.

BR was awake, but not totally alert for most of the day yesterday. Most of what he says is unintelligible, and we treasure the moments when he is able to clearly express his feelings. For example, when I told him Jay was coming, he let out a long "oooh, Lord!"

Yesterday morning, it looked as if BR was down to his last hours. His heart was racing. His blood pressure was very low. His hands, feet, knees and elbows were purple and splotchy. After a full day of company, his vitals stabilized. I'm guessing that he refuses to be left out of a good party.

The doctors added IV Ketamine to BR's pain med cocktail. Yes, Bob Duff -- BR is now mainlining Special K. And it seems to be working. There was no restlessness at all last night, and he woke up this morning asking for "happy coffee." Nevermind that he doesn't drink coffee. I'm trying hard not to get my hopes up, and instead I am just living in the present and letting the future take care of itself.

I need to wrap this up, but not before thanking Herrad, Richie, Anne, Stephany, and Patrick, for rallying the MS blogging world to our support. It's a strange and marvelous community, and I'm glad to be a part of it.

And finally, I've set up an online gallery for people to share their favorite photos of BR. If you have some to share, just go to http://gallery.me.com/bobrobertmckellar/100173, and click the "Upload" button in the toolbar.

Another rough night

BR didn't sleep well at all last night. In addition to moaning and yelling, he started forming sentences. "Honey, please help me" was repeated for six hours straight. Unfortunately, this was a monologue, and I couldn't get him to give me any instructions on what needed fixing. So I continued with the Ativan until morning.

Then around 9am, I asked him how he was doing, and he responded, "my legs and feet are killing me." I pushed my luck and offered him some water through a straw, which he eagerly drank. Not knowing how long this swallowing opportunity would remain, I quickly gave him his oral meds hoping they would reduce his leg pain. Before long, he was finally sleeping.

I called the hospice nurse to ask for more help keeping him comfortable. He called the doctor and they recommended checking BR into Christopher House for in-patient pain management. BR is now comfortable in a private room -- one that has that has Willie Nelson as its generous benefactor.

Rough night

BR hasn't regained consciousness since 8pm last night. He was moaning and yelling off and on most of the night, but since I couldn't get him to swallow anything, there wasn't much I could do. When the hospice nurse came out this morning, she told me to give him the methadone rectally, and to dissolve his Ativan in 1/2 cc of water, then use a medicine syringe to put it between his lower lip and gum. He's now resting comfortably again.

The hospice doctor offered two options: admit him into a hospital for a full battery of tests and treatment, or keep him at home and comfortable. I chose the latter -- it's what he wants. We will continue with the IV antibiotics, and the next 24-48 hours will be make or break.

Light a candle and say a prayer for him, please.

His worst pain

BR is hurting something awful today. When the hospice nurse came out this morning to check on him, he was running a low grade fever and sweating profusely. Despite drinking quite a bit of water, he's not putting out much urine, and what's there is turning brown. Also, like two years ago when he had the abscess in his mouth, he is beginning to struggle to comprehend his surroundings, and he is repeating even the most simple of thoughts dozens of times.

The urine culture taken earlier this week showed only the colonized bacteria, not anything growing out of control. His lungs are clear. His skin isn't yellow. So where on earth is this infection hiding? The doctor has decided to take the "big hammer" approach and start IV antibiotics this evening -- twice a day for 10 days. Since hospice is administering them, he will be allowed to remain at home. Nothing drives home the fact that BR is really sick like 20 IV balls in the fridge.



The PICC line nurse just left after an 80 minute procedure to insert the IV catheter. He also got a peripheral IV line, which will be used until an X-ray can confirm the catheter placement. She also taught me how to flush the catheter -- really pretty easy. The hospice nurse should be here any minute to draw blood and start the first antibiotic ball.

We now return you to your regularly scheduled blog ...

When we last left you, BR had entered hospice in an effort to bring his pain levels down. The hospice doctors had taken him off Fentanyl and put him on Methadone, with a modest reduction in pain.

Over the last two months, we have been gradually increasing the Methadone, but aren't seeing further benefits. I'm sure the next steps will include trying a different medication, and we've asked the doctors to start looking into alternatives.

BR's skin sensitivity is really hurting him. This is usually a sign of an infection, but I'm at a loss as to where. He just finished a suite of Levaquin to clear a Cipro resistant UTI. After reading up on Levaquin, it seems an odd antibiotic choice given the potential negative affects it can have on BR's already compromised central nervous system.

At the peak of the UTI, he was passing blood clots in his urine. Pretty frightening at first, but some online research shows it to be a fairly common occurrence among long term suprapubic catheter users. Once the UTI cleared, the clots stopped.

So the increased skin sensitivity remains a mystery. I'm going to start monitoring his body temperature today. Without a secondary sign of infection, like a temperature or cloudy urine, we have to treat the sensitivity as yet another mysterious and disabling MS symptom.

I feel bad saying this, but I've been feeling disappointed in hospice. I heard from so many people that they would swoop in and take care of everything, but that just hasn't been the case. BR's biggest needs are prescription maintenance and counseling. Before hospice, I was able to refill his non-triplicate prescriptions 24/7 at the local Walgreens. Hospice requires 24 hours notice, the refill requests must go through the case manager who isn't always available, and the pharmacy is only open M-F 8-5. Given how easy it is to predict when BR will run out of a refill, I asked the case manager to put a reminder in their computer to automatically order refills, but that request was denied. Given that hospice refills in 2 week increments, the burden on me has more than doubled.

As for counseling, hospice provides chaplains. Now BR takes a while to warm up to a person before he opens up, and just as he was getting to that point, the chaplain fell ill. After three weeks of missed appointments, BR requested a replacement chaplain. I hope we get one soon.

So that's where we stand. Trying to ignore the pain. Trying to keep pushing for what we need. Trying to savor the moments of joy.

I wanna be sedated

BR's been under hospice care for a bit over a month now, with the primary goal of getting his pain under control. They took him off the Fentanyl patches and percocet, and put him on Methadone and liquid morphine. Initial indicators were good. The pain immediately changed to something more tolerable, but still painful -- 4-6 instead of 7-8 on the pain scale. Since then, they have been gradually increasing the methadone, and he's now consistently a 4-5. With the last increase, though, sedation has started to rear its ugly head. He slept for a large part of the day yesterday. We'll have to wait and see where this new dosage settles, but there's a good chance we won't be able to increase again without compromising his ability to take his other oral medications on schedule.

When he is awake, though, he's in a much better frame of mind. And for that, I'm thankful.

Geaux Saints!

The Hospice Austin team officially took over BR's care on Wednesday. We met with his nurse and care coordinator that afternoon, and immediately replaced his Percocet with liquid Morphine for break-through pain. This brought about a small amount of pain relief, but not nearly enough to be called success.

Next, we met with the hospice doctor on Thursday, who decided to switch BR from Fentanyl patches to Methodone for sustained pain relief. We made the switch Friday, and again pain was knocked down another notch. So on average, BR is still in a great deal of pain, but feels better than before.

The Methodone has brought with it a bit more drowsiness, but not to the point where BR can't wake up and enjoy the day. It will be interesting to see what happens as the dosage is increased.

My niece, Jordan, has rejoined us as of Sunday to help out once again with the daily caregiving duties. It wasn't a moment too soon, as I had somehow thrown out my lower back while making groceries Saturday evening. Luckily, BR was already in bed, so the next transfer wasn't going to be until Sunday for the morning routine. Maybe I would feel better in the morning.

No such luck. When I woke up, my back was just as bad, if not worse than it was when I went to bed. So I convinced BR to delay the morning routine until Jordan arrived. And like an angel, arrive she did. She immediately took care of BR, then joined us as we watched the Saints advance to the Super Bowl. What a great evening!

Just breathe

I've had a cough since November. At first it was non-productive, but very annoying. By the end of the holidays, I'd developed full blown bronchitis. Combined with my annual cedar allergies, and I have only been capable of life's bare essentials for several weeks. A suite of antibiotics, Benedryl, and some codeine cough syrup later, and I'm back to the living.

We had a hospice assessment interview about a week ago. The intake nurse was as nice as nice can be, but she didn't hold out much hope for hospice. Based on what she'd seen, BR's prognosis didn't fall within the six month life expectancy. However, she did offer to have their palliative care doctor consult with the Which doctor on BR's pain management.

Oh, did I forget to tell you that we are staying with the Which doctor? After the Prialt trial failed in early December, we met with a new pain management doctor here in Austin that was recommended by MD Anderson. We were told that he would be open to helping BR through the transition to palliative care. Nothing could have been further from the truth. This doctor took one look at BR's medication list, and decided that he could not continue down that path. Being as open minded as we could, we asked what he recommended.

"You need to come off of these meds so we can see how much pain you are really in."

That didn't sound like much fun.

"What level of pain do you consider acceptable, Doctor?"

"So much of pain is how the mind perceives it. Consider if you won a million dollars in the lottery, and then I came up and hit you on the thumb with a hammer. You'd be pissed off with me, but you'd get over it. Now consider if you lost your ability to walk, and then I came up and hit you on the thumb with a hammer. You would likely fall into self pity that would only make the pain worse."

"Could you just not hit me on the thumb with a hammer?"

The whole time we were with the doctor, nurses and PAs were interrupting every five minutes or so to get his signature on different forms and prescriptions. After about 30 minutes, BR had had enough.

"Thank you for your time, Doctor. You obviously have more pressing things that need your attention."

As we left, the receptionist asked if we needed to make a follow-up appointment. "I don't know," I honestly responded. We now had a neurologist recommending hospice and palliative care, and a pain doctor wanting to take away all pain medications to see how painful it would be. My head was about to explode.

It takes about 30 minutes for us to drive home from the doctor's office. About 15 minutes into the drive, BR's cell phone rang. It was his neurologist. The pain doctor had called him to discuss BR's case. The neurologist basically laid it out like this: "You can either continue looking for alternate pain therapies that may or may not bring relief, or you can move on to palliative care. I will support either decision."

&$%$%&%^*#@%$^#!@#

When I look at BR, I can see how tired he is of all the pain. It's been over two years and he has only experienced relief a handful of times, most of which ended with him falling asleep for extended periods of time. Now, I'm no sadist. I'd rather he be comfortable and sleep a lot than spend the rest of his life in pain searching for a cure that may not exist at all.

Yet BR has been having a hard time choosing a course of treatment, even after some very helpful discussions with his family over the holidays. So far, he's agreed to have the hospice assessment, which, as I mentioned, took place last week. Well the call came this morning, and they want to start hospice services today. The reality of it all has me winding my butt and scratching my watch, as Truvy would say.

Is it time for hospice?

BR's neurologist seems to think so. He's going to arrange for an assessment.

Since we returned from Houston, BR has been sleeping long hours. He wakes in the late evening for what would normally be our morning routine. Medication that is normally spread out over 16 hours is condensed into 8. I've been getting to bed around 4am, and am exhausted.