Homeward

I've heard that it's the young deaths that kill you. JC was 17 years old, a native son of California. At 5 foot 9 inches and 210 lbs, he was a growing oak, with leaves green and vibrant from every angle, with the promise of mightiness. But in the towering shadows of outspread branches, a voracious beetle (chondrogenic osteosarcoma) was boring through the bark and into the concentric rings of the wood underneath. After undergoing a hemipelvectomy and assault by chemotherapy and then radiation, JC learned that the silent invader had proliferated and advanced into his femoral, sacral, and pelvic bones. We had taken care of him for two months. This included providing parenteral nutrition, and the usual care that would be expected to stay the effects of the well?you know?the thing that should not be named. He was treated until he was admitted for bacterial and fungal sepsis at a local Children's Hospital in June. When he returned to us in February, he was on hospice care for intractable pain. I knew it was the beginning of the end. His initial intravenous morphine 10?mg/h patient-controlled analgesia had escalated from 40?mg/hr to 80?mg/hr to 100?mg/hr to 300?mg/hr in just 10 days. He was completely bedridden and also on a dartboard of medications.? Although JC received temporary relief from multiple boluses and could find sleep in fleeting moments, the effects did not last for more than two to three hours at a time. He would wake up screaming, shaking, and jerking in excruciatingly sharp shooting pain emanating from his hip, pelvis, and back. His pain was aggravated by movement and quantified using the Visual Analog Scale as being 7/10 to 10/10 most of the time. The disease was silent no more. His mother sobbed on the phone, ?No mother should have to outlive her child and see so much pain.? It was so hard on her, a single mom trying to make ends meet. She was so exhausted down to her roots. JC was angry at the world and depressed in the moment. The puppy he had received as a birthday gift to welcome him home had just died of ?kennel cough.? She needed JC's grandmother to help with the caregiving. I remember her choked-up voice before she hung up, ?Please help me, please help us.? That was it, a simple plea for a not-so-simple situation. I called the hospice physician who was relieved to hear from me. She had JC's mother's permission to control his pain at any cost. Could we buy time with a trial of decreasing the morphine dosing, hoping for a possible opioid-i