I’ve felt like I had a logical understanding of morphine use in Malawi for some time now. I’ve spent the better part of four weeks working in palliative care at St. Gabe’s, so I have the logistics down pat. The need for a software to track morphine use appeared pretty clear after reading last year’s intern blogs almost religiously. I’ve even watched patients get started down the path of palliative care while shadowing. As far as I was concerned, the need for morphine tracking software could be explained in about three sentences:
Problems like chronic heart failure, cancer, stroke, and advanced AIDS can’t really be treated in Malawi. As a result, patients who have these chronic conditions often enter hospice for pain management (1), (2). Morphine, the strongest pain management tool in the palliative care arsenal, is strictly regulated and hard to procure (3), so keeping accurate records is important to ensuring that patients receive their medication without interruption.
Simple as that. To quote my man David Bowie, “Wham, bam, thank you, ma’am”.
Until today.
We accompanied Alex, the palliative care nurse, on home based care visits today. When we came to the first patient, I had to stoop to enter the low doorway of the brick hut. Inside, the rooms were mostly bare. The focal point immediately became the low mat, the pile of blankets tucked in the corner. Everything was still, quiet except for the guardian’s murmured greetings. Once the community health volunteers had settled in, I could hear low moans coming from the pile of cloths. The guardian, a stoic woman of late middle age, gingerly sat on the corner of the mat and began to answer our questions.
The patient, age 42, was suffering from HIV and late-stage anal cancer, the latter of which had manifested as large pus-filled lesions. As the volunteers closed around the bed, I realized that my initial assumptions that the bed was just covered with rags were understandable. She couldn’t have weighed more than 70 lbs. Dull skin was pulled taut, enough that every bone in the woman’s body appeared visible. Each joint seemed ready to snap as she was positioned for examination. Every movement was accompanied by low, antagonizing groans. Even the act of being repositioned into a seated posture caused her to nearly pass out from the pain.
I have never in my life seen anyone look that frail, that utterly breakable.
It was decided that the woman’s morphine dose should be doubled. The guardian’s mental wellbeing was assessed, and then the visit concluded with a word of prayer with the patient.
After visiting this patient, I understand the emotional and spiritual implications of morphine treatment. Tracking morphine stocks isn’t just the difference between having a medication and going without. Because although I can dream that this woman’s quality of life will improve with an increased morphine dose, I cannot even begin to imagine what she would be reduced to without any morphine at all.
Palliative care will never be sexy. It doesn’t present the adventure of surgery or the warm fuzziness of paeds. But for the patient I saw today, morphine is a concrete realization of comfort and peace in her final days.
**Side note: I had no intention of writing this blog post. I actually had another one written and cued up and everything. But after today, this is what came out, so this is what you get. I hope it means something.
(1). http://www.ncbi.nlm.nih.gov/pubmed/23561750
(2). Read the context on pages 6-9:
(3). Read the section on drug access: http://www.africa-health.com/articles/july_2011/P_care_overview.pdf