In Hospice: Should You Titrate?

What does titrate mean?

What does titrate mean?

Until working in hospice, and hanging around nurses and doctors, I’d never knowingly heard or used titrate in a sentence.

With no medical or chemistry background, I have darn good excuses for my ignorance.

In a patient care meeting, when a nurse asked a doctor about titrating the new medication for a patient, I’d keep a straight face. I’d maybe give a brief neutral nod, and then hoped there wouldn’t be a snap quiz after the coffee break.

Fortunately, while ignorant of many things, I’m equally curious about nearly everything! I own bunches of dictionaries and thesauruses! I can search the web! I can ask a nurse!

I eventually asked a nurse. Talking to a nice person is far better than aiming the dusty magnifying glass at a page in my Compact Edition of the Oxford English Dictionary. The definitions are printed in fonts so tiny an eagle would struggle to read a sentence.

So a friendly RN told me that many drugs should be titrated whenever introduced or discontinued as part of a patient’s care. In other words, she explained with a kind smile, there should be a gradual increase or decrease in the dosage over a period of time.

Why?

Everyone is unique. Finding the best dosage for a 72-year old 200-pound guy with prostate cancer will be different than the same drug on a 90-something great-grandmother with arteriosclerosis who’s as thin as a knitting needle. In medicine, as in life, one size does not fit all. There are also medications that should be slowly reduced over a period of days and doses. Titrating down a drug will often be the safest way to discontinue its use.

I wonder about the ways we titrate information and feelings to others.

  • What is the best way to tell someone they have a life-limiting illness and should consider hospice care?
  • How do you apologize to a dying friend or family member for the anger or lies or misunderstandings that have damaged your relationship?
  • As a dying parent, how do you tell your young children that your time on this earth, and most especially your time with them, will soon end?

Does titration with our explanations apply to these situations? Should we slowly, carefully, incrementally tell another about our concerns? Or should we have a “sink or swim” attitude, plunging in with our announcement, hoping the one who hears can tread the emotional water long enough to comprehend what we’ve shared?

In medicine, as in life, one size does not fit all.

In medicine, as in life, one size does not fit all.

For a patient in hospice, there is no tomorrow. Which is not true, but it’s true enough. In or out of hospice care, people live with terminal illnesses for days, weeks, months, and much more. But especially in matters of the heart . . . why wait? I have known too many situations where thoughtful, honest physicians told someone they have 5 weeks or 5 months to live, but the projected weeks became days, the projected months became weeks, and time literally ran out.

Don’t titrate your loving, necessary, honest, forgiving, or confessional words to another. Tell me them now. Tell them right away.

But let me disagree with myself.

I recall strongly suggesting to my mother a number of years ago that she and Dad should tell us kids about their wishes regarding end-of-life decisions. Did they want to be kept alive by every effort possible? Did they want to be buried or cremated? I rattled off other examples of information and encouraged Mom—since Thanksgiving was near and the family would gather—to do a little sharing at the November holiday.

So, around the Thanksgiving table, carving turkey and passing a plate of yams, Mom announced she’d had a chat with me on that subject, and please don’t do anything to prolong their life. She was blunt about a few other things. All of this occurred long before dessert.

Swell Thanksgiving. Thanks, Mom.

I’ll bet my sisters remember it differently. And maybe it did happen differently, but in my memory, I sure wish Mom had, er, titrated her words a smidgen more. It would’ve been nice to talk after the pumpkin pie and ice cream!

However, as much as my memory brings a sad, sweet smile to my face—my Mom could be blunt—she was willing to share! In or out of hospice care, I hope everyone risks sharing rather than withholding our most important words.

I always struggle when a family decides not to tell their loved one they are dying. In some cases, they have reasonable reasons. They want to wait until everyone is present. They know their beloved hates to know the future, regardless of what that future may be. They fear someone will “give up” if told they have a terminal illness. There are many excuses, and many clever ways to procrastinate.

One of the phrases I use in bereavement calls to families after a death is: Is this a good time to talk? That phrase is titrating the goal of my contact with someone: if they have visitors, or they’re shopping, or (in one call I made) gambling at a casino, maybe now isn’t the best option. But then we figure out a better time, and the conversation does take place.

But please don’t assume you can carefully, incrementally build toward seeking forgiveness, or telling someone how dearly you love her or him, in the perfect future moment with the perfect future words. Perfect is too often shoved aside by interruptions, accidents, and emergencies.

With certain drugs, it’s critical to increase or decrease dosages over a period of time.

With the most essential words we have for our loved ones, titration may the worst “medicine.”

(Hospice vigorously protects a patient’s privacy. I’ll take care with how I share my experiences. Any names used are fictitious. Events are combined and/or summarized.)

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Comments

  1. Your comment about your mom’s blunt comments about her wishes at Thanksgiving made me giggle a little.
    My parents were both diagnosed with a serious illness within a month of each other and the first family holiday after their diagnosis was Thanksgiving. I knew they did not have anything in writing about their wishes so I asked her to put what she wanted on paper and give me a copy just in case. Thanksgiving arrived and I hosted at my mother’s insistence for the first time to pass on our family traditions. We were all gathered in my tiny kitchen, reaching over each other and past one another to get it all on the table and my mother, in a very loud voice in the middle of this chaos said, “Your father and I …” and she very carefully detailed what they did and did not want with respect to their care, and final arrangements. We all stopped what we were doing, dumbfounded and well trained enough to listen when she spoke like that. When she finished, my father, from the living room, in a loud calm voice took roll from each of us with: ‘Do you understand…( and our name)?’ He waited for an answer and moved on to the next person. When he was done, we put the meal on the table and sat down to eat. It was the quietest Thanksgiving we ever had. At the end of the meal and before dessert, my dear sweet son started to giggle, put his hands over his ears and while moving his hands away from his head, quietly said ‘Kaboom’. The subject never came up again.

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