Should You Titrate?

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

The word titrate sounds like a poorly-named household cleaning product.

Until working in hospice, and hanging around nurses and physicians, I don’t recall hearing or using titrate in a sentence. It might have been mentioned on shows like House, Chicago Med or Grey’s Anatomy, but I was probably more fascinated by the shenanigans in the supply closet between two doctors in lust.

With no medical or chemistry background, I have excellent 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 ignorance is one of my dominate genes, I’m equally curious about nearly everything! I own bunches of dictionaries and thesauruses! I can search the web! I can talk to a nurse!

I eventually did ask 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. A friendly hospice 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 weary 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 is 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 then started wondering about how 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, blurting out our announcement, hoping the one who hears can tread the emotional water long enough to comprehend what we’ve shared?

For a patient in hospice, there is no tomorrow. Which is not true, but it’s true enough! When I was a hospice chaplain, and my assigned patient or family had questions or concerns, I wouldn’t make an appointment with them to “take care of it” next week or next month. I would, as much as possible, respond “right now.” In or out of hospice care, people often 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. An awkward now is far better than a forever never.

But let me disagree with myself.

A number of years ago, I urged my mother to tell us kids about our parents’ 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 the family would soon gather at Thanksgiving—to do a little sharing during the holiday weekend.

And thus, while 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 lives. She was blunt about a few other things. All of this occurred long before dessert. Dad was nodding agreement . . . I think?

Swell Thanksgiving. Thanks, Mom.

I’ll bet my sisters remember that Thanksgiving differently. It probably wasn’t as dramatic as my description (except for the yams). Nonetheless, 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—Mom could be candid—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 phone 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 medications, 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. Oh my, Larry! This is one of your reflections where I relaxed and laughed all the way through. This was just right. I’m used to seeing your name and thinking of LaVonne and Sam and I can feel myself tighten a bit. It’s been less lately. I think I have spilled my guts on every subject there is to do so regarding hospice.

    This was a comfortable, wonderful piece that made me feel – wait a minute – it made me recognize that I really am on the way to becoming whole again. Not the same whole. It was different after Sam died and now it’s different after LaVonne died. I’m sure each death brings a whole (no pun intended) new way of being. So, thanks, Larry.

    You are a good pastor. You’re the kind of pastor I wish each of my kids had in all the various states from coast to coast in which they live. You’re the kind of pastor I wish was a friend close enough so we could go and get a cup of coffee and talk about those who were lusting in the closet. You’re that and so much more. I hope everyone who is close to you geographically takes advantage and has laughs, coffee, tears, hugs and good times together.

    Cyberlly yours,

    pat

  2. This is wonderful. Fits many aspects of life. Learned a new word. My mom was candid, also. Always one to jump into the fire! My ability to be candid was tempered by my training as a teacher at conferences, where I used the “hamburger” approach…tell something good, then something concerning, then something good:) Thank you for reminding me that sometimes you can wait too long to have those important talks or to share serious feelings. Like telling you thank for your daily positive, humorous, and intellectually stimulating affect on my life 🙂

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