Name that Pain

I work in palliative care, and I find myself overwhelmed today by feelings of inadequacy and guilt after I was unable to help a patient in pain. Yet she will not follow any advice. Then she howls. She screams. And she wails. Like a banshee. A living ghost. It haunts me as I sit in the office trying to write up her notes.

She could have had radiotherapy. She could have had a nerve block. She is on an awful lot of medication. And yet all she wants is to be held, for someone - and that someone today has been me - to hold her hand, to rub her back, to be there. When I stop, sure enough the howling starts again. Unfortunately I have other patients to attend to, some of whom have tried to step in and take over when I leave her. She is exhausted. I too am totally spent.

We are the same age. When she is calm she asks me about my life. She cannot accept that she is dying. She mourns the loss of her future - the partner she never met, the children she never had, the home she never lived in, the career she never pursued. 

Exactly a whole century ago back in 1917 Freud describes in his paper "Mourning and Melancholia" two reactions to loss: mourning, where the object of loss is clear and can be psychologically and emotionally processed, and melancholia where the loss cannot be named. A dark shadowy loss that is looming incomprehensibly and unjustifiably in the dark recesses of the mind.

I asked a colleague for advice on where to go next with a patient who has declined every intervention on offer. This is a pain that won't go away, he said. All you can do is be there whenever you can be there, and stop trying to fix everything. For tonight all I can do is try to turn my melancholia into good old fashioned mourning and get a decent nights' sleep..