To Titrate or Not to Titrate?
Titration is necessary for many medicines in hospice care, but what about the words we need to share?
Titrate sounds like a poorly-named laundry detergent.
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 Grey’s Anatomy, but I focused more on the shenanigans in the supply closet between two doctors in lust.
With no medical background, I have darn good excuses for my ignorance.
In the patient care meetings I once attended, when a nurse asked a doctor about titrating the new medication for a patient, I kept a straight face. Maybe I’d give a brief neutral nod, and then hoped there wouldn’t be a pop 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 ask a nurse!
I eventually asked a nurse. Talking to a nice person is far better than aiming the dusty magnifying glass at the tiny print in my Compact Edition of the Oxford English Dictionary. 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.
Everyone is unique. Finding the best dosage for a 250-pound guy in his sixties 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 health care, 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 discuss it next week or month. I would try to 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 well-meaning physicians told someone they had a few weeks or months to live, but the projected weeks became days, the 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.
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.
Maybe my sisters remember that Thanksgiving differently. 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 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 clever ways to procrastinate.
One of the phrases I used in the follow-up bereavement phone calls to families after a death was: 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 figured out a better time, and the conversation did 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.
My book, A Companion for the Hospice Journey, is available at Amazon.