Helping someone in depression over metastatic cancer

Miscellaneous and Personal Stuff I Must Share
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I don’t post a great deal, but in my lurking, I’ve been impressed with the clearheadedness of the advice Dopers can give in really difficult situations. I hope I can benefit from some of that.

My now 80-year-old father-in-law got a prostate cancer diagnosis nearly twenty years ago. After the initial treatment, the cancer recurred about ten years ago, and was controlled with Lupron (the “chemical castration” drug). This worked, but it took a lot out of him. I’ve known him for about eight years, and he’s always been pessimistic, depressive seeming, even Eeyor-like. I’m told he’d always been a bit this way, but things got worse.

This summer, the cancer recurred again, this time with metastases to the bone, including the spine. The prognosis is not good, but the metastases are causing only controllable pain right now. He’s had radiation treatment to slow the metastases’ growth. This, or the cancer, or both, has made him too weak to get out of bed without a lot of assistance. Given the layout of his home and my MIL’s strength, he’s ended up in a nursing home–a very nice one, but a nursing home none the less.

If any one has reason to be depressed, he’s such a person. Well, he’s depressed. It’s not just that he says that he wants to die–that makes sense to me. It’s that he has no interest in being taken outside or anything else that seems as though it would make for a diversion. He mostly doesn’t answer his phone. I’ve spent time before with people in somewhat similar situations, and he’s definitely in the grimmest mood of anyone that I’ve encountered.

Because of my particular academic background, I’ve spent quite a bit of time thinking about personal autonomy in health care. I have all sorts of good intentions in the abstract. I haven’t a clue what to do for him or even how to talk to him. I’ve figured out some ways to be helpful to my mother-in-law, although we live about three hours drive away. With him, I can distract him a bit when I’m there, but I find I don’t know how to talk to him when he raises life-and-death issues, which he does regularly.

Any suggestions or resources? Neither my husband or I are much good at this. I’d note that we’re both non-religious as is he, although his family is fairly well tied to the local Jewish community. Any ideas will be gratefully received. I can only check in here in the evening during the workweek, so responses may be a bit slow.

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I’ve heard that hospice can be very good for terminal patients. I don’t know how different a nursing home is from hospice, but I’d start there. The other thing I’d want him to have is talk therapy or a support group. I don’t think it’s reasonable to expect him to not be depressed in his circumstance. Good luck though, and bless you for wanting to help him.

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You know it would be odd not to be depressed under his circumstances…

It’s hard to deal with this. He’s got real reasons to be angry, grumpy, upset, and yes, depressed and in despair. I think (personal opinion, may be wrong, all the usual disclaimers) that the best scenario is for him to find a way to deal with the issues so he gets the most out of his remaining time.

How do you do that? I don’t know. I don’t know this person. I mean, I might ask him if he has any unfinished business, anything he wants to see or do before he becomes too debilitated to do anything at all. Maybe he wants to have a shot of whiskey every night before bed. Maybe he wants to go watch a stripper. I don’t know - there are a number of things that are possible to arrange even if moving him around is difficult and/or inconvenient.

Being in a hospice situation might facilitate this to some degree - they might be more open to letting the old bastard have his nightcap, for instance, than the typical nursing home. The emphasis there is on patient comfort and wishes more than strict medical schedules and rules though, obviously, there are limits.

But the simple fact is that there may come a time when he just wants to be left alone. I saw that with my mother’s final weeks. She really just wanted to sleep a lot in a quiet, dark room. When she called and asked for something we provided it to the best of our abilities, but really, at a certain point a person might just give up struggling. Sometimes that’s harder for the healthy to come to terms with than the sick. It sounds like your FIL has been struggling for years with cancer and he just may be tired of fighting. In which case do what you can to keep him comfortable and let him be grumpy. I know that’s not a satisfying answer but sometimes it’s the best you can do. By all means, exhaust other options first, just be aware that that can be an outcome.

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That’s not too surprising given what you’ve described. He’s gone through a lot of shit because of this cancer and now it’s killing him. The posters recommending hospice care are right. They may be able to help him manage his pain, and if that gets under control his mood could improve. They might also suggest antidepressants.

If I had to wager, I’d say that you’re trying too hard. I think that’s the natural impulse in a situation like this. When you’re around someone who is depressed and sick, you don’t want to do or say anything that will remind them what condition they’re in (as if they don’t know) or that will make them feel bad. I think this causes people to walk on eggshells and it makes everybody uncomfortable. Maybe you can just listen. If he brings up a life or death issue about medical care, ask him what he wants. Talk to him about whatever comes to mind and don’t assume that he’s not interested in what is going on with you.

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I agree that the Hospice people would be the best people to help him with this. If they aren’t already involved in his care they should be. Just to make sure it’s clear though, hospice isn’t a “place” (though there are facilities that focus on providing hospice care). Hospice is just the name for a philosophy of care and many people receive hospice care in their own home or at a nursing home.

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Thanks, all. I thought hospice would be a good option, but it turns out that there are a couple of catches, albeit maybe ones that have solutions. The first is that he’s still being treated; that disqualifies him from hospice. This is actually quite stupid, since the treatment is simply palliative. It’s intended more as pain control than anything else. Nevertheless, those are the rules we’re stuck with. It may be that this will not be a problem now that the recent round of radiation is complete. I don’t think anyone is recommending more of anything like that.

The other problem may not exist–maybe someone knows more. While FIL was getting radiation, it was impossible for him to stay at home because MIL and neighbors combined had no good way of getting him into a wheelchair and out the door. Would home hospice care be a good source of the resources to care for someone who’s mostly bedridden but who is not in his last weeks? FIL is very clear that he wants to be at home. I would too. The thing that worries me is that some set ups would put too much of a burden on MIL. She’s doing well, all considered. She’s not young, though, and her energy is finite.

Does anyone have any experience with responding to someone in this sort of situation explicitly saying that s/he wants to die? It’s obviously very different from a healthy person expressing suicidal feelings, although I find it a little hard to not react as if it were. I suppose it would be helpful to know specifically what is intolerable, but I think he’s said it: he doesn’t like the nursing home and he can’t stand being as weak as he is. I can’t think of any response other than agreeing that the situation sucks. I’ve pretty much said that, and it’s not particularly helpful.

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Maybe there’s someone else or another agency you can talk to? That doesn’t sound like something that should disqualify him from hospice care at all, but different groups may have their own policies.

It should be.

Not directly. It’s hard to think of anything to say to something like that. But it could improve if his living situation and his pain are handled.

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I don’t have a lot of experience with that sort of situation, but I think it’s important to acknowledge the reality of the situation. His situation really does suck (you might want to use a different word choice). I think I’d acknowledge that yes, he’s got real reason to be in the state of mind he’s in, but meanwhile, can we do anything to make anything at all better for him?

Given his state, I’m guessing he might feel very out of control. Asking him what he wants, what he’d like, what he’s willing to put up with and what he really wants changed (if at all possible) might help him feel a little more in control. If he wants to go home that might be possible but it will take time to arrange.

If you’re discussing hospice and his mind is clear be sure to include him in the discussions. If he’s mentally capable he should be included in plans and decisions regarding his future even if physically he’s largely helpless. If he truly is at a point he wants to give up the fight then he can refuse medical treatment. That is his right - he is allowed to refuse ANY medical treatment. At that point, it may open the door to hospice and palliative care. However, it is his right to know the full consequences of any course he takes. This is mighty serious stuff you’re looking at. If he goes to hospice the focus will then be on making him comfortable, including sending him home with support if that is possible. It may also still include things like radiation treatments IF they genuinely help alleviate his symptoms. When my father in law was in hospice he had, if I recall, a couple surgeries to ease pain and disability from his cancer, the distinction being that they were performed to alleviate pain, not with any hope or goal of curing his disease. My mother was entirely bedridden her final month, hospice helped us care for her, and she avoided bedsores and other horrors entirely. It did take a lot of work from the family, but it wasn’t so much physical (and we had aides to help with the portions where that actually necessary) as having to get up frequently during the night and so froth. And the emotional toll. In some ways that was harder than the interrupted sleep and errand running.

My mother-in-law also took care of my father-in-aw during his final days with terminal cancer. He, too, died at home as he wanted. Pain control was more difficult for him than for my mother (mom didn’t have cancer - cancer really can be a nasty thing). He had bone cancer, and at the end it took about four people to turn him without breaking any bones. Again, between family and the hospice sufficient help was there to help with the physical stuff. It can’ be done, but don’t let anyone think it will be easy and you will need cooperation.

Good luck. I know this isn’t easy. Don’t forget to make sure the caregivers also take care of themselves. If you don’t take care of yourself you can’t take care of anyone else.

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My FIL’s an MD, so he’s involved in the medical choices a way that’s a bit unusual. The bad part of this is that I think he’s remembering every bad cancer death he ever saw. Because of his career path, most of his hospital experience was in the 1960s; pain control seems to be quite a bit better now.

I’ve had a couple of family friends die of brain cancer in the last three years. Although I was not involved in either of those people’s care, I saw enough of them to have a strong impression that the negative emotions they went through were distinct from what I recognize as depression. Both of those people were in pretty good emotional health at the time of their diagnoses as best I could tell. My father-in-law, by contrast. may well have been depressed even before the recurrence. I thought that he was. (The drug he was taking surely didn’t help. It’s a known drag on mood.) The recurrence, as you might expect, did not make things better.

You may have run into those studies that suggest that people suffering from depression are actually more accurate in their assessments of themselves and of likely outcomes than are those without. I think that I may see a bit of that at work here–although, as I said, I do think that my father in law is focused on the very worst possible outcomes. I’m wondering if it would be helpful to try to address the bad outcomes. If he’s imagining excruciating pain to come. maybe, particularly since he’s an MD, trying to get a pain management/palliative care person to talk to him about what can be done for pain that he is predicting that he’ll experience would help at all.

Let me note something on the dilemma of choosing between hospice and continued treatment. It’s a known and much-discussed problem with hospice care in the U.S. About five years ago, I thought I might want an L.L.M. in health law, and did a fair bit of the associated course work, including taking a class in Medicare law. One of the big discussions was the rigidity of the regulations for hospice care. In order for a patient to get hospice care under Medicare, he or she has to give up curative treatment and accept only palliative care. This sounds as if it’s just a definition of the nature of hospice programs. The flaw is an assumption about what is palliative. There was a time when radiation and–especially–chemotherapy were so unpleasant that no sane person would undergo them without some hope of cure or remission. That’s not always true now. However, the regulations don’t reflect that change, and Medicare is so much by far the main payer for hospice care that hospice rules reflect Medicare rules.

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(Double post)

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First, my sympathies. This is a very difficult situation for all of you. Second, listen to him. Just let him talk as much as he will. Let him, as far as you are able, say anything to you. If not you, someone. Get him the best pain control possible, as that will improve his quality of life more than anything, and reassure him that he won’t die in pain.

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He is lucky to have you. Make an appointment with Hospice so he can be reassured that his death will not be painful. Fighting incurable cancer is painful. Letting nature take it’s course along with comfort measures is the way to go. I have seen it a few times and the family is present and it is quick. You are right. pain measures have come a long way in recent years. I have been present for a couple Hospice deaths and there was no pain. It was much easier on the patient and the family.

If I get cancer and my chances are not good I’m going to go with Hospice. I am also going to enjoy every moment I have left. I have a living will and only comfort measures. It’s no different then having a baby naturally or having a spinal block. The outcome is the same but you choose whether or not to feel the pain.

My friends husband recently died from Pancreatic cancer. When she first told me I said take a vacation. He opted to fight it and instead of three months he lived 5 months and put his family through hell. It wasn’t a happy death and my friend looks like hell. The odd thing is her husband had just retired as a minister. Sometimes I think seeing so much death may make a person afraid. They say doctors make the worst patients also.

I’d let Hospice help him to find acceptance and know that it won’t be painful.