Alto — I think you know how deeply I respect and admire your journey.
Vince Fulco

Thanks for the comment and the question Vincent Fulco. It’s an excellent one, and certainly one that I have struggled with. How do I know David was pain free? Ultimately, I don’t, and unfortunately I never will. But there are a few reasons I strongly think that David’s death was pain free.

My level of confidence in those feelings are no doubt strengthened by my history in the medical field. In my days before I transitioned to flight medicine, one of the paramedic teams I was part of was the home hospice team, where an oncology nurse and a critical care paramedic would be dispatched to terminal patients who were cared for at home, so as to avoid unnecessary transfer to hospital. Because of that experience I became intimately familiar with the medical interventions we use to achieve pain cessation in palliative patients. As you more than likely saw with your wife, there are certain objective, clinical signs that you notice when effective pain relief is achieved. Decreased agitation, ability to focus (if not sedated), decreased pulse and respiration. So that’s one way to know.

Then there’s the subjective. I imagine over time and after getting to know and experience more about your wife’s specific pain events, you probably also had that somewhat subjective sense of knowing when whatever you were doing or treating her with worked, or was not helping. Nothing really specific, just a sense.

With David, my other assurance that his pain was relieved, and if not fully relieved then well managed, was the level of effective sedation. Close to the end he was on a high dose of both opiates and a benzodiazapine. A strategic combination of rapid, normal, and sustained release delivery methods ensured that even between doses, when the relief might have been light, the sedation ensured that his awareness of the pain was minimal. Obviously, with any kind of pain management, there is a trade off. With David, he was sedated often, thus decreasing our interactive time. But really, that was a small concession to make given the quality of relief he was getting.

From reading all you have written Vincent, and from my background in this field, I can say with a high level of confidence, you did everything you could, and I believe your wife was in minimal pain. But more importantly, you were there with her, present in every way you could be. That in itself, I think is a form of pain relief.

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