Homeopathy and end of life care
A case
Timothy W. Fior, M.D., D.Ht
(Published in the Journal of the American Institute of Homeopathy Vol.93, No. 2, Autumn 1999.)
Abstract
Opiumin high potency was prescribed with excellent results for a seemingly moribund semicomatose diabetic elderly man with prostate cancer, severe constipation, and painless abdominal distension. The issues of potency selection, access to remedies, and the potential benefit of treating patients at the end of life are discussed.
Keywords
End of life care, Opium, diabetes mellitus, prostate cancer, potency
End of life care is being recognized as an increasingly vital component of health care. In order to be taken seriously in the modern health care arena, homeopathy must also address the issue of end of life care. The following case is presented as an illustration of what homeopathy can offer in this realm.
The Case
A 74 year old hispanic man, HM, was first brought to me by his wife on 2/11/98 due to a recent overall decline in his health and an acute problem with vomiting. His wife has a PhD, works for a large pharmaceutical company, and has used homeopathy for over 50 years. One of his daughters who has been one of his local caretakers is a family physician and, although treated homeopathically as a child, has no present interest in homeopathy.
HM was a retired baptist pastor whose medical problems included poorly controlled insulin dependent diabetes mellitus with hemorrhagic proliferative diabetic retinopathy requiring several laser surgeries (most recently in 1/98) and a rising prostate specific antigen level (8 and then 10.1 four months later, and then 12.6 in 2/98). Since the quickly rising PSA was highly suggestive of prostate cancer, the urologist recommended a prostate biopsy which the physician/daughter and his wife both refused due to his debilitation. Because of his rapidly deteriorating vision, he has becomed depressed for which he was given Paxil for 6 weeks beginning in 1/98 and was then switched to St. John's Wort 150 mg daily 1-2 weeks before seeing me. He used to paint and was in the process of editing a history fiction book he has written, but he can continue neither of these pursuits now due to the declining vision. He has always had a very rigorous schedule, starting the day at 4am with prayer, but now he is totally dependent on his wife even for the activities of daily living. He has been reserved his entire life, but now has become much more affectionate, hugging his wife and telling her she is so special. He was possessive of his wife and was quite anxious. He was focused within himself, and wouldn't talk unless spoken to. During the first visit he sat quietly for most of it, looking at his wife. He was frustrated because when he retired he had many projects to do, but now cannot complete them. He has had 4 TIAs and one completed stroke recently. His medications included: Humulin insulin N & R bid, Rezulin, Zantac 150 mg daily, St. John's Wort, and two herbal mixtures. His past medical history included an appendectomy in 1938, partial gastrectomy for stomach ulcer in 1953, and cholecystectomy for cholelithiasis in 1992. His family history is only positive for cancer in his father who lived to the age of 65.
He had loud eructations and a chief complaint of vomiting water at night which is better with Arsenicum album 30C. He was not sleeping well, waking after one hour to walk from room to room, burp and say, "aye, aye, aye". He slept while his wife was at work during the day on his right side in a fetal position totally covered with the window closed.
Although warmer when young, he is now very chilly and worse cold. He does not perspire, and needs sunglasses only if the sun is out with lots of snow on the ground. His hair was black till 2 months ago, and since then has been turning white. His energy level is only 10% of normal and is worse if he walks too much. His appetite is decreased. He craves fruit (3) and can eat 6-12 bananas a day. He also craves toasted bread (2), ham and cheese sandwiches, french fries, coffee with milk, and egg omelettes. He has always had an aversion to sugar. He is thirsty only for hot (3) coffee, which his wife is eliminating from his diet. He has daily bowel movements, and gets up to urinate frequently at night.
He called his backyard his "little garden of eden", and sat there and went into another world, contemplating and praying. When he was sick he didn't want to be alone. Although he had always been reserved, he was very affectionate with his four children. He was very careful with his ministry, and his desk had to be neat (2). His books all had to be straight (2). If even one book was out of alignment, he would put it back in place. He was fastidious (3) and his family called him "Mr. Lint". He didn't want to be touched or to get dirty. He liked to look tidy, and was proud and didn't want to appear to be sick. He refused to wear glasses despite his poor vision. When he was strong, he would get critical if he didn't like something right away. If he couldn't get his seatbelt on, he'd criticize the car or some other thing, but would never criticize people or his wife. If his wife touched him, he'd say "you're throwing me down!"
He was very sensitive to offending God or not serving God. He loved classical music, but did not like loud, modern music. His eyes were always tearing, and he wanted to wear a flannel shirt with a buttoned collar. He had no fears.
Emotional traumas in his life included when his first child was stillborn in Argentina. After that in 1962 he moved from Buenos Aires to the United States, and then had three girls and a son. He cried when he almost lost his son to a high fever. He cried easily and wouldn't let his wife leave his side at times, telling her he felt like a burden to her.
His examination was remarkable for a very quiet, respectful man who was very apologetic and looked at his wife throughout the interview. He was pale and pensive and had a mapped tongue and arcus senilis bilaterally. His nails were thick.
The initial prescription was for Arsenicum album 200 Dunham ii po in the office and then ii in a glass of water and to be sipped as needed for nausea and vomiting. He was to talk to the doctor managing his diabetes about the possibility of discontinuing Rezulin, as his weakness had started after starting this medication.
Analysis and course
The Arsenicum album prescription was based on the vomiting of water, affection, restlessness and anxiety at night driving him from place to place, his chilliness <cold, his desire for fruit and bread and warm drinks, his desire for company, and his fastidiousness and censoriousness.
He has a good palliative response with the Arsenicum album as it stopped his nausea and vomiting and it helped his anxiety but only for a few hours. He had to take the remedy frequently. He weaned off the Rezulin.
I continued to treat him over the next five months with only mild to moderate palliative results. Remedies used included Aurum metallicum 200 Dunham, Arnica montana 30C, Phosphorus 30C and 200C, Lycopodium clavatum 200C, Arsenicum album 1M and 10M, Aconitum napellus 30C, Lachesis 30C and 200C. He had a right internal capsule stroke in April 1998. In June 1998 he was hospitalized three times, with one hospitalization for a seizure like episode thought to be due to a TIA. On 6/9/98 he had oral surgery for an abscess and was treated with Penicillin, to which he had a bad reaction. He was given a chronic indwelling urinary catheter which lead to UTIs requiring more antibiotics.
The crisis
Then on 7/14/98 his wife called me to say that HM was dying. Although he'd been eating daily, he had had no bowel movement in 16 days despite 3 enemas, and good bowel sounds. He stopped saying "Aye, Aye, Aye" all night after Arsenicum album 50M. He was now semicomatose and only occasionally opened his eyes for 5-10 sec to look at you then drifted off again to sleep. He slept most of the time and his breathing was better sleeping on three pillows. His sleep was very deep and comatose and he didn't awake even with shaking. He didn't speak, he only grunted. He had gurgling respirations at night, and a distended abdomen but no pain. His medications at this time included Humulin insulin, aspirin, dilantin, Univasc, and vitamin E. The conventional doctors had given up on him according to his wife and had encouraged her to prepare for his death, possibly within days.
Crisis analysis, prescription, and course
Although his wife did not really expect much at this point, I was still of the opinion that maybe homeopathy could help him when allopathic medicine had nothing left to offer. This being an over the phone prescription, I had only the wife's observations to guide me. The deep, comatose sleep, the noisey respirations, the painless abdominal distension, and extreme constipation pointed toward Opium, and so I gave him Opium 1M ii po once or twice daily as needed for constipation or deep sleep. His wife was to call me in a few days with the response.
Six days later on 7/20/98 his wife called. He had taken the remedy for 4 days and still had no bowel movement. For two days he was completely comatose and did not wake up. Then the last two days was up a little more, opening his eyes a little, and trying to talk, but only garbled sounds came out.
He had a slight response, but now he had gone 22 days without a stool, and a more dramatic response was needed urgently as death seemed imminent. So I asked his wife to give him Opium 10M ii po BID-TID until there was a reaction as the picture had not changed.
On 8/5/98 his wife called to tell me that the Opium 10M had helped a lot. Two days after the dose he had a large bowel movement and then vomited a lot of dark, slimy mucus. Then he came back to his senses and began asking "que pasa?", that is, what's happened. He then started having large bowel movements once a week, then gradually more till he was going three or more times a week. He was very emaciated and weak, but he continued to improve and became more alert. As he got stronger over the weeks ahead he was even able to go to church and talk to his children and grandchildren. His wife told me that the other doctors were incredulous at his improvement and his daughter who is a family physician even said after seeing the dramatic improvement that "there must be something to homeopathy."
I continued to treat him over the ensuing months for an acute cough which developed after the Opium. Remedies needed included Antimonium tartaricum 10M, Opium 10M, Sulphur 200C, Causticum 200C, Arsenicum album 10M 50M and CM, Rhus toxicodendron 30C and 200C for an acute balanitis due to his indwelling urinary catheter, Hyoscyamus niger 200 Dunham and 10M, Pulsatilla nigricans 30C, Influenzinum 30C, Tarentula hispanic 1M, Hydrastic 6C and 30C, Ferrum phosphoricum 6x. The Hyoscyamus niger 10M helped calm him when he was restless and rolling his sheets and bed clothing, and the Tarentula hispanica also helped his restlessness at times. He was able to spend Thanksgiving, Christmas and New Years with his family. In December he told his wife, "You've been a very good spouse and I love you" during a particularly lucid interval. Then after this he started declining again and becoming more restless and less alert. In mid December his hemoglobin had declined to 7.3, and his platelet count was 109,000. He was more alert once again for Christmas.
Then on 1/6/99 his wife called me one last time for her husband. He was deathly pale, comatose at times, screaming at other times, had had 4 greenish bowel movements in the previous 18 hours, was not moving, and had a pinched face. His urine output had dropped dramatically, and his body temperature was fluctuating. At this point I could not see a clear picture, so I asked her to continue a previous remedy (Arsenicum album 10M as she had run out of 50M and CM) until she could pick up a new remedy and a couple alternatives the next day at the office. She felt it was too long a drive to pick up the remedy that night (they lived about 45 to sixty minutes away) and no pharmacy was open which carried the remedy. She never got the remedy as Henry passed away the next morning.
A couple of weeks later his wife told me that when she checked him at 4:30am on 1/7/99 he was still breathing but that at 7:30am when she checked him he had expired. Near the end he would spit out the Tylenol and Ativan that his wife or daughter would try to give him, but he continued taking the homeopathic remedies until the end. Only at the very end did he refuse to take any more remedies.
The wife requested an autopsy which was performed on 1/7/99. It revealed red hepatization in the left lower lobe of the lung and cultures of the lung grew out E. coli, leading to a final pathological diagnosis of acute E. coli bronchopneumonia. Also, it revealed an atrophic pancreas consistent with the history of diabetes mellitus and a nodular prostate with a yellowish tumor extending outside the capsule which on histologic exam revealed adenocarcinoma of the prostate with extension into the capsule. There were no metastases from the prostate cancer.
Discussion
Reviewing this gentleman's case brought several things to mind of which I'd like to discuss three, namely, the possibilities, potency, and pharmacy access.
First, regarding the possibilities, I think this case clearly illustrates that homeopathy has a place in end of life care, and that it can dramatically improve quality of life at this time. The most dramatic response in this case came from the Opium prescription in what seemed to be his last few days of life. The response was dramatic both to the family and to me and to the other physicians involved in his care. It brought him from a semi-comatose state, into a much more lucid state where he was able to communicate with his wife and family in a meaningful way for over five months. These results were achieved despite the concomitant use of many other allopathic medications and interventions. Also, since he was in such a debilitated state and couldn't travel, and I was not able to see him at home, virtually all of his care was done over the phone. Thus, I was totally reliant on the wife for all the information needed for prescription. These are hardly optimal conditions, yet still some progress was made. One can only speculate what could be done with end of life cases like this with homeopathy under optimal conditions. Although an almost six month extension of life might seem trivial to some, in this case it made the wife extremely happy, and helped her come to terms with her husbands imminent death and left her feeling that she had left no stone unturned in her attempts to relieve his suffering.
Secondly, there is the issue of potency. In an article in this journal describing all the advantages of LM potencies it is stated that, "LM's are excellent in palliating incurable diseases (where there is great pathological damage) without the least danger of aggravation. As is well known, (italics mine) cases of advanced pathology such as cancer or diabetes cannnot be treated with high centesimal potencies for fear of aggravation. Centesimal practitioners are limited to low potencies like 6C which are far less effective than LM potencies."1 This case in which the patient had prostate cancer and insulin dependent diabetes mellitus and a host of other problems, and yet responded BEST to the higher centesimal potencies, most notably the Opium 10M, and then the Arsenicum album from 200 Dunham up to CM, clearly shows the fallacy of this rather dogmatic statement. In all fairness, the author states that he is simply quoting someone else but then also adds that he is also basing this on his own experience. He claims that these statements apply to all patients, but especially to hypersensitives. In my experience, potency selection is always an individual matter and does not depend on the name of the disease(s) present in the individual patient. One must always individualize posology with each patient as was done with this patient. Hahnemann addresses this in paragraph 278 of the Organon where he states, "To solve this problem, to determine for a given medicine used in homeopathic practice what dose would be sufficient and . . . effect the gentlest, quickest cure, is not a matter of theoretical conjecture, . . . . Theorizing and specious sophistry cannot enlighten us on this subject, nor can every possible eventuality be tabulated in advance. Only pure experiment, the meticulous observation of the sensitivity of each patient, and sound experience can determine this in each individual case." I would agree, however, that in some (not all) hypersensitives who have demonstrated hypersensitivity to homeopathic remedies as well, that clearly lower potencies may be preferable to start with in the individual case, whether they be low LM potencies or low centesimal potencies. However, even then, I've had hypersensitives who over time can tolerate higher and higher centesimal potencies. As you can see, in this case I used everything from a 6x to a CM potency.
Finally, I would like to address the issue of access to remedies at nearby pharmacies. This may seem like a trivial point, but in a case like this it may mean the difference between life and death. In order to treat people who are gravely ill like this, near immediate access to a very wide variety of remedies and potencies is essential. HM died of bronchopneumonia. The evening before his death I prescribed a remedy which his wife did not have and was not able to obtain from our office (she didn't feel up to sending someon to our office that night to pick it up from our mailbox) until the next day. Before she could get it he died. Maybe in this case the remedy would have made no difference. However, in a very similarly urgent situation about six months before his death, Opium did make a dramatic difference in the course of his illness. As homeopathic practitioners dealing with these kind of cases continue to explore what homeopathy can offer in the realm of end of life care, it would truly be a shame if simply lack of access to homeopathic remedies at a critical time were responsible for more of these failures.