Author Information

Journal of Hospice and Palliative Nursing

April 2002

John Grisham, Author

Charlottesville, VA

Dear Mr. Grisham:

I have just finished reading your latest novel, The Summons, which I enjoyed very much. Although my all-time favorite is still The Firm, I found your current book to be a good read for a rainy weekend.

I do, however, have one concern that I would like to bring to your attention. I believe you could have been more accurate with your depiction of Judge Atlee's cancer pain and its management. With your descriptions in the book you have, perhaps unwittingly, reinforced many stereotypes and myths that people hold as truth regarding pain and its management in the terminally ill. Those of us practicing in end-of-life and palliative care work hard on a daily basis to dispel these myths. Inaccuracies in the popular media, such as I found in your book, often become obstacles to our work.

It is true that pain is a very common symptom in advanced cancer patients. It is also the symptom that is most feared by people with cancer. Given Judge Atlee's diagnosis of stomach cancer, his age, and his comorbidities, it is likely that he would have been experiencing severe pain at this stage of his illness. At the same time, severe cancer pain can be controlled effectively in 90% to 95% of patients. This latter fact, unfortunately, is not well known by the general public, which leads to the myth that people with cancer will die in severe and uncontrolled pain. This is simply not true for the vast majority of patients.

It appears that Judge Atlee was under the care of a competent physician who was, in fact, managing his cancer pain appropriately. First, he was on morphine, which is considered the "gold standard" for treating cancer pain. Second, it appears that he was receiving his morphine in an intermittent subcutaneous infusion (although you referred to it as a "morphine pack"; I think "pump" would have been a more appropriate word). Patients approaching death often are not able to take opioids via the oral route, so this description was accurate.

What was not accurate, in my view, was the outcome of how his pain was managed. You describe him as crying and screaming from the pain; to get it under control, he required so much morphine that he became (first) stoned and (second) addicted. In fact, it is highly unlikely for terminally ill patients to become drug addicts. Morphine does not produce euphoria in patients with severe pain. Their need for the drug is limited to pain relief.

It is true that patients may develop a tolerance for their pain medication, requiring higher doses to maintain the desired effects. But, again, these higher doses usually do not result in a patient who is "stoned." Granted, patients in the end stages of a terminal illness may be greatly fatigued and may spend many hours resting, napping, or sleeping. These behaviors usually are a consequence of their disease, however, and not their pain management.

I realize it was partly a plot device to have the Judge be "out of it" so another character would have the opportunity for a few nefarious deeds. Still, the Judge could have been napping in the hammock under the pecan trees (or even sleeping soundly!!), with his pain in good control. Describing him as "stoned" and "addicted" served no useful purpose to the story, in my opinion.

I know your books are fiction and you may think I am being overly critical in my comments. But in my mind, your books are stories of fictional characters existing in the real world. It is obvious you do meticulous research to accurately depict the legal profession, the gambling industry, flying a plane, and even fancy dinners on swanky yachts. I hope that the next time you decide to write a terminally ill character into one of your stories, you will strive to be more accurate in how you illustrate the character's illness, symptoms, and the management of those symptoms, particularly pain.

Sincerely yours,

Leslie H. Nicoll, PhD, MBA, RN

Editor-in-Chief

Journal of Hospice and Palliative Nursing