Albany doctor Jonathan Ramachenderan, whose blog, theHealthyGP, is gaining wide readership, writes here about his work and life and how he manages them both.
I’ve never found a speciality in medicine that engages my passion for helping a wide cross-section of people, my interest in pharmacology and the sense of making a difference when it matters most.
But the most common question I encounter when I meet someone for the first time is, “Palliative Care? Doesn’t working around death and dying make you sad or depressed?”.
The truth is, it doesn’t.
Of course, I empathise and sometimes cry (often, actually, it is my release and it’s human to express emotion). However, for many nurses and doctors working in Palliative Care, it is our calling, our found passion. Our work with the dying is how we find meaning in life. We share this sense of meaning and joy in providing hope and relief for those who are suffering.
But not all days are the same. There are dark days in Palliative Care, days you’d rather forget and ones that live in your memory uncomfortably forever.
However, those who work in Palliative Care don’t blindly enter the world of the dying with little protection for ourselves. The practice of intentional self-care that I’ve seen among the professionals working in palliative care is abundantly clear and built into the fabric of their lives.
We understand that we will hear stories of loss, powerful cries of regret, witness suffering and extreme pain and be engaged in conversations that are actively avoided by many.
The dark days
We had a dark week here not too long ago.
We had two young patients die and we were dealing with several patients with difficult symptom issues, family distress and difficult decisions to make.
The atmosphere in our small office was thick with tension. Sometimes there are no words and yet we all know this is a safe place to express emotion, a judgement-free space to express our doubts, fears and complaints. An environment where ethical debate can occur. A culture that expects you to take time out for yourself regularly.
The one powerful aspect that I am learning about in the practice of good palliative care is that it takes maturity and wisdom and that only comes from self-reflection and self-care.
I have learned a great deal about myself in the past seven years in being a country general practitioner – my vulnerabilities, my energy levels and the need for replenishment and self-care, my beliefs and understanding of death and my life philosophy and spirituality.
Underlying everything that I do in palliative care is this thought and presupposition about my health and wellbeing: “I can only care for others if I make it my priority to care for myself.”
I exercise every day because it creates energy within me. I have every Saturday completely OFF (except when I am on-call) to disconnect and do things that make me feel happy and replenish me because this creates margins in my life and replenishes my energy stores. I ensure that I connect and talk with my wife every day and take a break every year together because it keeps our marriage strong. We go away each year with our sons because this is our time to experience the world together and gives me something to look forward to which anchors my year.
I take time out every month to connect with my spiritual mentor because this self-reflection is important to keep me focused on who I am as a man.
Talking and listening
I debrief regularly with our nurse manager and my clinical supervisor about the difficult cases we encounter because their perspective on my performance and the larger vision of palliative care is valuable.
That still leaves dark days. Before Christmas, I shared with our Palliative Care Coordinator that I wasn’t okay. She’d said something in passing that triggered an unexpected emotional response in me.
“This is likely to be their last Christmas”, she said, referring to a group of our patients with children a little older than mine.
My chest tightened and stomach churned and tears filled the corners of my eye. I wasn’t okay with that thought and it circled my mind for days, finding no rest and meaning.
As we were about to start our clinic, I shared with her how much this thought had affected me.
I couldn’t change their prognosis, nor could I make them live longer, but it had stuck close to my heart as I thought of MY young children and the joy of Christmas.
Hiding your emotion over time is destructive to your life energy and will eventually lead to you being depleted and broken. I don’t think you can be an effective palliative care professional if you don’t allow your heart to be softened by the stories of your patients.
We had a clinical debrief a few months ago and I learnt something profound from one of our long-serving hospice volunteers — a beautiful witty retired Scottish nurse. As she leaves the hospice after each volunteer shift, she physically pretends to take off her ‘hospice jacket’ and brush ‘the worry and sadness away’ and puts on her ‘home and outside coat’.
What she is doing is engaging in a ritual that helps to reminds her that ‘work has finished’.
Yes, sadness exists and broken bodies are getting closer to ultimate healing in death, but in this powerful ritual, she is setting the intention that ‘work has finished’ and readying her mind, body and heart to re-engage with her family life.
This has been a life-saver to me, my family and my wellbeing.
Brendan Burchard, in his book, High performance Habits says high performers “set intentions” about what they would like to see and achieve. With this in mind, I started to set the following intention, each time I arrived home after work. “Work is over, I set the intention of presence, peace, fun, laughter and hope.”
Home zone
With my eyes closed and a few mindful breaths in my car in the hospital carpark, I set this intention. This reframes my thoughts and sets my mind on what to expect at home – usually mealtime chaos, but also my lovely wife, children and sanctuary of Ramachenderan home life.
In the past year, I have begun to share my thoughts to audiences on my blog about ways that health-professionals and anyone engaged at the front-line of raw humanity can intentionally build self-care into their lives and thrive in their chosen field.
If you would like to know more, please send me a message or leave a comment, I’d love to hear from you and your story, as I have so much more to learn.
ED: Jonathan blogs at https://thehealthygp.com/
What I learnt from Doug
The surgical ward is no place for a dying man.
Doug was 52 years old and had been diagnosed with metastatic non-small cell lung cancer only four weeks earlier. He’d finally dragged himself to see his local doctor for no other reason than to refill his regular pain prescriptions. A simple chest x-ray showed the reason for Doug’s persistent cough and chest wall pain.
He had large right-sided lung tumour that was causing compression of the major blood vessels reducing his ability to breathe without pain.
Doug rolled around on his bed uncomfortably. He couldn’t lift his eyes to make contact with us as we stood in his room trying to assess and deduce the best clinical course of action. He could only respond in monosyllabic tones, “yeah” and “nah”.
He was barefoot and tall, dressed in tight fitting black jeans and a blue shearer’s singlet which clung to his thin but well-defined chest.
His long black hair covered his face and through the strands of his fringe, I finally made a connection with his dark brown eyes.
He was scared.
He was alone.
In stark contrast to the blue skies and radiant autumn sun bursting through the shutters of Doug’s single hospital room, he asked Lesley, the nurse who was with me, “Is it happening now? Am I going to die?”
He was the first patient I’d seen in many years, agitated and so obviously in pain.
With so many thoughts running through my mind, I struggled to know what to do next which is so often the case when clinical reason is flooded with emotion and psychological distress.
Who is this man? Why is he in so much pain? Why didn’t his doctors call us sooner? Is he going to die in front of me? Who is Doug?
We immediately started a subcutaneous infusion of morphine and midazolam to help calm his pain and settle his agitation.
The doses that we calculated was astonishingly high due to Doug’s background of chronic pain. I learnt later that he’d been in excruciating pain for at least a week and had recently returned from our tertiary centre on a bus with only a few day’s supply of pain medication.
The tension in his body eased into the slow rhythm of his breathing, his eyes were closed in momentary relief, and emotion in the room eased. Thankfulness could be seen in the eyes of the ward nurses who were previously desperate and stunned at the ferocity of Doug’s unrelieved pain.
We’d helped to bring Doug relief.
It was as if we’d found calm waters in the rough seas of what lay ahead. As we examined his scans, we could see that Doug had a superior vena cava obstruction due to tumour progression and we expected his course towards his death to be turbulent.
Cancer shows no respect to the people it afflicts. It is both demoralising and destabilising to a person’s resolve. Desperation is often what we see, a loss of choice and sometimes, devastatingly, a loss of hope.
This is the space in which Palliative Care works to restore hope in providing quality of life in the relief of symptom burden, supportive care for family and patient and most importantly the prevention of futility in the face of human physiological and psychological frailty.
Acute pain is always an emergency, especially in our palliative care population. I’ve learnt that escalating and unremitting pain is almost always associated with the fear of imminent death in our patients. Often this can be the case but the treatment of pain crises in palliative care is regular occurrence, physiologically due to disease progression.
Doug’s story is important. It has taught hundreds of people about benefits of good Palliative Care.
The last few months of his life is important to me because unlike any other patient I encountered in my training, the story of his life was intriguing and as we walked through his last days as a patient in our hospice, we learnt about forgiveness and reconciliation, the importance of completing end-of-life business and saying goodbye and how even in the midst of severe suffering, the practice of palliative care can bring hope, relief and ultimately eternal healing.