Who do you palliate in a pandemic and does the emotional strain have an effect on nurses?

Within the realms of palliative care, having an emotional day comes with the territory. It’s true to say that yes. In ‘normal times’, the accounts from nurses offer real-life insights into how staffing and time pressures hamper the care of dying patients. How nurses find it emotionally draining to give good end of life care in a pressured environment. This was then amplified when a world-wide pandemic was also added to one of the pressures they would have to face. 

Barrier to care. 

It is widely known that non-verbal communication is the most common way we communicate with people day to day without realising it. Within healthcare this is also the case. The importance of touch and facial expressions during an emotive conversation is key and vital for the information being delivered.  During the height of the pandemic, elderly people suffering with covidstarted to be admitted, it did not take long for this number to grow by maybe 2-3 patients a day and then by the end of the week 20/30 patients a day suffering uncontrolled covid symptoms and often these patient would deteriorate extremely quickly, it felt like you were never making a dent in what needed to be done. 

Elderly people being admitted to the hospital with a disease that affects their respiratory system, causing panic naturally as they are struggling to breathe. Elderly people coming in alone and unable to have the comfort or reassurance of a loved one near them. The feeling of being held and giving patients the sensation of a being in a safe dock was taken away. 

The PPE made reassuring these patients and being able to give any kind of empathetic nursing care near enough impossible. Behind a mask and visors and gown, it’s hard for the patient to really even know who is comforting them at their time of need. The whole scenario felt clinical and cold. The very contrast of what palliative nursing is meant to be described as. 

It was during the height of the pandemic, that I worked within the intensive care department, having experience in this department before I was keen to return to it and also use my palliative skills where I could. 

It became apparent very quickly how many people needed advanced care plans that just simply were not prepared. An advanced care plan discusses the wishes of a patients and how far they would want their medical intervention to go. This is where a DNAR is often discussed with patients and their families. These conversations usually can take up to an hour due to the sensitivity of the discussion. This luxury of time was taken away from us working within the ITU in the midst of the pandemic. It was a never ending stream of patients that were deteriorating quickly and needing further medical intervention such as intubating in order to be connected to a ventilator which would do their breathing for them. But who do you intubate if you had to choose? This was never a question my colleagues and I have ever been prepared for as it was  assumed a situation such as that would never occur in England in the 21st century, sure enough this was unfortunately the diar reality we were faced with. 

One instance that I can recall is caring for a gentleman who was 76, he had no other past medical history and clearly very unwell, he was gasping for breath yet still had a sense of humour, during a facetime with his wife, he reassured her he would be ok and that there was absolutely no good looking nurses to be seen as he couldn’t see their faces anyway. 

I shortly call the wife, who was currently at home suffering from covid herself,  to explain that as cheery as he seemed, he was in fact extremely poorly and that without being intubated he will not survive as his lungs are failing and he is unable to keep his oxygen levels up anymore. Naturally, in my next breath I want to explain to her I think it is a good idea if you come in and see him as I do not think he has long to live now. But nothing about this situation was natural. A  man who had no other health conditions denied a ventilator and also denied the opportunity of being with his wife of 50 years in his last moments of life. 

She cries. Obviously. She had many questions she wanted answers to; if he does die will we attempt to restart his heart, she began listing of all the things he had done in his life and just how healthy it was. It began to feel like she was bargaining with me and this sat uneasy with me. Knowone should have to justify why one person’s life is worth more than another. 

It was explained to her that no we wouldn’t be attempting to restart his heart. More tears came and then a lot of shouting, understandably.  It was hard to give news like this when you don’t deliver it with the conviction you should when you don’t agree with the plan that is being organised in front of you, but what do you do?

I listen to her cry and I hold back the tears, I tell her I’m with her husband and I won’t leave him. I don’t leave him, I did stay by his side for 2 hours before he arrested and became hypoxic, very quickly began to turn blue, he became very agitated and a look of fear in his eyes, unfortunately he only had me, a set of eyes he had never seen before today to reassure him.  I administered some medication to help him feel more relaxed and he died approximately 45 minutes after this. 

This type of scenario was repeated at least 5 or 6 times in one shift. 

The above scenario demonstrates how a patient went from a patient who was having active treatment to someone that was deemed to be palliative in the matter of a few minutes when he began to deteriorate. This was happening more and more. Family and friends of patients were furious and hearts broken when examples like the above were explained to them. Nurses delivering this news took the brunt of feeling like you had made that executive decision. It was unnatural to come to work every day and in my opinion deliver palliative care so badly yet this was the only option we could see. 

Nurses supporting other nurses became an integral and vital part of the job, more than it ever had been before. There often wasn’t enough time to be upset or get emotional because you already had another person to deliver bad news to and you can’t seem out of control. You must never be seen to be out of control, how can patients and their families  rely on you if we aren’t holding it togever.

 Clare Troy