A day in the life of a palliative care nurse
Wednesday 10 January 2018
In our hospitals and in the community, palliative care staff care for patients who are nearing the end of their life. This might be because of an ongoing life-limiting illness, advanced age or from a sudden illness or injury.
Palliative care takes a ‘whole of person’ approach to caring for someone who is dying. Palliative care staff look after their patients’ physical and emotional needs, and also offer support for their family and loved ones. You can read more about palliative care in our article ‘What is palliative care and why is it important?’.
We spent some time with palliative care nurse Louise at Redland Hospital, to find out what a day in the life of a palliative care nurse entails.
Louise’s day begins with an education session. Her team, including doctors, nurses and social workers, meet to learn about supporting adolescents who are part of a patient’s family group. This training will help Louise and her colleagues ensure that young people have their voices heard during family discussions and feel supported by palliative care staff.
The dialysis ward
While most hospitals will have a designated palliative care ward, palliative care staff work in many different wards. On this day, Louise’s first patients are in the dialysis unit of the hospital.
Dialysis is the process of filtering a person’s blood through a machine when their kidneys aren’t able to do the work. Some of the patients who regularly receive dialysis treatment at the hospital are coming to the end of their lives. As well as kidney problems, they have other health issues that are not curable. Louise is looking after them to ensure they have the best quality of life possible as they approach the end of their lives.
She checks in with the head nurse of the ward, then pulls a large paper file for her first patient.
A balancing act
As Louise approaches her bed, the patient’s eyes light up. Louise visits this woman at least once a week, and they spend a few minutes catching up on what’s been happening for her over the past few days. They discuss medical issues, but Louise also asks after her family and talks over the activities the woman enjoys doing at home.
Balancing different treatments and their side effects is a large part of Louise’s job. Louise asks the woman about her symptoms and her ability to function at home. One of the goals for this patient is to be able to walk around at home and stay mobile for as long as possible, so she can keep doing the things she enjoys, while also feeling comfortable and not experiencing unnecessary pain. Louise discusses altering medication with the Palliative Care Specialist – to ensure that her patient’s pain continues to be well managed, while allowing her to be as independent as possible.
In the file, Louise documents her visit and notes this change of medication. She also discusses it with the ward nurses as well as the patient’s doctor, and she’ll call the hospital pharmacist to let them know about the change in needs.
Small changes can mean big things
Louise pulls the file for her next patient and the process starts again. Louise is seeing another female patient that she’s been working with regularly for some time.
There are a number of things to discuss with this patient, including her wishes about receiving life extending treatments. As her health continues to deteriorate, it’s important to the patient that her wishes to only be made comfortable, not given treatments like resuscitation which would not be beneficial and would cause suffering, are heard and recorded. Louise reassures her that her wishes will be made clear to all the staff at the hospital and makes sure this is noted clearly in her file.
Sensing there’s something else to discuss, Louise asks a few questions. Is she experiencing pain or discomfort? The woman answers that she’s not, but there is something else that is bothering her. She’s begun to feel anxious, but she doesn’t know why. Louise gently asks more questions, finding out what is causing the woman’s symptoms of shortness of breath and restlessness.
The patient is concerned that her family are not prepared to let her go yet. Louise offers to arrange for a nurse or counsellor to talk to the woman’s family. “I know it’s not an easy conversation to have,” Louise says, gently resting her hand on the patient’s. Together they decide that one of the renal nurses who has cared for her for some time would be the best person to talk with the woman and her family and Louise arranges for this to happen.
As well as a change in medication that will help her to feel calmer, Louise thinks the woman might feel better if she had a chair she could sit in, so she’s not always in her hospital bed. She could even be wheeled out to the gardens in it when her family come to visit. Louise asks if this sounds like a good idea and the patient agrees immediately. When she asks if it’s really possible, Louise flashes a smile: she’ll make it happen. Even though it’s a small change, it will make a big difference if Louise can help her patient feel comfortable and relaxed.
After leaving the treatment area, Louise finishes filling out both of her patients’ files. She then spends time with the head nurse of the ward, filling them in on the ideas and changes she’s discussed with the women.
Then, she heads to a different ward to hunt down the special armchair on wheels for her second patient and leaves it in her hospital room, a nice surprise for when she returns from treatment.
It’s already nearly noon, and Louise has another patient to meet with.
Communication is key
An elderly lady sits up in her chair. One side of her face is badly bruised after a fall, but she greets Louise with a large smile.
Louise hasn’t met this patient before and it will likely be their only encounter. The woman has recovered from her fall, and Louise’s priority is getting her back to the assisted living facility she calls home.
Her first question for the patient: is she comfortable with the idea of going home? Yes, is the emphatic answer, home is where she wants to be. After a friendly conversation, Louise agrees that the woman would be stable to return back to her facility and hands over to the nursing staff to ensure that they are aware of her condition.
Louise recommends some pain medication in case the woman’s injuries begin to hurt and lets the ward nurse know that she thinks she’s ready to go home. This leads to another set of phone calls: there are many people who need to be communicated with. First, she calls the pharmacist to inform them of the new medication. Then, she rings the home where the patient lives, to check that the nurses know she’ll be returning that afternoon. Louise also calls the patient’s family to make sure they know that she’s heading home today. Keeping everyone informed and on the same page is a big part of a palliative care nurse’s job.
At lunch time, Louise meets with the community based palliative care team. The community team work with patients and their families in their homes, some of whom will choose to die at home, and some who will eventually come to hospital.
Over lunch, the team catch up on what’s been going on, talking about which patients have gone where, how they are and who everyone is seeing. This kind of information sharing helps drive the patient-centred care that the palliative care staff deliver, as well as providing a break from a busy day.
Louise spends time entering patient information and updates in the electronic patient record. This way, the community team and after hours on call staff will have up-to-date patient information as needed.
Louise’s day wraps up about 4pm. Each palliative care nurse takes turns being on call overnight and on weekends, so they can provide support for any patients in the hospital or in the community.
No typical day
For palliative care staff like Louise, no two days are the same. As we’ve seen on this day, not every shift involves being present at a patient’s death, though that’s definitely part of the job. Palliative care is just as much about a patient’s living as their dying. As part of the palliative care team, along with the rest of the staff at the hospital, Louise works to support people and their families to live well while they are dying, whether that’s in their last months and weeks, or their final hours.
Thank you to Louise and the palliative care team at Redland Hospital for allowing us to share your stories!