Palliative care, under optimal circumstances.

I work as a palliative care NP on an inpatient consult team at an academic medical center in Massachusetts. In the best of times, palliative care teams are exemplars of interdisciplinary functioning. According to nationally accepted consensus reports, since palliative care is holistic in nature, it must be administered by a team that can address the multidimensional elements of suffering for both patients and families in the setting of serious or life-limiting illness.

In my experiences on two interdisciplinary palliative care teams, we were damn strong together. We met each morning to divvy up the workload; around the crowded table were NPs, physicians, chaplains, social workers, sometimes a pharmacist or a librarian, and a bevy of rotating students of all disciplines. On the table was often food: from someone’s garden, our own kitchens, or the grocery store bakery.

A ‘thread of lightheartedness’ amidst the heaviness.

The work was seemingly endless (as many people as there were around the table, there were scores more patient consults), and the situations were heavy and complex. We took our work seriously because the situations we waded into day after day were often worst-case scenarios for our patients and their families.

But there was also a thread of lightheartedness that ran through the days and weeks. We prioritized team and clinician wellness, and often laughter was the centerpiece of the table. We strategized together, cried and fretted about our patients, roared or seared in frustration, and yes, we watched funny cat videos to keep the balance of energy from tipping too far into the dark realm.

With the loss of a team’s shared rituals, a ‘fractured’ sense of purpose.

When the COVID-19 surge hit last spring, we could no longer sit in the crowded, laughter-filled room for our meetings. We donned masks and had our meeting via video conference from separate or socially distanced spaces. When the peak came, we dropped the intentional wellness exercises. Watching funny videos felt inappropriate. The fear that one of us might get the virus stiffened the team to one another; we put our heads down, did the work we did not always recognize, and then went home to rinse off the day to protect our families from us.

With hindsight’s perspective, I can see now that without the scaffolding of the team and the intentionality of team wholeness, our group struggled and the team fractured apart. For me, the spring in my step faltered and I felt isolated and graceless in my work.

An improvised ritual of connection.

One day, I was assigned a patient who was dying from congestive heart failure on a COVID unit and whose family had elected to change to comfort-focused care the night before. The plan was to discontinue her BiPAP mask and give her comfort medications if she needed them, allowing her death to come naturally.

As I approached the room, I saw that her nurse (who was in full PPE) had a panic-stricken look in her eyes. She hadn’t considered having the comfort medications ready and the patient was struggling to breathe after the BiPAP mask had been taken down. Since it was a COVID-positive isolation unit and we were preserving PPE, there was no family present and I was not permitted to enter the room. Together, we quickly got orders written and medications administered so that the patient was more comfortable.

I felt grateful that I had serendipitously arrived with the skills needed to help the patient. As I turned to say goodbye to the nurse and leave the unit, I saw that she was crying. When I asked her what was wrong, she told me that she felt distressed by the fact that the patient was dying alone and that she didn’t have time to be with her. At that moment, she looked to me like a warrior in her PPE. My instinct was to give her a hug or to put my arm on her shoulder, neither of which was permissible.

I looked down and saw her hospital-worn clogs and my own next to hers. I told her she was a warrior and that she was an excellent nurse doing the best she could in an impossible situation. Then I told her that I was going to kick her clog with mine because I could not hug her and I wanted to physically console her and connect with her in some way.

She nodded assent, and I gently kicked her clog with mine. However limited as a gesture, the kick connected us in some way, and I thought of it as a kind of spiritual care for us both. I don’t know if that experience or the peculiar “clog kick” remains in the mind of that warrior nurse, but it does in mine. In times like this pandemic, we need to adapt our definition of excellent patient care and team wellness and unearth new ways to band together. I haven’t kicked anyone else’s clog since that day, but have reflected on the experience at length.

Our patient died later that day, comfortable but alone in her private room on the seventh floor.

By Sarah Rossmassler, DNP, ANP-BC, AGPCNP-BC, ACHPN, assistant professor, MGH Institute of Health Professions, Boston, MA, and a nurse practitioner in palliative care at Baystate Medical Center, Springfield, MA.