When I met Judy Tobin, a nurse with 25 years experience—the last 6 with the Palliative Care Unit at Credit Valley Hospital—I was immediately struck with how quickly my stereotypical thinking about nurses fell apart.

She gently corrected my belief that nurses maintain their professional demeanour by keeping an emotional distance from their patients, in order to function--especially in a unit where most of the patients will die.  “The connection with patients and their families is a true and intense and honest connection,” Judy said.  “If you try to put up a barrier to protect yourself from the grief, it backfires.  The patient doesn’t get a chance to feel your compassion and you burn out from trying to hold all your emotion back in…I can be myself when walking in that unit; my tears and anger are acceptable…it’s very freeing.”

Judy admits that in nursing you can get so caught up in the day-to-day procedures and techniques that you can forget that there is a person who is part of it all at the other end.  But in palliative care, staff try to minimize invasive procedures and intrusive machines--the beeps, the monitors--to allow for a more natural environment. 

While kindness often can go missing in clinical environments, Judy believes that the simplicity of kindness is possible every day in palliative care.  As she says, “Sometimes people just need to be scooped up and hugged.”  It is clear that Judy has an abundance of kindness, compassion and sensitivity, and I was struck by her thoughtful character and ability to listen to others—characteristics that must be cherished in a palliative unit.  She is grateful that her strong mothering instinct, which cannot be used in many work environments, can blossom in the palliative environment.

Judy talked about the differences between a “difficult” or chaotic death and a “good” death.  The difficult death may be one in which the family, patient and medical staff are in disharmony, often because someone is not coming to terms with the impending death.  For example, a family member may try to feed a patient who no longer can swallow, in the belief that they will live longer.  Or the relatives may get angry with medical staff because they want more aggressive medical measures to keep the patient alive when the patient refuses them; or conversely, they want to withdraw or withhold medicine that may provide comfort to the patient, out of a belief that the medicine is harmful.  In those cases, doctors and nurses like Judy try to educate the families about the medications and work together to understand and meet the needs of the patient and family.

In the difficult death there can also be spiritual distress, which may be due to a struggle with one’s relationship with God--however that person understands God.  Sometimes the patient does not believe in God and will struggle to achieve a sense of meaning or transcendence.  Or patients may feel that God will not accept them after death.  When these situations arise, the hospital chaplain may be called in to discuss existential or ethical questions. 

When families expect more life than the patient has to give, it can cause immense emotional pain, and this upsets Judy.  Family members can be so overwhelmed with grief they don’t know how to deal with it.  Sometimes families are in denial and think the patient will come back, which can lead to a complete emotional shut down—they just cannot absorb the amount of emotional pain they are going through.  “People find it difficult to face pain…grief just overwhelms and flattens people…death is the ultimate dismissal.”  Judy understands the reactions families can have to an impending death, and believes that each individual experience must be respected, as people are just doing their best to get through the palliative process.

In the good death, symptom control has been managed.  If you can control the pain, the vomiting, make it easier for the patient to breathe, the physical relief can lead to emotional relief.  In the good death, spiritual and emotional issues have been dealt with, to the best of everyone’s ability, and so the person dies in peace and the family accepts the death.  While everyone still has to deal with grief and feelings of loss, it is not complicated by negative factors such are found in the “difficult” death. 

The sense of peace that results in the good death can come with the patient finding a resolution, sometimes spiritual in nature, emotional or physical.  Sometimes at that point, patients may become less alert or withdraw from their family and go off into an internal place not shared by others.  In contrast, other patients will remain remarkably present with their families until close to death.

Judy embraces being with the patient as they die because with that last breath she knows whatever struggle was there, is gone, and that they are at peace.  In some ways the death is anti-climactic because the palliative experience is about the communal process between patient, friends and family as they struggle to accept what lies ahead. 

With such a wide variety of good and difficult deaths, Judy finds there’s little predictability about how her day will go.  Sometimes she’ll have a “Mother Theresa day” and other days will be very difficult because she will feel overwhelmed with other people’s emotions.  Those are the days where she says that she just doesn’t “feel the ground beneath my feet.”

As we chatted I told her that I consider her and her work to be special—that it takes a very exceptional person to work with patients you know are going to die.  She was genuinely puzzled by this comment.  “None of us see ourselves as special…we just accept that death is part of life.”  It was a breathtakingly simple answer.  Most astonishingly--and shattering yet another myth--Judy does not believe that the palliative care unit is a depressing place to be.  “It’s such a richly textured place—so much is going on in such a short span of time and all in one place…Every room has a different story and you start to appreciate how really unique people’s lives are.”  She feels good about helping others.

How does a nurse manage to stay in palliative care?  Judy feels she has something to offer others.  “I know I’ve been given certain characteristics in my life to be used for myself and others and I know when I use those gifts, my life works beautifully and I thrive on it.” 

But if nurses only ever give to their patients and their families, how do they cope and re-energize themselves?  To relieve stress, the close-knit palliative staff members discuss deaths or situations that have affected them in de-briefing sessions.  In addition, Judy finds that she recharges her batteries away from the hospital.  Her home, family and friends anchor her.  Her connection with nature is also important and she believes that many palliative staff enjoy nature.  She likes to take walks and do other physical things.  She also meditates and sings.  (She recently won the hospital’s “Credit Valley Idol” competition and now will record a jingle to be played on radio station Wave 94.7fm).

As my interview ended with Judy, the thought struck me that if one of my relatives or friends had to experience palliative care, I would hope their journey could be eased by a nurse like Judy.  And my last thought was that I’d just have to disagree with her on one point, because she is very special!