DON'T TELL LISA

MONDAY MUSINGS - My tears dry on their own - Part 2

Last week I talked about the human urge to cry and how we so often supress that. Crying is a mix of neuroscience, hormones, psychology, and body regulation. It’s therefore pretty important and natural human response for us, and it may happen whenever emotions exceed the brain’s normal regulation capacity. At times we can be overwhelmed by the emotions that lead to our tears, and there is just nothing we can do about it.

I talked about how difficult that can be for nurses (obviously not exclusively, but I can only speak for my own profession). I can say with some confidence that most nurses will have story about tears they have shed whilst on duty - and sometimes that will be secretly in a cupboard, so no one sees.

As a Nurse, you are in constant contact with pain, fear, death, recovery, families in crisis, and at times impossible time pressure. A nurse might go from helping someone breathe, to comforting a grieving relative, or even an angry relative, to reliving all of those experiences again when it comes to documenting it all — and that can sometimes all happen in the same hour. You could say therefore that the emotional switching required for the role is intense. Crying must be the only way to offer some release at some point.

As a palliative care nurse in a hospital team, collectively you cover the whole hospital, and you will go wherever there is a patient requiring palliative input. And this may come as a surprise to many, but not all patients requiring specialist palliative input in the hospital setting are dying.

There may be someone who is living with an incurable illness and is in hospital either due to a complication, or an acute issue that is deemed to be treatable.

There may be someone who has presented to the Emergency Department with abdominal pain, and are now facing incurable pancreatic cancer, and they need support to cope with this, understand their options, or need input into managing their pain.

There may be someone struggling to manage challenging symptoms, or experiencing unmanageable side effects of their medication or treatments.

An acute admission may make some want to address practical issues, or document wishes for the future, and we are there to talk those things through with them.

We may need to spend time with families helping them to understand, and them helping us to fill in some of the gaps, or provide the missing pieces of the puzzle.

We work alongside the multi-disciplinary team (MDT) and may have input in making medical decisions about ongoing treatment.

We support families to plan for discharge from hospital, and work out what that looks like for them, and how realistic and feasible that is, and what support they may need in the future and ensure that they are appropriately linked in with community teams.

We may also have to talk to them about death, and their preferred place of death, and if we can, we will facilitate that.

Then we do have patients who are end of life, in last weeks, days, or sometimes only hours.

We are the ‘experts’ in symptom management, and we think outside the box when it comes to medications. We manage subcutaneous continuous infusions when patients have difficulty swallowing, or absorbing oral medications. And also to keep patients comfortable and pain free when they are approaching end of life.

In my various roles as a palliative care nurse, I have been there as many people have died. As well as moments before, and moments after. I have comforted sobbing relatives, and broken hearted soul mates. I have washed and prepared bodies soon after death, I have sat alone with deceased patients who live alone, until the funeral directors arrived, and as a community nurse, I would often go out to patients homes to do verification of death.

I know to many that will sound just like all too much, and may even want to make people stop reading this. But the reason I feel this is important to share is for a sense of perspective - because I need to mention that if I allowed myself to be emotionally impacted, or carried home the emotional baggage of each of those encounters every day I went home, I could never survive. I could never keep going back to work.

So when writing about our frequent desire to hold back tears last week, it made me think about the times I have cried as a Nurse at work. Luckily it’s only a couple of times, but they are times I reflect on a lot. And I honestly can’t say why one of those encounters made me cry, when all the other times I have been able to ‘hold it together’. Why did the usual armour that my uniform provides, just seem to malfunction on this occasion?

It was a young lady - I’ll call her ‘Sally’. I had met Sally a few times previously, as she was living with incurable cancer and had several acute admissions with pleural effusion (fluid build up in the pleural space between the lungs and the chest wall). Frequent hospital admissions when living with cancer are generally considered not a good prognostic sign. Because I had been called to Sally now on a few occasions, I got to know her husband and her teenage daughter, who had really been struggling with her mothers diagnosis and prognosis.

Sally was likeable, had a sense of humour and always genuinely seemed pleased to see me. This admission she was admitted to the Medical Acute Dependency Unit because she was struggling with her breathing and needed closer monitoring. There had been some delay and complications in the procedure she would need to drain some of the fluid that had built up in her lungs, and she was struggling the anxiety and exhaustion of her breathlessness.

I went to see Sally on about the 5th day of her admission, I had been delayed with another patient, and the ward had called me to see if I could come sooner, and I could hear there was urgency in that call, so I got there as quickly as I could. When I eventually arrived that morning, Sally had just died.

Somewhere awash with the adrenaline that overwhelmed me as I had felt the urgency to get there, I was confronted with the harsh reality that she was gone. It was not my fault I couldn’t get there sooner, as I had another equally poorly patient, but you still can’t help but feel you wish you’d got there sooner, even though there was probably little I could have done at that point.

I couldn't have saved Sally, nor was that ever what I was there to do. But could I have made her more comfortable, could I have protected her, and could I have had a chance to say goodbye? As I saw her pale peaceful face on the pillow I somehow felt I had let Sally down. I hadn’t. But in that moment, I felt I had, overwhelmingly. I could feel the burn of the tears, I knew I wasn’t going to be able to hold them in. I took a deep breath as the nurse in charge (I’ll call her Cheryl) came in. She told me the husband and daughter were with her when she died, and they have taken some time out in the relatives room.

Together, Cheryl and I performed last offices for Sally. As we lowered the head of the bed to lay Sally’s lifeless body flat, I watched one of my salty tears fall onto the bed sheets. But as I looked up at Cheryl - her eyes were also filled with tears. We looked at each other for a split second, but we said nothing. The only task in hand was offering the last bit of dignity and care we could provide for this lovely patient that we shared.

There we were - two completely silent nurses overcome with emotion, not able to hold back our tears, and somehow having some bizarre unconventional solidarity in that. We felt something equally and simultaneously. We felt the pain of this life before us lost.

And we cared.

We both dried our eyes and washed our hands. Still no words exchanged. We almost raised our heads, and our shoulders, as if to dust ourselves off, ready to face the real world just outside the side room door - where we would have to don our armour again to continue on for the rest of our shifts.

Cheryl flung her arms around me, and we stood there in a silent embrace that oozed compassion, understanding, and connection. It’s a moment I wont forget. And then Cheryl broke our mutual silence, as she spoke straight into my ear, as we embraced.

“Don’t tell Lisa about this!” she said firmly.

We separated and both laughed! Somehow I understood why she wouldn’t want Lisa to know about this, but equally I can’t really explain why - I just get it. Lisa was my colleague (and now a dear friend), who Cheryl knows well - but everyone knows Lisa! (and if you don’t I would highly recommended her)

You could say this is a valuable example of the culture in healthcare where you must ‘hold it all together’ and maintain a certain standard of professionalism. Her first thought in that moment was not wanting a colleague to know that she had shown weakness in crying - I guess that shows how imbedded that is in all of us. But what this statement really did was bring us gently back to reality, and turned our tears to laughter almost instantly. It reminded us that we are alive, and we are doing the best we can, and ensuring that Lisa respects us and feels pride towards us just clearly meant something to us both. It reminded us that we are human, and we feel sadness, but can also feel happiness again.

So you see, a Nurses tears contain a plethora of pent up emotion, life changing, and life ending memories. A Nurses tears play a very important part in reminding them that they are human, that they care, that they feel. I think as a palliative nurse it’s good to have those reminders every now and then, particularly when death and dying becomes such a ‘normal’ part of your every day. You never want to become numb to it, you never want to feel completely emotionally blocked.

So I embrace those tears, even when I think about them today. That morning, I let them flow, and I also discovered the true ‘human’ in a fellow nurse that day.

Oh and I told Lisa.