I love my job as a Palliative Care doctor.
There is nothing that I look forward to more on a Monday morning than meeting with our team, solving problems and helping to relieve suffering in our patients and their families.
It compels me out of bed early and is the only job that I see myself doing until my wife or body tells me to stop.
I’ve never found a speciality in medicine that engages my passion for helping a wide cross-section of people, love of pharmacology and the joy of making a difference when it matters most to many.
But the most common question I encounter when I meet someone for the first time is,
“Palliative Care? Doesn’t working around death and dying make you sad or depressed?”.
The truth is, it doesn’t.
I do empathise and sometimes I cry (often actually ) it is my release and human to experience emotion)
For many nurses and doctors working in Palliative Care, this is our calling, our found passion.
Our work in death and dying is how we find meaning in life.
Most importantly beyond religion and spirituality, we have found a way to deal personally with death, which allows us to give ourselves fully to the care of the dying.
The one thing that I‘ve noted about those who love their work in Palliative Care, is the sense of meaning and the joy they feel in providing hope and relief for those who are suffering.
But not all days are the same.
There are dark days in Palliative Care, days which you’d rather forget and ones that live in your memory, uncomfortably forever.
However, the one thing that you must know is that we don’t blindly enter the world of the dying with little protection for ourselves.
The practice of intentional self-care that I’ve seen in the lives of the pioneers in palliative care is abundantly clear and built into the fabric of their lives.
We understand that we will hear stories of loss, cries of regret that are powerful, see suffering and total pain that can be unfathomable and be engaged in conversations that actively avoided by many.
Recently the one thing that has brought unease in my spirit, is the increasing number of young people with cancer and end-organ failure.
Dark days are inevitable in Palliative Care, but it is how you choose to move forward and the safeguards that you’ve built into your life, that determine your longevity and legacy.
The light will shine
We had a dark week not too long ago.
There was little laughter and jokes at each others expense.
We had two young patients die and we were dealing with several patients with difficult symptom issues, family distress and difficult decisions to make.
The air was thick with tension.
Sometimes there are no words but silence.
In the midst this, we all acknowledge that in our small office, it is:
A safe place to express emotion.
A judgment-free space to express our doubts and fears and complaint.
An environment where ethical debate can occur.
A culture that expects you to take time out for yourself regularly.
The one powerful aspect that I am learning about in the practice of good palliative care is that it takes maturity, wisdom and rest that only comes from self-reflection from self-care.
I have learned a great deal about myself in the last seven years in being a country General Practitioner.
My vulnerabilities — Shame and guilt that I carried and how this affects me daily.
My weaknesses — Areas where I struggled and needed grace.
My energy levels and needs for replenishment — The essence of intentional self-care.
My beliefs and understanding of death — The cornerstone of Palliative care practice
My life philosophy and who I’ve been created to be — A servant leader for Almighty God who solves problems and relieves suffering.
How I manage my intentional self-care
Underlying everything that I do in palliative care is this thought and presupposition about my health and wellbeing.
“I can only care for others if I make it my priority to care for myself first”
In other words, as I grow as a Pain and Palliative Care professional, I need to become an expert in self-care for myself. I need to know the drivers of my physical, emotional, spiritual and psychological energy states and how to replenish them continually.
One common trait of our leaders in Palliative Care who are leaving a lasting legacy, is their commitment to and the place of importance that rest and replenishment plays in their lives.
How futile does it seem to sacrifice your health and wellbeing at the altar of work and care for other people and not yourself and your family?
To me it is madness because of this:
Once you’ve tasted good health, replenishing relationships and happiness that you’ve created through making space in your life for rest……you will NEVER go back.
I exercise every day because it creates energy within me and makes me feel unstoppable.
I have every Saturday completely OFF (minus those that I have to be on-call) to disconnect and do things that make me feel happy and replenish me because this creates margin in my life and restores my stores of energy.
I ensure that Kylie and I connect and talk every day and take one break alone
by ourselves EVERY year because it keeps our marriage strong.
Kylie and I arrange one epic holiday every year with the boys because this our time to experience the world together but more importantly that than, it gives me something to look forward to and anchor my year.
I take time out every month to connect with my spiritual mentor who speaks into my life about my marriage, parenting the boys and my struggles because this self-reflection is important to keep me focused on who I am as a man.
I debrief regularly with our nurse manager and my clinical supervisor about the difficult cases we encounter because their perspective on my performance and the larger vision of palliative care is valuable.
Can you see how much this all means to me?
The desire for my work life, more than anything else, is to serve dying patients and their families with my best.
To do this, caring for myself, comes first.
Practising self-care is intentional and required by every person on the frontline who deals with raw unfiltered humanity.
It is necessary for those who want to remain passionate and effective in their mission to serve.
I will never go back because to lapse into apathy and self-neglect as a palliative care professional will not just be detrimental to my health, but to that of my family’s and my patients whom I have been called and purposed to serve.
How do you deal with dark days and sad cases?
It is normal to feel for your patients and desire to bring comfort to them.
Let your heart be open — don’t hide your distress.
Its okay not to be okay.
Before Christmas, I shared with our Palliative Care Coordinator that I wasn’t okay. She’d said something in passing that triggered an unexpected emotional response in me.
“This is likely to be their last Christmas”, she said, referring to a group of our patients with children a little older than mine.
My chest tightened and stomach churned and tears filled the corners of my eye.
I wasn’t okay with that thought and it circled my mind for days, finding no rest and meaning.
As we were about to start our clinic, I shared with her how much this thought had affected me and expressed my emotion.
I couldn’t change their prognosis, nor could I make them live longer. I had tried to wipe this thought away, but it had stuck close to my heart as I thought of MY young children and the joy of Christmas.
Hiding your emotion over time is destructive to your life energy and will eventually lead to you being depleted and broken.
There is no way that you can be an effective palliative care professional if you don’t allow your heart to be softened by the stories of your patients.
With this in mind, I’d like to share with you an important thought that I was introduced to by my mentor, who counsels hundreds of people a year, often in a state of great despair. It is something that I am learning to practice and reassuringly seeing unfold in my work.
You are responsible for yourself + your marriage and your children (if you any).
You are only responsible to your patients.
“For” and “to” are two extremely important words to understand in context.
We are responsible “for” our families, relationships and lives because this is what remains when work is over and what matters most at the end of life.
Conversely, we are responsible “to” our patients when were are at work, engaged in professional practice and giving them our best knowledge, skill and energy. We are also bound legally by our clinical actions.
However, when we leave work, we should be no longer responsible “for” our patients in our minds and hearts.
This is because we sometimes cannot change our patient’s trajectory, their thoughts and feelings about their disease, their family’s distress, their acceptance of the disease and most importantly, their perceived suffering.
We can try, but sometimes it cannot be changed.
This means you carry the burdens of your spouse and kids and your inner world with you wherever you go, but not those of your patients, unless you purposely allow it.
This is easier said than done and it takes practice to disengage, something that I am learning.
When you work, you do so with excellence, to the best of your trained ability and experience, but that ends when you leave the hospital, hospice or care facility.
We had a clinical debrief a few months and I learnt something profound from one of our long serving hospice volunteers — a beautiful witty retired Scottish nurse.
As she leaves the Hospice after each volunteer shift, she physically pretends to take off her “hospice jacket” and brush “the worry and sadness away” and puts on her “home and outside coat”.
What she is doing is a clever habit that is mentally engaging her in a ritual that helps to reminds her that “work has finished”.
Yes, sadness exists and broken bodies are getting closer to ultimate healing in death, BUT in this powerful ritual, she is setting the intention that “work has finished” and readying her mind, body and heart to re-engage with her family life.
This may not seem profound to you but it has been life-saving to me, my family and my wellbeing.
Brendan Burchard taught me in his book “High-performance Habits” that high performers “set intentions” about what they would like to see and achieve. With this in mind, I started to set the following intention, each time I arrived home after work.
“Work is over, I set the intention of presence, peace, fun, laughter and hope”
With my eyes closed and a few mindful breaths in my car in the hospital carpark, I set this intention. This reframes my thoughts and sets my mind on what to expect at home – usually mealtime chaos, but also my lovely wife and sanctuary of Ramachenderan home life.
Forward we go!
The practice and study of intentional self-care and learning to become a master in caring for myself is something that I am very passionate about.
In the last year, I have begun to share my thoughts to audiences about ways that health-professionals and anyone engaged at the front-line of raw humanity can intentionally build self-care into their lives and thrive in their chosen field.
If you would like to know more, please send me a message or leave a comment, I’d love to hear from you and your story, as I have so much more to learn.
Thank you for reading and please remember to be kind to yourself.
Enjoy your health!
Dr. Jonathan Ramachenderan