Who is Palliating Us?

A cacophony of beeping IV poles greets me as I enter the intensive care unit (ICU). My eyes follow their thin long tubing as it snakes its way through closed doors marked “COVID positive.” ¹ IV poles, ubiquitous to the bedside of intensive care life, now litter the halls. They appear out of place and apprehensive, as if yearning for the comfort zone of their patients' presence. I feel the cognitive dissonance as I stroll through taking stock of this new normal. What once was a pristine sterilized corridor is now lined with folding tables covered with a litany of disinfectants. The tables seem more appropriate for holding potato salad at a church potluck than virus killing chemicals at this state-of-the-art hospital. I peer into a family meeting room that's now packed with containers that look like children's toy crates. Each tub filled with personal protective equipment (PPE) and marked with a name in permanent marker on duct tape. The exhausted owner has staked their claim to its unwanted contents: the reused germ-ridden protective equipment is mine and mine alone. Even our attire feels the sting of isolation.

My mind nostalgically wanders to all the discussions that had happened in this room. Joy, anger, fear, grief, and all the byproducts of unexpected change had coursed through these walls. The family meeting is the palliative care doctors' greatest tool. The strategically placed box of tissues, chairs positioned in an inviting circle, and the note on the door reserving the time and place—the ultimate setting in which to align our treatment plans around the central focus of patient values. ² Nowhere is the intensity, complexity, and limitations of medical care more realized on a daily basis than in these rooms, and it is an honor to bear witness to it. It is a sacred space, and the ghosts of conversations past linger in my mind. Now it's filled with plastic bins, industrial storage shelves, and a dusty dialysis machine.

A nurse enters the room to grab her gear for the monotonous task of donning. Her eyes are weary and I wonder how we got to this point. Early in the pandemic, there was a collective societal push toward facing this together. The world, mostly oblivious to hospital life, suddenly was teeming with interest. “Support our frontline workers” became a rally cry: handwritten signs, military jet flyovers, and daily meal deliveries from local restaurants. The tired battle analogies that often ring hollow in medicine sprang to life again. My stethoscope became my dog tag, my isolation gown my armor, and my N95 my helmet. It really felt like going off to war, and to call it a life-or-death battle is not an embellishment. We held our loved ones more tightly not knowing the extent of our exposure risk and the fear of facing an invisible enemy.

Death is no stranger to hospital work, but there is often an expected rhythm to life's inevitable end. What causes it, when it should happen and what we can (and cannot) do to stave it off. But the pandemic has washed away the solid footing of our assurances. The chasm between the expected and unexpected, the known and unknown, has left us with trepidation. It is a vast cavernous abyss we aren't sure how to traverse. And although the uncertainty and anxiety of a crisis not yet fully realized brought its own weight, there also was a sense of “this is what we are meant to do.” So we got in our cars, took a deep breath, and pulled out onto eerily quiet highways. We, the health care workers of the world, drive toward the problem; because if not us then who?

But that was the spring. The summer days have slipped into the predictability of fall leaves and winter chill. The world has moved on. The lunches, cards, and social media hearts have slowed to a trickle. Medical advice has been politicized so that unity seems impossible and suspicion reigns. The initial push that catered to our better human characteristics of duty, selflessness, and courage has been clouded. Overworked, underappreciated, and often underpaid workers across the health care spectrum have felt their resiliency wane as the slow burn of an unrelenting enemy leaves silent scars from untreated emotional wounds. A staggering array of health care workers are experiencing symptoms of burnout.^3–5 The horrors of pandemic work are pushed down deep for none to see, but the simmering strain is etched into the eyes. You just have to look in their eyes.

I ask our palliative care team, “What can we do to better support our frontline staff, nurses, and providers?”

“But who is palliating us?” comes the response.

This consequential question strikes me as I try to process what seems to be incomprehensible. Palliative care is a unique brand of medicine, and baked into our very definition are the proverbial ideas of minimizing suffering and supporting others. The blending of the metaphysical with the historically rigid science of modern medicine continues to baffle many in the general public and health care community alike. We believe there is healing power in advocating that medical care be more than just about the longevity of our cells. But our tools of value alignment, emotional validation, and walking alongside our most vulnerable have been stripped bare by visitor restrictions and layers of protective gear. Holding a patients' hand skin-to-skin feels like a distant memory.

It's then that I allow myself to recognize—I'm not well. The trauma and grief of the unexpected mixed with the “norm” of isolation created a concoction of unsettling stew that I realize I am not well equipped to digest. I wonder whether the draw of palliating others creates an ironic dichotomy of not palliating ourselves. We are the steady hand, the emotionally centered stabilizing force that willfully wades into the most traumatic, volatile, and chaotic cases our hospitals can throw at us. But behind the scenes we are still people: who mourn, and break and desperately need help beyond our own willpower. And if this is true for me, it must be true for many who find themselves at the crossroads of unrelenting pandemic work and crumbling resolve.

We are in the chronic liminal phase of the pandemic. And now more than ever we all must find within us the unnatural ability to raise our hands and acknowledge that we cannot do this on our own. Yes, for the sake of our patients, but also for ourselves. We don't need a military flyover to feel appreciated, but we do need help.

I walk away from the family meeting room turned storage closet and look at my consult list. It's long and I sigh deeply. My patients need me and I must have the fortitude to do my job well. But I think I'll also call a friend tonight and actually schedule that appointment with a therapist that I've been putting off for years. Because the reality is, it must be ok to not always be ok.