PORTRAITS IN PALLIATIVE CARE
Nurse Manager Judith Marchessault on Adapting the Practice of Palliative Care to the Reality of COVID-19
“I am very proud of my team and how they have behaved in this pandemic crisis – how they continue to take good care of the patients, how they have adapted to the craziness of the situation and have learned new things. As the Prime Minister said, we are driving the plane while we are constructing it.”
By Devon Phillips. According to Judith Marchessault, Nurse Manager at Mount Sinai Hospital in Montreal, the COVID-19 pandemic has required the palliative care nursing staff to rapidly adapt to new ways of delivering care in order to keep staff, patients and family members safe. Despite the sense of separation created by new infection control policies, Judith and her team work hard to uphold the humanity of palliative care and ensure compassion remains an essential part of care.
Q: I understand you have considerable experience in palliative care, and at Mount Sinai in particular. Tell me about your role.
A: I’ve been in working in palliative care for 25 years, 19 years at Mount Sinai and before that I was working at CLSC NDG . I am the Head Nurse on the third floor at Mount Sinai which is a mixed unit of palliative care and rehab. Having two different populations is a good balance for our nurses. They are dealing with palliative care and loving this, but also seeing other patients go back home and continue to enjoy life. And then March arrived and we were hit with COVID.
Part of my job is taking care of the nursing staff and I have tried to be an advocate for my staff, making sure they are safe. During the last several months with COVID, managers have had to consult with each other and infection control regarding the security of our staff, the patients, the visitors. That’s been a challenge and hard decisions have been made that might seem cruel, like limiting the number of visitors. Recently we had a daughter of a patient who asked my nurse, “Can I kiss my Dad?” He had just passed away. Everyone has a certain distance that we never had before. Before kids would grab each other, we cannot do that anymore. So COVID has had an impact on everybody.
Q: How have you and your team adapted to COVID-19?
A: I am very proud of my staff because everyone is on board. It was a shock at the beginning and there was a lot of anxiety. Policies were changing dramatically from one day to the next. We needed a lot of information sessions. We were worried we would not have enough masks and equipment to protect ourselves. Since the beginning of the pandemic, we have had 3 patients and 5 staff on the unit who developed COVID. It has been challenging to come to work and not know if you’re going to be infected. Nevertheless, staff still came to work. It takes a lot of dedication to do this. My team is exceptional!
Q: Has the advent of COVID changed the practice of palliative care?
A: Definitely this crisis has modified the way we work with patients and I would say it has created a separation. It is difficult for families to have a loved one dying in this period. According to government rules and also for our protection, we are not allowed to have discussions with families in the corridor. Families are not allowed to go to the nursing station to ask questions so if they want to talk to us they have to call us. We are in protection mode, not as much in caring mode, so this is one of the realities of COVID.
From the time of admission patients are in isolation in their rooms and according to new government policy, the staff has to wear the mask with goggles or with a face shield, as well as the gown and the gloves every time they go in the room. Patients cannot see our facial expressions. They don’t know even what we look like now. And it takes 5 minutes to put all the equipment on. Each of us has a personal face shield that has to be disinfected going in and then going out and we also have to wash it with soap and water because if we only disinfect it we can’t see through it and you have to be able see what you are doing, for example, when you are giving an injection.
We have to focus much more on procedure. In palliative care we usually cry with the families, we hug each other, but this is not possible now. So it does change a lot of the close connection to patients and families. We see it for ourselves. You know when I have a crying nurse in my office, my way of working would be to hold her so she can cry in my arms, and then we get back to business but we can’t do that anymore. But it’s like this for everyone so we are all in this together. Working in palliative care with the heaviness of having people dying and not being able to support each other the way we did before, this is hard.
Q: How are patients and families doing?
A: At the beginning our whole population has been living in a kind of shock. Our patients struggle not having their families with them all the time. It was very difficult for them not to be surrounded by their loved one in such a critical part of life.
I would say that now the situation is better than at the beginning of the pandemic as more family members can be with their loved ones. But because they have to wear PPE (personal protective equipment), it still creates a separation from the patient. Some families are scared of coming to the hospital. The rules about PPE discourage some families from being present with their loved ones. We have asked for support through our Foundation to have iPads available for patients so that they can see their families.
Q: Has COVID impacted the process of grieving?
A: Yes I do think that this pandemic has affected how people can grieve. Funerals are suspended. I am not sure how people are allowed to grieve because in a pandemic, individual loss is not being recognized. We are counting the deaths on the news every day and we are forgetting the actual people behind those deaths. I have the impression that especially when families were not allowed to come to hospitals, it complicated the grieving process for a lot of families as they couldn’t support their loved one. It is taking a toll on the humanity of palliative care.
Q: I understand there are also no volunteers permitted in hospitals at this time. Have you found any ways to help bridge the gaps created by the absence of family and volunteers?
A: Because of COVID, volunteers have to stay home. Our volunteer coordinator Carol Steadman is here with us and she plays an important role in connecting patients with their families through Skype and Facetime on a daily basis. So we try our best to keep families connected. It is not like being there with the patient, but it is certainly helping.
Q: What does the nursing staff need at this time?
A: I would like my staff to have more psychological support. I think that nurses are tired, and worried about the future. We are trying to organize a virtual meeting with a psychologist but it may not be as easy for some people as a face-to-face meeting. People are not used to this.
This is taking an emotional toll on the nurses. Nurses need to protect themselves emotionally. Plus some of the nurses’ rights have been removed. Vacations have been cancelled for the last two months. The knowledge that you cannot have what you are entitled to is anxiety-provoking. The government needs to provide answers.
I also hope there will be more recognition for nurses and PABs after all this is over. It’s not only money that is important, it’s also the perception of our work. I don’t think the public realizes how much we put aside in our own lives in order to do our job. I hope there will be some changes.
But as I said my gang is here and we still manage to have some fun. We try to keep our sense of humor. I am very proud of them.
Q: As the restrictions start to loosen up, do you have any concerns?
A: Yes, we are worried about the impact of deconfinement on our capacity to control what’s going on in the hospital.
We are all afraid of the second wave. People are less careful than before because everyone is tired of the pandemic. In the hospital we have to make sure that people are following the rules of infection control so we don’t put anyone at risk. But this is not easy for families or patients. We hope that when the restrictions are less important, people still respect the isolation rules in health care, because all the patients are so fragile and should be able to have their families surrounding them. If a second wave happens, we don’t want to have to reconfine, as people need to be accompanied by loved ones when they are in the last phases of life.
Q: Is there any good to come out of this pandemic?
A: Yes, we have had extraordinary collaboration from our hospital foundation and the community. We are receiving meals twice a week, and gifts from different Montreal businesses. At one point the firemen and the policemen came by and honked to show their support because there is a sense of connection between us. We are proud of what we do; we are here and we are continuing to do our job.
We have also developed the use of communication technology. The CIUSSS was able to adapt the communication tools so that the staff is kept informed of new developments daily. As managers, we have used new tools to keep all departments aware on a rapid basis. As for the rest of the population, the pandemic had a positive impact on virtual communication.
Q: Despite the difficulties presented by the pandemic, are you hopeful about the field of palliative care and the ability to deliver good care in the future?
A: I would like people to know that the field of palliative care is amazing. Since the beginning palliative care has always been about compassion - compassion between families and staff, compassion between staff members. We provide support to each other. When we are more adapted to COVID in the future, we will be able to return to a more human way of providing care. We are missing the human touch we had before COVID, hugging each other, comforting each other and being present to each other. This is so much a part of palliative care whether it’s patients, families, staff, students. And that’s the other thing that has been missing for us- we have not had any students for several months so I hope they will be back with us soon. We are learning together a new way to provide palliative care.