A Different Kind of Caring

Some patients in Karen Britzky’s charge are old, some heartbreakingly young. They are angry. They are serene. Some lie fast, while others rouge their cheeks and play weekly rounds of bridge. A few speak little English.

About the only thing her patients have in common is that none of them ever get well. And that is why she cares for them.

Nurses like Karen Britzky, who live daily with death, know that grief is not a single phenomenon at the end of a life. There can be a succession of small griefs along the way—grief over a mother too weak to cook for her family, grief over a night spent needlessly in pain, grief over unresolved relationships. Hospice workers witness so many losses, in so many incarnations, that many families and researchers wonder whether hospice nurses eventually become consumed by sorrow.

Yet most research has found just the opposite. While a family naturally mourns death, hospice nurses draw gratification from having rescued death from pain and anxiety. Hospice nursing appears to have more job satisfaction and less turnover than other fields, and most sources of stress have less to do with day-to-day care for dying patients and more to do with external dynamics, such as an increasing workload or patients referred too far along in their illness. “It is possible to grow and thrive in the presence of death,” says Mary Vachon of the University of Toronto, who has long studied hospice nursing. “You can learn to cherish life through death.”

Studies support this view. For example, one national sample of 376 hospice nurses and critical care nurses, reported in the journal Psychological Reports, found that hospice nurses reported less occupational stress, burnout and anxiety about death than their colleagues in critical care. In 2001, a British investigator asked 89 hospice nurses to undergo a battery of questionnaires to gauge their level of emotional exhaustion and patient detachment. The study, described in the Journal of Advanced Nursing, also found a surprisingly low encroachment of burnout.

This is partly because many hospice nurses consider their occupation a mission, not just a job. They believe that enabling a person to die without regret is a profound act of care, and leaves a lasting legacy for the next generation. Hospice nurses are, by turns, medical professionals, hand-holders, hairdressers and storytellers. They see how impending death can liberate a family from pretense and grudge, and release a startling amount of laughter into a home.

Nurses who gravitate to hospice often have a high spiritual quotient in their lives. They feel satisfying the needs of the body frees a person to contemplate the needs of the soul. “It’s a different kind of nursing,” says Ron Panzer, president of the advocacy group Hospice Patients Alliance in Rockford, Michigan. “It’s a different kind of healthcare.” A nurse who is uncomfortable with cumulative deaths usually would not choose the field, he says, or not stay long once there.

“Most hospices don’t have high turnover,” agrees Bridget Montana, president of the Hospice and Palliative Nurses Association. It is indeed common to see an early shakeout for those who find they are not suited, says Montana, who is also chief operating officer of the Hospice of the Western Reserve in Cleveland. A few don’t last through the orientation.

Those who remain tend to do so with fervor. From the moment Karen Britzky took a course in nursing school on caring for the dying, “it was always in my mind I would do this one day,” she says. Her first patient four years ago had an inoperable oral tumor that kept her from eating and speaking clearly. Though a longtime oncology nurse, Britzky, who works in North Texas, had never tended to someone she knew would die. She learned that medical needs often clash with the patient’s needs. The woman would not take her pain medicine because doing so left her too numb to maintain her role as wife and mother. During the last eight months the woman lived, Britzky became enfolded into the family routine. When Britzky paid respects at her patient’s coffin, it was release, not despair, she felt. She imagined a woman who was whole again, and eating the chocolate cake she so loved.

Other patients instill sadness, Britzky says. One woman, dying of cancer, couldn’t believe she used to dread taking her young children shopping. Now, she missed most the mundane acts of motherhood. “Cherish the trips to the grocery store,” the woman told her. “Don’t ever wish away these things.”

Her patients, she says, “have taught me tremendously the preciousness of life.” The lesson came home a year and a half ago when Britzky herself was diagnosed with breast cancer. Though now finished with treatment, the experience transformed her as a person and as a nurse. She realizes more now how simple, ordinary acts like baking a cake and putting on makeup can be just as paramount as medicine from a vial. Britzky has learned hospice nurses, perhaps more so than many other nurses, have the opportunity to connect with patients. To just sit and listen.

Patients notice the slower pace. When Anita Harkey’s father was in the final throes of metastatic bladder cancer a decade ago, the hospice nurse became central to the family’s life. “It felt like we were her only patient in the world,” Harkey says. Her father stayed comfortable and calm. The nurse somehow found the emotional tightrope between caring too much and too little.

“She wept at my father’s memorial service,” Harkey says. “I think they are the most feeling medical professionals I’ve encountered.” The experience of watching first her father, and then her mother die in care of such nurses so moved her that Harkey now volunteers with a Texas hospice.

Trudi Kozak, of Cleveland, started out as a hospital nurse but has now been a hospice nurse for 11 years. Kozak says hospice nurses often feel they leave a lasting imprint on families, which is one of the job’s rewards. She knew this from the death of her first patient, a man with lung cancer that had spread to his brain. At first, the family was frightened of the idea of death, loss and even their own grief. Over time, Kozak says everyone accepted their fears as normal and healthy, and the patient died with his wife, son and two daughters at his bedside. “What better gift can you give a patient than to die in peace and not be afraid?”