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Naturopathic Approaches for Palliative Care with Sarah Franklin

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Naturopathic Approaches for Palliative Care with Sarah Franklin

Is there a place for naturopathic medicine in palliative care? What is the active role a naturopath can play within a patient's healthcare team when a person's illness progresses to a palliative care phase?

Sarah Franklin is a Registered Nurse, Naturopath and Acupuncturist with a vast breadth of expertise in oncology care and today we'll discuss the more personal, sometimes confronting aspects of naturopathic care when our patient's prognosis changes to palliation. Sarah shares her expertise on how to best manage symptoms and offer ethical, safe and compassionate care to enrich and honour a person's final days. 

Covered in this episode

[00:57] Welcoming back Sarah Franklin
[01:56] What is palliative care?
[04:52] Understanding what's within your scope of practice
[07:56] Being sensitive to cultural differences with end of life practices
[10:53] The patient's "support crew" 
[16:07] Where can integrative medicine be applied in palliative care?
[21:49] Managing expectations
[26:23] Getting comfortable with death
[34:45] Practitioners need to develop a supportive network
[40:38] Be realistic about what's achievable


Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Sarah Franklin, who's a Gold Coast-based naturopath, registered nurse, acupuncturist, and winner of the 2016 BIMA Award for Naturopathy. 

Sarah is specialised in oncology nursing by initially training as a registered nurse and specialising in oncology and palliative care, with further education in cytotoxic drug administration through the Royal College of Nursing. 

Over a period of time, Sarah could see the benefit of integrative medicine with oncology patients, which encouraged her to further her education in naturopathy and acupuncture. Sarah works with patients and educates local cancer-based support groups, cancer councils, oncology nurses, and oncologists on the use of safe integrative approaches in regards to oncology. 

Welcome to FX Medicine, Sarah Franklin. How are you?

Sarah: I'm very well, and thanks for having me.

Andrew: Sarah, today we're going to be talking about a sadder aspect of integrative care, and that's palliative care. You've got a lot of experience in this because you're a registered nurse, and you've nursed in that area as well as being an integrative practitioner in that area outside of hospital. But I think we need to go back right to the beginning with the definition, palliative care, what is it?

Sarah: Well, palliative care, it's one of those...it's a really broad topic, but basically palliative care means the care that you're specifically giving a patient towards the end of their life. So, that can be a really broad thing because there's lots of aspects to palliative care. But basically the focus should be on improving the quality of the life of the patient and supporting the family around that patient. But it's also important to remember that a lot of patients get anxiety when palliative care teams get involved during the end of their life, and there is a negative stigma about the word "palliative care." In that when people talk about palliative care, they tend to think end of life, or dying, but palliative care is that whole process leading up to that, too.

So, palliative care is about making sure their quality of life during that phase is there, not just the death part at the end. So, it's quite really important to understand that palliative care isn't just the dying bit at the end, that it's about the whole process towards the end of life. As far as once a patient's disease is at that point where, you know, that there's not going to be any recovery from it.

Andrew: And, indeed this can be lengthened by integrative naturopathic care. So, maybe we should think about a different term. What do you think about the term like "non-curative care?"

Sarah: Yeah. Something like that might just get rid of that stigma for the patients. Because in the community or...and death is such a taboo subject in Australia, anyway, so nobody likes to talk about it, and it tends to be something that a lot of people are uncomfortable to talk to their patients about, or they like to skirt around the outside. Because once you start talking to a patient about palliative care, then it becomes...I know we've talked about before, that, do people think that you're giving up on them? Do they give up on hope for their treatment? But that's not the case. It's just that the treatment or the focus for your treatment is starting to shift.

But it would be something like more non-curative disease. There definitely could be a better word for it because I think a lot of the people when they think palliative care think death rather than all the other things that encompass leading up to that. It's not just that...that death part at the end is such a small part of that process.

Andrew: Yeah. Indeed, I can remember a great transcript that I read, I didn't listen to it, but it was on The Conversation. I think the thing was it's not all about death. You know, conversations with patients in palliative care, there's this assumptive focus on death and dying. And I'm not saying, indeed pointedly not saying that we shouldn't talk about death and dying, that we should dispel the stigma of those discussions. 

But, there is also that thing about that part that it isn't all about death, and there are things that we can do. There's a lot that we can do in helping them to even elongate their days.

Sarah: Absolutely. And, that's where, like, we have the benefit as integrative practitioners to, I guess, from a medical perspective, you're sort of more focused on specific symptoms that are occurring. Whether it be constipation, or insomnia, or cachexia, or the specific things that you're focusing on. But for integrative practitioners, although that we can certainly help support all of those things, we can definitely focus on other things, too. So energy, mood, appetite, there's so many other things that we as integrative practitioners can focus on, too, rather than just putting out the spot fires that tend to pop up as the disease tends to progress.

And, that's where, as a practitioner... So, the same in my perspective, so I work predominantly as a naturopath in my clinic, that I have to be really real about what is within my scope of practice, and what is not. So, I know that people that listen to your podcast are from diverse disciplines. Some of them are doctors, and some of them are dieticians, and some of them might be physios. So, it's really being realistic about what your focus is, and what your capabilities are, and how you can benefit that patient. But also being realistic about, does that patient need to be referred for grief counselling with a psychologist, or do they need a referral to a dietician for their cachexia, or do they need a referral to exercise physiologist to try and maintain mobility that might be through degenerating disease, or...

So, it's really becoming aware of what is within your scope, and when you need to refer on. And I think if you do that, you know, you're definitely going to do a better service to your patient, but you're also not going to end up in a position where you end up going, "I could have or should have done things differently," towards the end when the patient does deteriorate significantly. So should have you implemented these things earlier? So, it's just being realistic about what you can do and what you can't do, and then building that team around you to work with those patients with their specialist, or GPs, or other doctors that work in that field as well.

Andrew: And, this is, of course, the goals of care, which, you know, ASCO even talks about now. I think the lesson is to have these goals of care early, not late, correct?

Sarah: Definitely. And that all comes about, like you were saying before, that comes about having those conversations with the patient. And, that doesn't mean on your first appointment that you bring up the death topic and it doesn't even...

Andrew: Talk about dying. Probably not appropriate.

Sarah: Probably not. 

But, definitely, you have to start sussing out what their... Definitely, palliative care, one of the big things that we focused on when I went to the university and when I did more study on that, was that even though two people can have the same cultural beliefs, they can be so different. 

So, if you're looking in Australia, if you looked at Christians, the views on how a Jehovah Witness versus a Roman Catholic dictates their health care are so different. But from someone who doesn't understand Christianity that well, you might go, "Well, they're all the same." It's like, well, they’re not, they're very different. So, it's really important that, as Australians, where we probably understand Christianity a bit better, but it's being realistic, same thing with Hinduism, or Judaism, or the Muslim religions, that they are culturally different, too, within their subsets.

So, it's really important that when you're talking to patients is to find out and to make sure that you're supporting and that you're valuing all those beliefs that they have, because it's not your beliefs that you're putting onto them. It's really understanding, you know, they might have certain beliefs around what food they can and can't eat. Or they might have certain beliefs about whether they would have a male or female support teams physically. Because there are certain religions where you can't touch…

Andrew: Right, yeah. 

Sarah: The opposite sex towards the end of life.

Andrew: Yeah. 

Sarah: Or that you need to be a certain religion. Do you know what I mean? You’ve got to respect those religious dates...

Andrew: Sure.

Sarah: And all those sort of things within those groups. So, it's really important that you're talking to the patient to find out what do they want, you know? And, you'll know when a patient is ready to start to admit that things aren't going well. So, in the meantime, you sort of focus on, well, you know, what are your goals? Is it to, you know...did you want to try and stay at home as long as possible, or if the care requires it, did you want to go to hospital? Do you know what I mean? If you're unwell, how did you want to... Do you know what I mean? And that's really different things for different people. 

So, some people prefer to be in that hospital environment where they feel a bit safer while other people prefer just to be at home with their family where they've got that family support around them, but being realistic that when that occurs there's a much greater demand on the support network for patients that do stay at home. So, then it's making sure that they've got the services in place to help them with that process.

Andrew: When you talk about the support network, that indeed can be a whole other ballgame when the carer, who is very often the partner, is eventually left without somebody to care for when the patient dies. And there's a whole chapter opening up there.

Sarah: Absolutely. And, it's really being sensitive to the partner. So, you've got to be realistic that that's their support person. And you've got to be realistic that patients in the palliative phases can get quite aggressive, and they can get quite agitated and bits and pieces. And some of that comes from fear because they're scared. Some of it comes because they're in pain and they're uncomfortable a lot of the time, so we all get irritable when we're like that, anyway. But you've also got to be realistic there are some metabolic things that occur during palliative care that can make them quite confused and agitated cerebrally, as well, which we say in palliative with the calcium levels and different things going off.

Andrew: Yep. 

Sarah: So, it's really important that you support the support person because it's a really unusual role, and there has been some research out to show that, just you know, just for cancer patients that aren't palliative, is that the post-traumatic stress period can last longer for the support person than it can to the person undergoing treatment. 

So, they're definitely showing that there is a lot of trauma associated for those people that are caring for somebody when everything's out of control for them. So they can't control anything, they've, sort of, just got a buckle in for the ride, so to speak. 

But it's also being aware that that relationship changes, too. So, if you've got a husband and a wife, for example, and the husband's in a palliative situation, the wife almost becomes the mother. So they become this caring role, and then that shifts the dynamics within the marriage because that imbalances, then you end up with, like a mother-son relationship rather than a...

Andrew: Rather than an intimate relationship.

Sarah: ...husband-wife relationship, yeah. So, it's really important to make sure that, you know...and sometimes, with patients and support people, it's just making them aware that that's not happening. So, you know, the reality is that you're still their wife, you're not their mother, so your relationship is different. You're definitely there as a carer, but you don't want to lose that other relationship because that's what it was. If that makes sense? 

So, it's being really aware that those relationships can shift, too, so they really need support as far as... Or the same thing for children, children becoming a parent role when...

Andrew: Oh, gosh.

Sarah: ...they're the child. So, there's a lot of conflict...

Andrew: That's hard, isn't it?

Sarah: Yeah...that occurs. So, it's the same thing. But if you're all talking about it and you're all aware of it, then I think the patients and the support crew deals with it much better than when you just...you know, a patient's coming in, and, "Why are you here?" And, "Okay, yep, yep. You're anxious or depressed. We'll give you this and off you go.” Rather than actually sitting there and spending time with the patient to figure out what's going on. Because it's...you know, it really is...palliative care is such an individual approach with every patient. You know, there's some patients who might be quite accepting of the whole thing, and then you've got others that will be in denial right up to when it all occurs even though the family around them are aware of the situation.

Andrew: You said a very interesting word just earlier, and that was "support crew" rather than "support people." Does that word, "crew," does that engender a teamwork approach, a collective approach, a bolstering approach to their psyche? Does it help?

Sarah: I think so. And I think a lot of people think, "Well, it's the immediate family that are going to be the primary carers," when it's not often the case. 

And, the same thing going back to cultural diversity. So, I know from a nursing perspective, when we're doing palliative nursing, there's such a stark difference between, say, traditional English lineage where we tend to you're 18 years old, you move out of home, when you're too old, you'll probably go to a nursing home. So, that tends to be a more English approach where, like, you know, you see some of the Italian families, and some of the European families where the cousins and everybody are all involved in that care and management. So, you know, they take a lot of responsibility, and the way that they approach is a lot different.

But, when you're looking at support crew, I guess, it's looking at that whole other team. So your naturopaths, your massage, or your physios, like, you're all a part of that patient's support team, and you would all emotionally be getting affected by what you see every day doing what you're doing, and you should be. So, it's a supporting... Like, I'm aware of my patients with even my reception, so the girls that take the appointments and do all of those things, I'm really aware of, you know, if a patient passes away, are they doing okay? Because they're the person that's, you know, speaking to them on the phone, and, "Do you need appointment?" And all of those sort of things. 

So there's a lot of people involved in their care that you just want to make sure that everyone's doing okay.

Andrew: Who cares for the carer? When we're talking as an integrative practitioner, as opposed to an orthodox team, when we're thinking as an integrative practitioner, what aspects can we help with, with regards to palliative care?

Sarah: So, I guess the main things as an integrative practitioner, so some of the main things that we come across, so the first thing before I go into those would be, just really take seriously your medication interactions. So, lot of palliative patients are on a lot of medications. A lot of them are sedating, a lot of pain medication usually. So, really just watch your drug interactions so that we're not over-sedating patients, and that we're not clearing them out through the CYP enzymes with the liver because then we're being counter-antagonist. So, first off, just make sure with whatever we do that you're making sure that it's safe.

Probably one of the main focuses would be the cachexia. Which is when in the palliative stage...and this is not just cancer. So, when people talk about palliative, they often go, "Cancer," where there's lots of diseases that are palliative. So, your dementia, your Alzheimer's, your CBAs, there's so many diseases that are palliative, that can go on for a period of time where a patient can deteriorate. 

Andrew: Yeah, yeah. 

Sarah: But cachexia is something we definitely see with a lot of disorders, so the neurodegeneration diseases, and cancer. So, that's where a patient loses weight, loses muscle tone, fatigue, when they're not meaning to. So, they're sort of losing weight, and they just can't keep it on.

So, cachexia is one thing. So, that's when we're really focusing on their diet. So really focusing on making sure that their calorie intake is a lot greater than what it should be. So making sure that they are eating enough. And really focusing on the proteins, the fats, and the carbohydrates. So, you're sort of...you're definitely wanting to bolster as much of that stuff as possible. But, keep in mind if the patient is on dietary advice from the hospitals, then follow it. So if the patient is say, on a low residue diet because there's bowel obstructions and things happening, obviously don't disregard specific diets that they've been put on because they're there for a reason. 

Andrew: Yep. 

Sarah: So, really with the cachexia, trying to get that caloric intake up. The same thing can be used with those patients, is your protein powders or your, you know, I'm not a fan of the Sustagens, but you get to a point where you're just trying to get anything in to keep the energy and the calories up. 

So, that would be one thing to focus on. There's, I think it's University of Technology Sydney are currently doing it. They're doing some clinical trials on cachexia and cannabis. They're trialling two different forms of cannabis products to see if that can help with appetite, stimulate appetite, with palliative patients. So they're doing a trial at the moment.

So, that would be the first thing in the integrative, so are they getting enough nutrition? So, really focusing on that nutritional intake. 

One of the other things we see a lot of is bowel issues. So constipation's your big one. So constipation because of the medications or painkillers that they're taking. But, again, just be mindful that, you know, with bowel obstructions we don't normally use anything stimulating. And, be realistic because some of these patients may have had significant abdominal surgery, so they might have adhesions or things like that. So just...

Andrew: Even colostomies.

Sarah: Yeah, absolutely. Absolutely. So, managing all of those sort of things. So trying to use things to keep their bowels active. So, that's probably one of the big things that we see. Because once they get constipated and they start getting bowel obstructions, then they just lose their appetite straight away, and then their stomach shrinks, and then you're, sort of, back to trying to feed them up again afterwards. 

Andrew: Yeah. 

Sarah: And, obviously when they're in hospital, they’re nil by mouth for a few days until the obstruction clears, if they can't clear it normally.

And, obviously just liaising with those patients, too, if they've got PEG feeds or nasogastrics, is liaising with the medical team. So, don't ever attempt to put anything through a nasogastric or a PEG without speaking to the medical team. So, there are some things that, you know, I've used before with PEGs, or whatever. But you really need to run it by the team to make sure that you're not going to do any damage to those devices. 

And, at the end of the day, being realistic. So, I think that's what I've seen as a practitioner, is that I'll have palliative patients coming to me, and they've been put on these no dairy, no wheat, no sugar, really restrictive diets, and they're following because they're desperate. But they're right in their palliative stages, and it's like, well, it's not...that's when you've got to start to get realistic about what your treatment focus is. So, are you going for cure, or are you not? And then, if you're not, it's being realistic that they need to have some quality of life, too. So, if they occasionally want to have that wine, or they want to have...you know, they go out and they have a dessert, it's not the end of the world. Do you know what I mean?

Andrew: Yeah.

Sarah: So they have to enjoy...

Andrew: It's enjoying.

Sarah: ...their quality of life. Yeah. So, for some people, food is...you know, it gives them a lot of pleasure. And other people it could give it or take it. 

So, it's being mindful of, you know, sometimes if you're too rigid and you're too restrictive with some of the things you’re doing in the palliative care, you're not helping with that, so you're, sort of, creating a lot more anxiety around what they do with that.

Andrew: I covered this off with Lise Alschuler, and she's got this brilliant positive mind. I mean, she's such an amazing lady. But the topic was, changing the focus when people are desperate. So, they're in desperation. They really are towards the end of their days. They're in the hospital. Nothing more can be done medically. You'll find probably that the medical team is more open to anything integrative because they can do nothing more medically. 

The problem comes, though, when the patient is desperate and wants a cure, and there's this drowning man sort of period. How do you handle that with regards to palliative care? How do you handle it with regards to the patient? And, how do you handle it with regards to the team?

Sarah: I think you've really got to listen to the patient. Because the patient can sometimes be saying they want a cure but you can tell that they are thinking otherwise. I guess it's making sure where they’re coming from. Because some patients are fixed on a cure but...you know, I've had so many patients that I've treated that are like, "I've had enough. Like, I've had enough, but my family are pushing me to keep going." 

Andrew: Right. 

Sarah: But they've had enough. So, it's trying to figure out, well, who's driving it? So, is the patient driving it, or is the family driving it, to a degree?

Andrew: What do you do there, though, when it's the fear of the family?

Sarah: Yeah. And, I think that's when...you know, I guess, I’ve probably, over time, I probably...I wouldn't say I'm a bull-at-the-gate, but at the same point I'm not going to mince my words when it comes to...not in a mean way at all, but I'm not going to give somebody false hope. So, if they're at that point...

Andrew: I think that's the worst thing you could do.

Sarah: Yeah. If you're at that point...and we definitely see patients, too, where that's happened to. Where patients are being told, "Yep, we're going to give you all this integrative medicine stuff, and we're going to cure you," but it just doesn't. Do you know what I mean?

Andrew: Totally unethical.

Sarah: That's unethical. So, it's being realistic about what you can and can't do. And I think there's a part as a practitioner, too, where if you say to a patient, "I can't help you," that you're failing as a practitioner. 

Andrew: Yeah. 

Sarah: So, I think practitioners feel like, "Oh, I'm failing, and I don't know what to do, and there's nothing I can do to help you, so I'm failing as a practitioner." Rather than maybe you're not failing, maybe you're acknowledging that that's where you're at right now.

Andrew: Limitations, yeah.

Sarah: Yeah, your limitations, that this is moving forward, this is how I can support you in the right way. 

So, I think it's definitely...I think you learn in time when you're dealing with them that you know when that point is to have that discussion. To go, you know, "Where are you at? What's going on?" And, I guess if you feel like their family are really driving it, that's when you try to get the patient on their own, because generally they'll always be there with them, those type of families. 

Andrew: Yeah. 

Sarah: It's trying to get the patient on their own. And, it's amazing what candid discussions that they can have where they can just, you know, voice their concerns and their fear about, you know, "Is my family going to be okay, and is everyone going to be okay when I pass away?" But they can't, they don't feel like they can have those discussions with some of the family members. And that's nothing negative within the family structure, it's just different people feeling comfortable expressing different views.

But I think, yeah, as a practitioner, I think if you're aware of your limitations, you're not going to string a patient on in that way. But I think patients...I think...sorry, practitioners definitely need to be realistic and really accountable for what they're saying as far as how much hope they're giving or what advice they're giving. Because patients hang on every word, and often these palliative patients are with you because the medical system couldn't offer them anymore, so then they've ended up here.

Andrew: Yep. 

Sarah: Just like they do with a lot of, you know, with naturopaths, a lot of skin disorders and everything else, they've been around the traps and no one can help, and then they end up with a naturopath.

So, I think it's, yeah, definitely being aware of your limitations. But I think you start to know when the patient's...you know, you definitely know when you're ready to start to have that discussion about, well, you know, maybe instead of focusing on that, maybe we start focusing more on your digestion and your energy just so you're feeling better.

Andrew: What do you think about the work of Dr. Ranjana Srivastava and Bronnie Ware with regards to what patients want to have, what conversations they want to have, and indeed their regrets?

Sarah: I think, with patients, yes, we definitely have those discussions about what...I think, regardless of what my patients walk in the door, I always want to know early in the piece what their goals...what do they actually want? So, what I think they should be doing can be very different to what the patient's wanting to focus on.

Andrew: Right. 

Sarah: But I think it is very important to focus on, well, what...I think you do bring up that really early in the piece where you go, "Okay, well, if this doesn't work, if what we're doing doesn't work, then, I guess, what are your thoughts, or where are you thinking of going with that?"

Andrew: Yeah. 

Sarah: There are psychologists around who specifically deal with grief. Like, there are specific grief psychologists out there that just do a lot more of that sort of work, which are really beneficial, because not all psychologists focus on grief in the palliative stages. 

So, it's definitely seeing how comfortable the patient is with their own death, and, again, what their beliefs are around that. And I think that's really important as far as a practitioner before you even go there with a patient is you need to be really comfortable with what your concept of death is.

Andrew: Yeah. 

Sarah: So, you need to be really comfortable with your own immortality, that we are all immortal, and that we're not all going to be here forever, so we're all going to be in that palliative stage, you know, at some point. 

Andrew: Yeah. 

Sarah: So, I think, as a practitioner, before you can have those comfortable conversations with a patient where you're relaxed with it, I think you definitely need to be comfortable with your own sense of death. 

So, coming from a nursing perspective when I first did palliative care in a nursing aspect, I remember I was only 21 and I'd lost 7 patients in my first 5 days, or something. And I was immortal, I was 21, you know, you're 10-foot tall and bulletproof.

Andrew: Yeah. No, you're not, Sarah. You are not 10-foot tall.

Sarah: Oh, Okay. Come on, Andrew, they can’t see me. And I really had to process how I thought about this. So, I had a lot of anxiety about death, and I remember going to the nursing unit manager and saying, "Oh, I don't think I'm cut out for this palliative care because it's...you know, I'm thinking about it all the time." 

But, eventually I got to a point where I was comfortable with it, and I was comfortable with my own mortality that, yes, I was going to die, and I was okay with that. So, I really was comfortable with it. And, I really saw the work that I'm doing with palliative patients as a privilege.

So, I see dealing with a patient, people go, "How can you deal with palliative patients all the time?" It’s like, I see it as a privilege. So, I really believe that you can help someone to have a good death, and to have a good end of life just like, you know, the midwives can help women, or babies come into the life, and have a beautiful birth and a beautiful experience. 

So, I think us as practitioners can play a really vital role and you can either make it something really beautiful, and loving, and calm, and peaceful. Or you can make it really traumatic and scary, and everything else. So, I think if you can be really calm and comfortable in your own skin, then I think you can really sit with a patient humbly and go, "How can we help, and how can we work through this together? How can I help you work through this together?" But, I think if you're not comfortable with where you're at, I think you'll struggle.

So, I think some practitioners definitely need to sit in that space to a degree. And the same thing, I was very comfortable with it, and now I’ve found years later after I had children I had a spike in order...you know, just a spike in that little bit of when you're dealing with death all the time, and you're around people that are dying all the time, you get a skewed vision of the world where you think everyone's dying when they're not. 

And, I remember having the kids and it spiked again. I was like, "What's that about? Like, I was really comfortable with it. Why am I getting a bit anxious now about my own immortality?" 

Andrew: Right. 

Sarah: And it came around, and it took me a while to get there, where I went, "It's my ego. It's my ego that I think that I'm so self-important that if I die, my kids aren't going to be okay."

Andrew: Oh, I see.

Sarah: And, it took me a while to go, "The reality is my kids would be okay." 

Andrew: Right. 

Sarah: So, yes, they'd be sad, but there's lots of kids that have lost their parents and they've grown up to be strong, wonderful, beautiful people who, yes, are very sad, and I'm sure they'd prefer their parent to be there, but it didn't stop them from being who they were. 

Andrew: Yeah. 

Sarah: Do you know what I mean? So, that was my ego that I thought I was irreplaceable, when the reality is I am.

So, it's the same thing, you, sort of, have to come back around and go, "Okay, you know, I'm comfortable with it. If something happened, I know that it's..." Do you know what I mean? You have to really be comfortable with it. And, I think if you can be comfortable with it, I think you can be less desensitised to it. Which is something that we see in the medical profession a lot more where practitioners are quite desensitised to a lot of things that happen. So they're quite disconnected and they don't grieve at all when you lose a patient that you've been looking after for months. But I think that that comes from a fear base, too. Where it's just easier to disconnect than it is to hug a patient or hold their hand and go, "I'm sorry, and I'm really genuinely sorry that this is happening to you," and to have a cry with them, and that's okay. Do you know what I mean? Rather than not having any emotion, because I think you do need to provide good care, I think you really do need to feel and be compassionate to what's going on.

Andrew: You actually struck a chord there. I was just blinking away tears. But, indeed this is what Ranjana...forgive me, I'm going to mispronounce her name, Ranjana Srivastava...I've confirmed her name, she talks about, and there's this disconnect. Particularly she talks about her own profession, medicine. So, doctors are disconnected from their patients because of these fears. 

But, there's also been work done by a nurse in palliative care, and forgive me, I cannot remember her name, but she has also interviewed a lot of patients, talking to them about what are their regrets? What are their thoughts about their life and their fears?

Sarah: Is that Kübler-Ross?

Andrew: No, not Elisabeth Kübler-Ross, that's the stages of dying. This was a lady more recently who's interviewed patients about their regrets in life, or about their thoughts about dying. And it was like most people, by far, had their regrets about not being with their family, not living to their own full potential, that sort of thing. Nothing, nothing was regarding money or things. It all went back to people. It was really interesting.

Sarah: Yeah. And, you know, it does strip away all of those things that are important or, you know, things that we waste time on that we just shouldn't be wasting time on. So, it definitely puts...I think that's an advantage of working with palliative care, is that you certainly...you're a bit more realistic and a bit more grateful for things, I think, in life than other things that people take for granted, that they just think you're going to be there tomorrow, but they won't be. 

And I think that's where there needs to be...there's not a lot of education around palliative care, or there's not a lot of education on death, dying, bereavement. There is probably more so in the nursing realms.

Andrew: Yeah. 

Sarah: But a lot of the other industries don't really focus on how you can be of benefit at that stage. And they all have such a...all of those, there's different disciplines, your physios, your massage therapists, they can all play such a really vital role in, you know, just touching a patient or...you know, just that contact with some patients is something that, you know, they just need.

Andrew: Yeah. What about the point of letting go? What about telling somebody that it's okay to let go. That it's okay for them to choose when they want to go, rather than hanging around for others? You know, how nursing staff go through this quite a lot where they say, "Look, just go and grab a cup of coffee," and the person dies while they're just away. You know that sort of, "Let them die alone because everybody will die alone in the end.” Family can be around you, but there's this...it's almost like people hang on so as people aren't there to see them breathe their last breath.

Sarah: Yeah. I think, yeah, patients definitely choose. I'd probably say more...yeah. And, definitely, you know, I've been with patients where you've gone, "It's okay to go. Like, it's okay to stop fighting," because I think they've fought for so long they don't know what else to do. 

But, I think, like, I guess, from a naturopath's perspective, we don't see patients at that end, that end-end-stage, which, as a nurse, we do. And I think that's where if practitioners saw patients in their palliative stage, I think they'd be a lot more accountable for what they do with their care and their management.

So, I think, because I've nursed so many patients with death, I'm very realistic about my accountability with that patient when I'm treating them in my rooms. So, I'm very realistic about, I've seen the patients lie there in bed and go...you know, the ones that might have done all chemotherapy, and nothing integrative, and they'll lie there in bed and go, "I wish I'd changed my diet, or I wish I'd done something differently." And, vice versa, you can have someone in there that did no chemotherapy, and did all naturally, going, "I wish I'd had surgery, or I wish I'd...what if I'd done something differently?"

So, I think that's when it comes to treating those patients, I think if you saw more of that, you'd be more realistic that at the end of the day, it's that patient that's going to live with the consequences, not you. 

Andrew: Yeah. 

Sarah: So, it's them that are going to experience it.

Andrew: Live and die with the consequences.

Sarah: Yeah, absolutely. So, I think you need to have more accountability with that, but it’s okay, you know, it's okay to have those discussions with those patients, and to let them know that it's okay if they don't want to fight anymore. Like, that's okay. 

So, I think a lot of...you know, they're not doing it for themself anymore, they're just doing it for everyone else. But that's not why they should be doing it.

Andrew: So, there's so much more to discuss with this, I mean, it's such a...

Sarah: It's a massive subject.

Andrew: Massive.

Sarah: But, I don't think...as far as the medical body and the nursing body goes, I think, particularly the nursing body, is that we have really good support networks in place for us as nurses. So I think nurses are very good at debriefing with each other. I think we have support. We've got psychologists if we need them, we can all relate because you can finish your shift and then you can go...you know, all the girls or guys know what we're experiencing during those shifts. So...you know what I mean? You don't need to talk about it as much because you get it, you're doing it and you're experiencing it together. 

But I think, with solo practitioners, or practitioners out there that are naturopaths or dieticians, I think they don't have that support network around.

Andrew: Yeah. Who cares for the carer?

Sarah: Yeah. So, it's really important that those people have other practitioners to go having a really bad day, or, you know, "This has happened with the patient. I don't know what to do."

Andrew: That's a really insightful thing, you know, Sarah, because we like to say, "Wow. You know, integrative medicine is so good." There some things you can't help. There's some times where patients just don't get better, even when you're doing the best that you can. And, I think you bring up a really relevant point, that as integrative practitioners we need to be supporting each other more, not just in a piecemeal way, but in a formatted way, in a program, set-up way, to say there are going to be times when you're going to need support.

Sarah: Yeah, absolutely, and that you're going to need someone to talk to. Because when you're dealing with palliative care, it just brings up so many issues, and the reality is, like, all of us, when you're treating a patient, you can always see aspects of yourself in a patient, or you go, "Oh, I should be doing that, or I shouldn't be doing that." 

But, it's the same thing, when you're dealing with palliative care, yeah, your belief systems about death, and your belief systems about other things are all going to come up. And, you know, some patients may get anxiety about that, so it's really important that we're building networks with each other so that those practitioners have got people to speak to. But, a lot of practitioners, you know, may not want to do that because, oh, does that mean I'm not coping or? And, it's not that you're not coping...

Andrew: You're normal.

Sarah: ...it's just supporting each other. Yeah, absolutely. So, it's finding those people to talk to to go...you know, because I think, yeah, when you're in independent practices, you don't have that support network that you do in the hospital systems, or those other ones that obviously because you're seeing a lot more of it those systems are in place. But, you know, you might get a run of a few patients where if that's not something that you do very often, it can be really disturbing emotionally for you. 

So, it's really learning, you know, do you need to see a psychologist? Do you need to come up with some strategies of how you're going to manage that, or maybe you don't need to see a psychologist, you just need to find someone else, another colleague that understands, that you can go and have a drink with after work and talk about it, which is what nurses do.

Andrew: The virtues of alcohol. I love it. 

I'd like to also add in there that...I think this goes right back, right back, in the beginning, to education. When you feel that you've had a good education, once you've got that you've got to then get the experience behind you so that you are solid in yourself to say, "I am practicing good practice. I am doing the best for my patients," and that's indeed where you come from.

Sarah: Yeah, absolutely. And, it's one of those things that you've got to be realistic, is it easier to just keep moving forward with a patient than it is to actually stop and to have that discussion? So, the reality is it's easier to keep moving forward than it is to stop and to go, "What are we actually doing?" 

Andrew: Yeah. 

Sarah: So, I think that's where patient...you know, it's just an easier choice, but I think if you can understand it and be more comfortable with that, then it's easier for you to stop and go, "Hang on, hang on. I think we're going down a road that is going to lead us to nowhere." So, I think we need to come back and revisit, and like you're saying with Lise, it's you get to that point where you need to go, "Okay, we need to shift where we're going now," and be realistic about what you can achieve and what you can't achieve.

Andrew: Wise words, Sarah. Thank you so much for taking us through this on FX Medicine. I look forward to our next chat. I certainly have got to say you don't mince words at all, you really bring up topical stuff, and yet...

Sarah: We're keeping it real.

Andrew: Yeah, keeping it real. You are that. But, you know, you and I chat outside of FX Medicine, and you are always positive, and mindful, and respectful of what all facets, you know, can be done for patients, so I really thank you for that, for taking us through on FX Medicine today.

Sarah: Thanks Andrew, thanks for giving me the time.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook

Additional Resources

Sarah Franklin
 
 

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FX Medicine Podcast
FX Medicine is at the forefront of ensuring functional and integrative medicine gains the recognition it deserves and ultimately establishes itself as an integral part of standard medical practice. Hosted by Andrew Whitfield-Cook, our podcasts are designed to promote research and evidence-based therapeutic practises, acting as a progressive force for change and improvement in patient health and wellbeing.