I am thrilled to have Julie McFadden, RN, a hospice and palliative care nurse with over 15 years of experience, joining me today.
Julie is committed to normalizing death and dying. In our conversation, we address common misconceptions surrounding hospice care and why discussions about death and dying make us feel uncomfortable. We explore the concept of death with dignity, emphasizing the importance of open, honest conversations around end-of-life issues, including advanced directives, living wills, and code status. We address the challenges of technology within traditional allopathic medicine, clarify what hospice truly is, and explain the ICU signs that indicate someone is close to the end of their life. We also share some practical tips for processing grief and uncomfortable feelings.
This discussion with Julie McFadden is a must-listen for healthcare professionals as it is full of valuable insights. Her book, Nothing to Fear: Demystifying Death to Live More Fully, is also helpful as a resource for anyone navigating end-of-life concerns with loved ones or friends.
IN THIS EPISODE YOU WILL LEARN:
How hospice is all about providing comfort and quality of life
The challenges associated with prolonging life in traditional allopathic medicine
Why conversations about death and dying are essential
How the medical system has changed the way we view death
How hospice differs from palliative care
Why patients should get informed about the progression of their disease and why their families must prepare for the end of their lives
How advanced directives and living wills ensure that the wishes of patients are respected, and some examples of those directives
How interventions can sometimes cause more harm than good
Julie offers tips for processing grief and supporting others who are grieving.
How clinicians can support one another when dealing with traumatic experiences
“When death started happening in hospitals, it changed the way we started viewing death and dying.”
-Julie McFadden
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Submit your questions to support@cynthiathurlow.com
Connect with Julie McFadden
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Julie McFadden. She's a hospice and palliative care nurse with more than 15 years of experience, and she's passionate about normalizing death and dying. At the request of many listeners, I am looking for the nurses and advanced practice nurses that are doing amazing things in the health and wellness space and I know you will find this conversation invaluable. We focused in on what are some of the biggest misconceptions surrounding hospice, the challenges of technology as it pertains to traditional allopathic medicine, why talking about death and dying makes us so uncomfortable, defining what hospice is and is not as well as death with dignity and provoking honest conversations, the role of advanced directives, living wills and code status, the ways that we prolong life in the ICU, signs that someone is transitioning closer to death, why there can be so much resistance around talking about death, tips on grief, and lastly, how to process uncomfortable feelings if you are a healthcare professional. I know this will be an invaluable conversation and Julie's book is a really helpful resource for those who are dealing with end-of-life concerns around loved ones or family and friends.
[00:01:49] Welcome, Julie. I've been so looking forward to this conversation. I think the work that you're doing and helping to spread awareness about end-of-life care is invaluable.
Julie McFadden: [00:02:00] Thank you. Thank you so much. I'm happy to be here.
Cynthia Thurlow: [00:02:02] Yeah. So, as a clinician, what do you think of some of the biggest misconceptions around hospice? I can think of many, but I think for the benefit of listeners, helping them understand, I think many of us have started to kind of enter in this time in our lives where maybe we're the talking about end-of-life care, perhaps palliative care, hospice. What are some of the major misconceptions that you see as a nurse?
Julie McFadden: [00:02:25] The biggest one, including other healthcare workers, thinking this is, that it's a bad thing. It's a bad word to bring up. It's a whispered word, “Have we thought about hospice?” Oh, not yet, not yet. And it's this thing that's like, “Not helpful.” That's like, “I'm sorry to tell you this, but we're thinking hospice.” To me, hospice is not about dying. As cheesy as that sounds, it's about living. We're all going to die. So how do you want to live out the rest of your life? So that's the first biggest one. Everyone thinks it's like this dirty bad word, this dirty bad place. The second thing is that we kill people literally through giving too much medication, too much morphine. Oh, they just give morphine until they die. They just give morphine so they die just so wrong and incorrect. Those are the two main things. It's a bad place. We want to wait to the very, very last minute, and all we do is kill people.
Cynthia Thurlow: [00:03:27] Yeah. I think that as someone, as both a nurse and then later a nurse practitioner, I have so much experience with end of days for patients whether it's a peaceful passing, an unpeaceful, unexpected passing. I know that when I worked for this very large cardiology group in northern Virginia, outside of Washington DC, more often than not, it was the NPs that were starting those conversations with patients. And it's not to suggest that there weren't physicians that were comfortable, but I found that I was the one that was sticking my foot in my mouth, because sometimes the physician was not ready to have that conversation. Like, it was so evident to me sometimes objectively, I would walk in and I'm like, “Who's not having this conversation?” Because I think in many ways, nurses in particular are at the bedside. They are with the patient more than the physicians, the NPs, the PAs, and you get a sense day to day, hour to hour how a patient is doing.
[00:04:28] And I think, in a lot of ways are very technology focused, traditional allopathic medical model. We've done a really great job figuring out how to prolong life as long as possible. I will give some examples. So I would round in the ICU oftentimes on the weekends when I was covering call. And grandma’s like 95, and grandma has kidney failure and the decision is made to put her on dialysis and it's evident it's not like grandma was still mowing grass and playing tennis. Grandma had a very sedentary lifestyle, had a lot of chronic health problems, and the decision is made to start dialysis. And I would say, “Has anyone talked to the family about, like how hard that is on a normal patient's body, let alone a 95-year-old? And that became the norm when I was rounding, that I was sometimes shocked at the degree to which we would go to prolong life.
[00:05:28] And I think that one thing that has really become apparent over the last 25 years is that we've gotten very siloed in medicine, meaning we put our blinders on. You are the kidney doctor and you just look at the kidneys. And you are the heart doctor, you just look at the heart and no one's thinking big picture. And I would imagine for you, having worked as an ICU nurse for so many years that you were witness to seeing this lack of communication between specialties. Did you find that frustrating as a nurse in terms of navigating, advocating for your patient? Because really nurse’s role is really patient advocacy first and foremost.
Julie McFadden: [00:06:08] Yes, you are speaking my language. [Cynthia laughs] You are speaking my language. It took me a good two years really to be an ICU nurse, to start seeing that, to start seeing the patterns of, like, what we were doing, not with everybody, but with many people. Where it was like we’re prolonging life at all costs and for no reason except for suffering. Like, it was just causing suffering. This person was going to die whether we did this or not, and we're just prolonging it and creating more suffering for them and for the family. And no one was talking about it. I felt like everyone was thinking it was someone else's job including me, including me.
[00:06:45] Then finally one day, I just did speak up because I had been a nurse long enough, I cared about this patient enough that I was kind of like, I guess no one else is going to say this, so I'm just going to like, “We need to get a family meeting together. We need to talk about--” I think I didn't even say end of life because I was too afraid. I think I said next steps or like, the future planning, very, very big. But everyone knew what I meant including the family. That's what I mean people think no one knows, but people know. People sense something's up, and then they're like, “Well, no one else will say anything. So I guess I'm wrong.” So I just started finding my voice that way by speaking up and then seeing that everyone was thinking the same thing. And, yes, let's get that together. Yes, let's make that happen.
[00:07:32] And next thing you know, we're having a family meeting that day. And guess what? Machines are turned off and the person dies somewhat peacefully in the ICU. Not exactly as I would like, but at the time, I didn't know any better. So I do, I think we pass the buck a lot. We think we're afraid. We're so afraid to talk about the real thing, death that we're seeing, possible death, getting close to death, end of life, that we think the cardiologist must have said something. This is really a cardiology patient. They must have said something, or the kidney doctor must have said something, or I'm going to wait until the attendee gets here because they'll probably say something and no one says anything. And we just assume the family wants to keep going or maybe we're too afraid to talk about it. I don't know, I think it's all of the things, I think it's all of the things. And what I have found now as a nurse who's not afraid to talk about it, who's not afraid to bring it up, most people are grateful that you did, most people. Every once in a while, you do get someone, “How dare you?” Every once in a while. But most of the time, people are like, “Thank you. Thank you for explaining this to me.”
Cynthia Thurlow: [00:08:39] Well, that degree of bravery really needs to be commended. I think, for anyone who's listening that has worked in healthcare, you understand that. But it's really challenging when the environment is,-- you are pushing forward at 150 miles per hour and the goal is to keep the patient alive period. And that is the goal. And it's very different if you have an 18-year-old in the ICU versus a very frail sick with multiple comorbidities, which means a lot of different things wrong with them. That's 80, 90, 100 years old, that's very, very different. What do you think it is about speaking about death or dying that makes us so uncomfortable as a culture? Because I really do view it to be a cultural issue. And I say this with tremendous love and reverence.
[00:09:24] I have a family member, gosh, this is more than 15 years ago, that was diagnosed with a really terrible cancer, esophageal cancer. If anyone has dealt with this, they know by the time it's diagnosed, more often than not, it's already metastatic, it's already spread. And it was hard to speak up and to say, “Six months in, has anyone talked about quality life metrics? Has anyone talked about hospice?” And there were people in my family that were angry at me for having that conversation. But yet as soon as this individual entered into hospice, and I know we'll talk about hospice, they suddenly, it was like, as if they just finally like exhaled. They were finally comfortable. They knew that the end result was not going to change. But having said that, what makes the whole discussion around death so profoundly uncomfortable? Is it a fear of losing our loved one? It's like, almost like if we say the words or think about those things, like, this might be their end of life, that it somehow makes it more real and tangible.
Julie McFadden: [00:10:25] One, I don't know what makes it so hard. I have theories of my own, which I think are, you know we have developed a medical system that really has prolonged life, that really has helped us live longer over the past 100 years, let's say. In the late 1800s, which is not that long ago, people were dying in the homes. People were not sent to the hospital to die. There wasn't like, we do everything-- because we didn't have everything to try to keep people alive. So I think many, many people were dying in the homes. So people were seeing it, and people were actually caring for their loved one while they died in the home. It wasn't an emergency. They knew what was going on. They had wakes in the home. They had community. The community would come together and have a funeral in the home, and they would dress the house in black. So people knew this was like a mourning house. So there was a whole ritual around death and dying, which I think made a little more obvious that, “Hey, guess what? We're all going to die.”
[00:11:24] And then slowly, which is a good thing, there was medical advances, right? And people started living longer. Death started happening in hospitals. I think it just sort of changed the way we started viewing death and dying, which was like, “We don't think it happens or if it does, let's tuck it away.” And only that small little people in the family and the doctor and the nurse who are there can experience it, and then they are hushed talking about it. You don't want to talk about your grief and how traumatizing it was and what happened. So I think we've just over the years have just developed this like, “It feels bad, it's scary. We don't want to do it or admit that we're dying, so let's just not talk about it at all.” And it's even seeped into our medical system. I can't remember nursing school very much because it was so traumatizing-
[laughter]
[00:12:11] -but I don't remember learning about death and dying. I don't remember learning about hospice. If we did, it was like, literally a chapter or a paragraph. Even in all of my training in the ICU, never. I had six months of amazing training because I worked at a teaching hospital, it was amazing. We did not talk about end of life. We did not talk about end of life. And people were dying all around us. It was like a failure if someone died. So I think we've just developed over the years this, all of us culturally, everyone, just don't talk about it. We don't like bad feelings. It feels bad. So we're going to avoid it. And we need to stop doing that end of story, period, just by doing this. Me and you on a podcast talking about it. My book talking about it. Many books, not just mine, there's many books talking about death and dying. We just need to start doing it. I have a whole chapter in my book called Death Is Not a Dirty Word.
[00:13:02] People are like, “Well, it feels a little harsh.” I would push back a little bit and say it feels a little harsh because we don't ever say it. And I get it. I do get it. We want to say, “My loved one passed away.” And I still do that too. I get it. It does soften the blow a little bit. And I think death and dying, my loved one died sounds so harsh because we never say those words, utter that word. I think we just need to change that. And how we change it is just by doing it and starting it and saying it's not wrong.
Cynthia Thurlow: [00:13:36] Yeah. I think it's the finale, it's the recognition that it's a transition. Just like birth is a transition, death is a transition. And you do such a good job talking about how our culture sanitizes it, hide it, embalm, makeup, Photoshop, don't say the word. We don't allow our children to participate. And I recall when my maternal grandfather passed away when I was in high school and my mom was so distressed and distraught that she left, flew across the country, went to my grandfather's funeral, and my brother and I never got to process that. But yet, when my father passed away in June, my boys actually spoke at his funeral. They wanted to. They had a desire to be involved in that. And I think it's so helpful for us to have those conversations.
[00:14:26] I'm not suggesting-- my dad was 80 years old, he lived a long life. It's very different when it's a young person, something's traumatic, there's been an injury very, very different. But having said that, I think it is so important to start those conversations, to have those conversations, because I jokingly say, “Certain things in life are definitive. You're going to pay taxes, you're going to die eventually. That is the trajectory of our lifetime.” Hopefully it is later in the future and not sooner. But having said that, I think for each one of us examining our beliefs, our discomfort or comfort level around this terminology, you don't have to necessarily be a healthcare provider. I was an ER nurse in Baltimore and I saw so much death, even as a brand-new nurse, as a nursing student, that I remember telling probably my friends, because most people didn't want to gravitate towards the ER.
Julie McFadden: [00:15:17] Mm-hmm.
Cynthia Thurlow: [00:15:18] You had plenty of people who we will call DOA, they were dead on arrival or they would die in the emergency room and I have to take them to the morgue. And over time, you get desensitized as a clinician to the dying process. However, it does not negate the importance of having those conversations because it is so hard for people to process, but if we don't talk about it just makes it more mysterious, it makes it less tangible, and yet it is something that is a natural progression of life.
Julie McFadden: [00:15:51] Yes. And dare I say, I feel like by not talking about it, we really do ourselves a disservice because it can be-- it's such a strange word to use, but a beautiful thing. Again, someone's young, tragic accident, obviously I'm not saying that's beautiful, but there are certain diseases that people will die from most likely, and it can be a beautiful experience. It can still be -- beautiful and sad and tragic. And I think people miss that a lot because of the fact that we don't discuss it and we don't educate people about it. That's what I've witnessed. I'm saying that from firsthand experience of being an ICU nurse for many years and then a hospice nurse for many years.
[00:16:36] And that's the first thing I started noticing when I was a hospice nurse the first year, my mind was blown about all the things I didn't know. About how beautiful and natural and special and sacred, watching someone take their last breath on hospice, because a hospice death last breath does look different sometimes than an ICU last breath. We can talk about that in detail if you want. But the one thing I wanted to say is I was an ICU nurse in Baltimore too.
Cynthia Thurlow: [00:17:06] Were you?
Julie McFadden: [00:17:05] Yeah, I worked at Johns Hopkins.
Cynthia Thurlow: [00:17:06] Oh, well, I trained at Johns Hopkins.
Julie McFadden: [00:17:09] Yeah. Yeah, it was wild. It was such a great experience, but also traumatic. [laughs]
Cynthia Thurlow: [00:17:14] Yes. Well, you see lots of weird things. At one point, I recall thinking about going to the ICU, and I remember I went to probably at Hopkins, it might have been the SICU or MICU, so for people listening, the Surgical ICU, the Medical ICU, and the nurse that was walking me through the Surgical ICU said, “You're way too nice to be a nurse here.” That was like, resounding. She's like, “You're just such a nice person. You will get eaten alive.” [crosstalk] She said, “As an ER nurse, you're an adrenaline junkie, you can handle all that stuff, but here you will be eaten alive.”
Julie McFadden: [00:17:47] [chuckles] Yeah. I was either going to do ER or ICU, and I interviewed at Hopkins at two different ICUs, and the one interview, the nurse who I was shadowing with literally said, “Don't come here. [chuckles] Don't make this your first job.” [Cynthia laughs] Because I was like, “I'm moving from Pennsylvania. I don't know anyone here. I'm so excited.” She was like, “Don't do it. Don't do this one.” So, I ended up going with a different, like, nicer surgical ICU. But I did end up working at all the different both Surgical ICUs and the Medical ICU. Medical ICU, it was more rougher to me there. I don't know why. I think there was more like chronic illness.
Cynthia Thurlow: [00:18:24] Mm-hmm.
Julie McFadden: [00:18:25] And it was just like, “Oof, this is a hard place to work.”
Cynthia Thurlow: [00:18:29] Yeah. I think for anyone listening that thinks of the ICU, it depends on some hospital systems. There's just one of the hospitals that I left in northern Virginia when I was still working for this cardiology group, they had a trauma ICU, they had a neuro ICU, they had a surgical, they had four or five different ICUs. It was a very, very specialized tertiary care center. And so for anyone that's listening, that's thinking, “Oh, my goodness, it's like alphabet soup.” Yes, indeed it is. But if it's a thousand bed hospital, they're probably going to have multiple iterations and very specialized. Let's talk about what hospice represents, because I think a lot of people lump hospice and palliative care together. We know that they're quite different. What are some of the things that help differentiate hospice from palliative care as a starting point?
Julie McFadden: [00:19:18] One thing, I always like to talk about, which is slightly boring, but I think it's important, is hospice is funded by Medicare for the most part. So all hospices across the nation should be working the same, having the same rules. We have the same boss, which is Medicare, and Medicare basically dictates what we're allowed to do and what we're not allowed to do. And that's a good and bad thing. It's good because we do get a lot of resources. It's bad because there's a lot of tape we have to get through, hoops we have to jump through and rules we have to follow. And some hospices do and some hospices don't. And that's why things get really confusing as far as like, “Well, this hospice said we could and this hospice said we couldn't.” So that's one difference, because some palliative care programs are funded through Medicare, but many are not.
[00:20:05] To me, palliative care is a symptom management program, I love palliative care, I do that too, where they are really looking at the person as a whole and helping them manage the symptoms they're having either due to their disease or due to the treatment they're receiving because of their disease. So they're about treating the person as a whole, planning their future as far as like, how their disease is going to progress, how they're going to help them and manage those symptoms so they can live their life. Hospice is the same, except you are no longer really treating that disease that you're going to die from. So it's all about comfort, it's all about staying home. I don't like saying it like this, but just to be clear, you can lose something, so you aren't allowed to receive chemo and radiation for the cancer that is terminal. You have to stop doing all the treatment for the thing that you're coming onto hospice for. So hospice is really focused on basically what you want, how you want the rest of your life to be while you're still alive, because you still are, by the way, when you come onto hospice, and it's just more about comfort focused.
Cynthia Thurlow: [00:21:18] I think that's a really good description and give everyone a sense, and I'll use my personal circumstances from the summer as a good example, like when it was clear that my dad was not going to get better from having subdural hematomas or head bleeds and respecting his direct wishes. He did not want to go to surgery. He had an episode where he neurologically decompensated. The neurosurgery team and the trauma ICU doctor really were pushing us to make a decision to take him to surgery. And I really pushed back and said this is not what he wanted. He would not be a good surgical candidate, and we could certainly unpack that. But having said that, it was very, very clear that he had been very adamant about what he did and did not want. And so when you talk about hospice allowing people to have a peaceful passing, a peaceful death, again, there I am using the-
Julie McFadden: [00:22:11] I do it too.
Cynthia Thurlow: [00:22:13] -word pass as opposed to death. For you, what differentiates someone having a peaceful death versus a nonpeaceful death? Because I think as you as an ICU nurse, really all those years you were at the bedside versus your experience now as a hospice nurse, what are some high-level ways to educate this community about those differentiators? Because they are quite significant. I think sometimes it is very common for loved ones to not understand that they have options when they're in the throes of end-of-life care.
Julie McFadden: [00:22:50] So I'm going to talk about a specific disease and how it can like and how it can look different. I'm just going to talk about one. But there’re any kind of advanced cancer, meaning like we'll say pancreatic cancer is usually a terminal diagnosis. Now there's things you can do. Some people can live five years, seven years, depending on surgeries you have and things like that. But let's just take that broad general disease, which is usually a terminal illness. So I believe we do people a disservice by not being more forthright about how their disease is going to progress and knowing that we can do X, Y and Z, possibly a surgery, if you're a surgical candidate, possibly chemo and radiation for a little bit, but generally speaking, you are going to die from this disease. I think we should stop there, period.
[00:23:37] Let them think about that, because I think what we do is we go, “You're likely going to die from this disease.” But here's what we can-- and I get it because it's so uncomfortable to give that news that they want to kind of sugarcoat it in a way of like, maybe there's a thing and then people hang on to that, but maybe there's a thing. And it really hurts them truly, because what they do is they don't contemplate their own mortality and really think about what they would really want. What do you really want if you are likely going to be gone, dead, as harsh as that sounds, in a year let's say, how would you want that last year to look? And they don't know any better, right? I'm not saying don't treat it at all. You treat it for as long as you can. And that can mean chemo, radiation, in and out of hospital, in and out of doctors’ appointments. That's annoying. That's hard. There's going to be some symptoms, pain, you might get ascites, which is like your abdomen swelling up because your liver is usually involved. So there's procedures you have to do.
[00:24:41] I think we need to prepare them. Maybe not all in one visit. It's a little much, right. But really prepare them about how the progression of the disease is going to look. And if you continue to make them think the only way is to keep going into the hospital every time you have a symptom. Keep going into the hospital every time you decline from this disease, which you will. If you don't let them know that, I'm not answering this very well. I think people, they don't know what they don't know, so you need to help them see the progression of the disease so they know, “Oh, this is getting towards the end. I am getting towards the end.”
Cynthia Thurlow: [00:25:25] I think what you're really speaking to is preparing them for the inevitable.
Julie McFadden: [00:25:29] Yeah.
Cynthia Thurlow: [00:25:30] Helping them understand what's coming.
Julie McFadden: [00:25:33] What's coming. Because what I hear a lot is in younger people and I understand, but it breaks my heart when I see someone coming onto hospice and they're younger to me. You know they're 60 years old and they go, “My oncologist said I don't meet criteria to get more chemo yet, so I'm just going to come on to hospice so I can get more strength. And then once I get more strength, I'm going to go get more chemo.”
Cynthia Thurlow: [00:25:57] That's what the oncologist has told them.
Julie McFadden: [00:25:59] Yes. It makes me want to weep even just saying it right now, because I just want to be, like, “Unfair. That's so unfair to you that someone said that.” Because you know and I'm not trying to blame all oncologists. People hear what they want to hear and who knows what that oncologist said. But the fact that someone led them to believe they possibly have the-- maybe they're going to get stronger. That's what I think is unfair because generally speaking, we know as healthcare workers how this is going to go. This person's not going to get stronger. And you know that, Mr. or Mrs. Oncologist, but you don't know how to say that, so you say,” Maybe you will.” And I get it, because that makes you feel more comfortable too. “Maybe you will.” I don't know what's going to happen to this person. And I kind of want to push back there and say, “Yes, you freaking do.”
Cynthia Thurlow: [00:26:49] I think we all fundamentally want to be hopeful.
Julie McFadden: [00:26:53] I know. And we need to--
Cynthia Thurlow: [00:26:54] At our core, and there is definitively a time, like you and I were talking before we started recording. As an ER nurse a thousand years ago, there was one particular hospitalist who did not like patients dying in the ER. And I'm sure that we will talk about advanced directives and why they are so important. So if anyone's listening that has not gotten their will in estate planning started, you need to. We would have grandma, who was like 85. Grandma had emphysema. She had bad COPD, so she was struggling to breathe. She was on oxygen. Her oxygen saturation wasn't great. We were doing the full court press because that's what the family wanted. And grandma had a do not resuscitate, do not intubate.
[00:27:40] And this one particular physician would swoop in to admit the patient, and the first thing he would say to the family, “Would you like to make mom more comfortable?” And what family is going to deny, making their family member more comfortable? What they meant was, we're going to intubate, we're going to put a breathing tube in. She's probably going to be ventilator dependent for a period of time. She'll probably get pneumonia, and then it's like a domino effect. And this one physician who used to drive all the nurses crazy because we knew as soon as he walked in, he would get the family to rescind whatever advance directive had been in place. And it was so sad because that patient's expressed wishes were not being honored. And I think that's so important, to have those hard conversations with your loved ones. I'm in that sandwich generation. I know that you're a bit younger, but I went directly to my mom when my dad passed and said, they've been divorced for a long time. I was like, “Make sure all your stuff is organized, because it could have been a mess if dad had not been very clear about what he did or didn't want.”
Julie McFadden: [00:28:43] Exactly.
Cynthia Thurlow: [00:28:43] Did you see that happen in the ICU where expressed wishes were rescinded? Or sometimes maybe the provider was uncomfortable with what was transitioning with this patient, and they kind of intervened to encourage the family in a situation where things were not going to change. Let me be very clear. We're not talking about, we're not going to say, don't intubate and ventilate the 18-year-old. We're talking about people that have longstanding disease, illness, etc., that are just not getting better.
Julie McFadden: [00:29:12] Yeah, we saw it all the time. Honestly, as an ICU nurse, we never even-- I just assumed everyone was full code, which means we give CPR. [crosstalk] Yeah, I just assumed. We didn't even talk about it. We didn't address it. We didn't talk about it. If they did, I wasn't there because I never heard it and we did daily rounds. So it wasn't even the fact of like people changing things. It was like it wasn't even addressed. We just assumed, we just assumed. And like I said, and many people, it's appropriate, right? They are going to survive. They are going to get out of the ICU. They do have a life to live. But many people, as time went on, I saw that it was like, “This is not. We are doing a disservice.” Not only are we keeping people alive, we're actually hurting people by trying to keep them alive, we're hurting them because death is inevitable sometimes.
Cynthia Thurlow: [00:30:06] Well, there's something in medicine called beneficence, and, you know first, do no harm. And I think many people forget that. I was kind of an ethics nerd, and I really enjoyed the bioethics classes we’re required to take as undergrad in grad school. And beneficence really being conscientious about what's doing what's best for our patients and advocating for them when appropriate. Well, we should always advocate, but you know what I mean?
Julie McFadden: [00:30:32] Mm-hmm.
Cynthia Thurlow: [00:30:33] Sometimes you really have to push. What do you think are things that every person listening should have in place that help express whatever their thought process is, whether if someone's older and they don't want to be resuscitated. Let's talk about what it's like to do CPR on someone who is osteoporotic, frail, elderly, how ugly that is.
Julie McFadden: [00:30:57] All right.
Cynthia Thurlow: [00:30:58] Helping people understand there's a time and a place to express advance directives, your living will, code status, which is what you were alluding to earlier, that in the ICU, generally, the thought process was, they must be a full code because we have not been instructed otherwise.
Julie McFadden: [00:31:14] Yeah. I think everyone listening should have some form of advance directive. So there's easy ones called like, a POLST or a MOLST. Wherever you are located in the US, where it's basically three or four simple questions, “Do you want CPR? Do you want intubation? Do you want tube feed if you can no longer swallow or if something happens where you can't eat.” And depending on what you want, so everyone does get free will to choose they want. You can fill out something as simple as that. Some people will say, “I want CPR, meaning chest compressions, which is violent, by the way.” No matter who you are, no matter what age, it's violent. You will break ribs most likely. It's not what the movies show you. It's, “I hate doing CPR. It's horrific.” Okay, so CPR and intubation usually go hand in hand because some people will say, “Oh, I want CPR, but no, don't put me on machines.”
[laughter]
[00:32:12] And I say, “Listen, if you're doing one, you're doing the other.” I don't think I've ever seen anyone-- I'm sure it's happened. But me personally, I've never seen someone who is getting a CPR and is not intubated. So they kind of go hand in hand. So just have something as simple as that filled out. Now, I would personally say anyone listening right now should have an advance directive where you can really write out specific circumstances so your family knows what you want. Because guess what? It's going to be very hard for your family to say, “No, don't put that feeding tube in if my dad has a stroke and could no longer swallow.” But if you say, “I do not want a feeding tube in, if I can no longer swallow.” It's still hard, but it's easier for them to go, “No, I know what they want. They do not want a feeding tube.” So you can be really specific in your advance directives.
[00:33:01] Now, there's a bunch of other things I think you should do too. You should get your will in place. You should get your finances in place in the sense of like know where things are going, who they should go to, get it in writing, have a lawyer look over it, write your passwords down somewhere, put beneficiaries to your bank account. There's so many things, but that's a lot to take in. So if you only want to do one thing, I would say, look into advance directives and be very specific, and guess what they can change. And just, I am a 41-year-old, almost 42. I have these things in place. Now they will change over time, because right now, I am a full code, and I do want things done if my heart randomly stops in the mall. But over time, I'm not going to want that. But I have those things in place and people I love know what I want.
Cynthia Thurlow: [00:33:49] It's such an important distinction.
Julie McFadden: [00:33:50] Never too early.
Cynthia Thurlow: [00:33:51] Yeah, it's interesting to me. As soon as I became a parent or before I became a parent, my husband and I sat down and did all of those things. And God forbid something happens to both of us, who’s going to take care of our children? Having said that, your point about your plans can change. This is not written in stone. This can change over time. And I think that that is certainly one of the most important takeaways from our conversation is get yourself prepared, because I think about my mom's husband, who is like the most organized human being I've ever met. Every time I see him, he reminds me where all of their estate planning materials are.
Julie McFadden: [00:34:30] Yes, I love this guy.
Cynthia Thurlow: [00:34:32] He has everything indexed. Oh, yes. Well, he's a former Air Force Colonel, so he's very orderly. But he always shows me again, he wants to make sure I don't forget. I was like, “I've got it. We've got it.” [laughs] But having said that, I can tell you what my brother-- So I was the medical power of attorney. My brother was the overall power of attorney. My brother, my dad had, I don't know 15 bank accounts. I don't know what it was that my dad needed to have everything not consolidated. But my brother said the amount of time it took to hunt down all of these accounts, and even with him being organized, it can be quite a big job. So just something to be thinking of and make sure if you are an older person, you're dealing with a terminal illness, you're sick. Make sure your loved ones know what you want. Like, my dad was so clear, so crystal clear, it made the decisions as hard as they were. It made it so much easier.
Julie McFadden: [00:35:20] Yeah.
Cynthia Thurlow: [00:35:21] Now, having had all this experience in the ICU, for the benefit of listeners, what are some of the things that we do in medicine that actually prolong life in instances where maybe someone's natural death was going to come about a bit faster if these interventions had not been available?
Julie McFadden: [00:35:41] Yeah.
Cynthia Thurlow: [00:35:42] Starting from very low tech, let's just put it that way, because I think there are some presumptions, and you talk about this so eloquently in the book, about making people aware that, some of these very low-tech interventions can actually prolong life at the end of life.
Julie McFadden: [00:35:58] Yeah. So the main things I always think about are machines. You know, we have intubation, which is putting someone on breathing machine and putting them on machine to help them breathe. Any kind of dialysis machine, even medications. Any kind of pressers that keep your blood pressure up, that keep your heart going, “that keep your heart pumping as good,” but it's like there comes a time when no matter what you do, you can put someone on all of those things and their body is just saying, “No, no.” I mean, even little things like hydration, oh, my gosh. I could go on and on and on about hydration. And again, this is a fine line here because I'm not talking about an 18-year-old who was in an accident, there are some but the first thing people do in a hospital is pump people full of fluid. [chuckles]
[00:36:58] And then guess what? They're not taking into account that you're a 90-year-old woman who has heart failure. They just know that you fell and you're unconscious and whatever. They're pumping you full of fluid. And guess whose heart can't handle that fluids, hers. So then you have to be intubated because they fluid overload you, and then your body can't handle that fluid, so you start going into respiratory distress. So then you have to get intubated. Then when you're intubated, they have to take that fluid off, so they diurese you and they diurese you too much so it hurts your kidneys. Like, this is what I've seen over and over and over again. And it's because no one's doing anything, “wrong.” They're doing what they need to do to keep you alive. But if you don't work in healthcare and this is your mom, you just think this is what's supposed to be happening, when really it's like, “Why didn't we have this conversation prior to this fall or whatever happened, that this person is getting towards the end of their life.” Tons of fluid at the end of life is not going to beneficial and it's going to cause issues and make them be intubated and then diurese and then hurt their kidneys.
[00:38:00] There's this whole cycle that we don't end it-- It would all not happen if we already had a plan in place, if we already knew that all these things that we're doing are not going to help, and they're probably going to hurt. That's the difference between a hospice death and an ICU death right there. If we just didn't take this person to the hospital because maybe they already planned everything and they were already on hospice because of their end-stage heart failure, first off, they wouldn't get fluid overloaded, so they'd be drier and they would feel better which sounds crazy, but it's true. I witnessed it with my own eyes. I probably wouldn't even have believed that as an ICU nurse.
[00:38:40] But as a hospice nurse, I see it so clearly now. People who are dehydrated at the end of life usually feel better depending on what they're dying from. I'm being general here, and they could be home, on hospice. They can be given medication if they are short of breath, if they do have pain. A lot of people don't even need medication at the end of life because their bodies are built, not theirs iur bodies are built to die. And if we allow the natural progression, it can be very, very peaceful without even medications. You can be there with your loved ones. You can talk about your life, the things you wanted to say. You can laugh together. You can sleep when you want to sleep. You can eat when you want to eat. And I only know this because of my experience as a hospice nurse.
[00:39:24] It was mind blowing to see how people died in their home and how I thought it'd be scary because what are we supposed to do? How are we supposed to help? And most of the time, we didn't need to do anything. You know, certain diseases come with symptoms, but many don't. Especially if you're elderly, especially if you're older and your body's already kind of going through their transition naturally. You don't need to do much except for listen to that person, let them sleep, don't make them eat and drink if they don't want to and they basically fall asleep until they die. You know they can look a little different. The actively dying phase makes people a little nervous because they're breathing differently, they're not waking up, they look a little different. But generally speaking, our bodies know how to help us die. To me, it's a miracle. Even though someone's dying, it feels like a miracle because I can't believe the body just knows what to do.
Cynthia Thurlow: [00:40:18] And it's so interesting, and I'm so glad that you touched on the hydration piece, because as a former ER nurse, as a cardiology NP, we were starting everyone on fluids that made us feel good because we were doing something. And inevitably, in cardiology, we got to see the 90-year-olds that got fluid overloaded from the ED appropriately because maybe at the time, she was probably a little hypovolemic. Her blood pressure and pulse were not really optimized. And then I would be the one ordering IV Lasix, which is a diuretic, to get the excess fluid off. And then you have to be very conscientious, because as we get older, things don't work quite as well. And your GFR, your glomerular filtration rate, your kidney function isn't as vibrant. You have to be careful with medications in the elderly on so many different levels.
[00:41:06] And to your point about, we as clinicians sometimes get very uncomfortable monitoring signs of this transitional period, and we feel like we have to intervene. It goes against our nature to not-- we want to do something, and sometimes the best thing we can do in those end stage situations is to do less or to do nothing.
Julie McFadden: [00:41:30] Yeah.
Cynthia Thurlow: [00:41:31] Just make the patient comfortable. And I'm sure for you, it's like you have these very diametrically opposed but very significant experiences as an ICU nurse and later as a hospice nurse. What are some of the things that you've been able to experience with your patients that maybe individuals who have not seen a loved one pass on or don't work in healthcare that are more common for people to witness if a loved one is passing away at home or they're not actually at their bedside in the hospital, that give you some clues that they're transitioning? This is the word my dad's hospice nurse used. My stepmother's hospice nurse will use, “I think she's transitioning. I think we're getting to that point where we're getting ready to make that next leap, closer to death. What are things that stand out for you?”
Julie McFadden: [00:42:22] Sleep and not eating and drinking. Those are the main things when you're transitioning, that word is so vague, right? The last phase of life.
Cynthia Thurlow: [00:42:30] It's so benign, right? It's like they're transitioning.
[laughter]
Julie McFadden: [00:42:36] Yes. So to me, actively dying phase is the last phase of life that's very distinct. It usually lasts a few hours, maybe a couple days. I've actually seen people last for a couple of weeks in the actively dying phase, very strange but every once in a while. It's usually only a few days though. The time before that time is that transitioning phase. And I mostly just see people are sleeping more than they're awake. So they're literally sleeping 18, 20 hours a day. Maybe not full on, but just constantly falling asleep, even mid-sentence, sometimes just falling asleep and then barely eating and drinking, barely eating and drinking. So those are the main things I see. Barely eating and drinking and falling asleep.
[00:43:23] And I think that's our body's way of preparing ourselves to our bodies. And the more we just allow that to go on, as hard as that may because it's like we're trained like, “They need to eat, they need to get up, they need to move.” It's like we need to do the opposite of what we think they need, which we just need to let them be. I always say, “As long as they are clean, safe, and comfortable, we're good. You did a good jo, right.” So there's not much except for sleeping a lot and not eating and drinking.
Cynthia Thurlow: [00:43:54] And inevitably, what do people focus on the most? That I used to hear was, “They don't want to drink anything. They don't want to eat anything.” And I was like, “That's okay. That is totally okay.” Letting them respond to the cues that their body is performing. And I think for a lot of people, whether they know this or not, as you get dehydrated in many ways your body will go in and scavenge up, first utilizing some stored carbohydrate, then they move into fatty acids, and then they can become ketotic and for those of us in the intermittent fasting space, it makes people feel good. Like, surprisingly, it kind of suppress their need to eat on top of that. And so I don't per se think that's a bad thing, but I think in my world with an Italian mom, it's like, “Eat, eat, eat is always the focus.” And I always say, “Let your body tell you what you need to be doing.”
[00:44:42] What do you find to be when you're having conversations with and you do a beautiful job in the book talking about different patients and those that were ready for a peaceful death, those who are not. Has it been your experience that the people that choose to go the route of hospice have a very different quality of life towards the end? And again, this is kind of a prevailing over theme. I'm sure there's exceptions in every instance. Do you feel like those people tend to be more accepting of the process that's ongoing.
Julie McFadden: [00:45:16] I don't know, there are definitely people in hospice and families in hospice that are not ready for it. And again, we'll even say,” Don't say hospice. I'm not really dying.” So there's people who still avoid the idea that they're going to die on hospice. But for the most part, most people on hospice I wouldn't even say are ready. It's not even about being ready or saying, “I'm okay. I accept this.” It's really about any patient that I've seen just who can openly talk about what's happening with them and how they truly feel about what's going on, even if it's a “negative way.” I'm afraid to die. I don't want to die. I'm angry. This can't be happening. Even those patients, I always say to them, “Listen, the fact that you're even saying that out loud is going to help you.” There is something about getting it out and talking about it that helps people transition into a peaceful death. It's the ones that truly try to avoid it.
[00:46:15] And even then, their bodies still sometimes are like too bad and they have a peaceful death, right? So it's not like, “Oh, you're not going to have one if you can't discuss it.” But it does help, it does help. And I definitely have seen people who are unwilling that I do think causes some of the struggle at the end of life. There's a lot of existential pain that can happen at the end of life if you are not willing to at least talk about it, even if it's like, “I don't want to talk about it.” I don't. Even negatively, go ahead, say whatever you need to say. But most people in hospice, to me, eventually get to a space where they're like, “Okay, at least their bodies do, really.” The body's an amazing thing for the most part, because my grief is removed. It's not my loved one. It feels like a birth. It really does. The same feeling I get when I see someone have a baby is like, what it feels like.
[00:47:11] Most people are not struggling. Families may be hurting and crying, but the person themselves are not struggling. That body is naturally letting go. And it can feel, like I said, “Beautiful. It can feel beautiful.” It can feel like sacred, time stints still a little bit. It's this strange energy that shifts when someone takes their last breath. It was surprising to me as a hospice nurse. Now it's not as surprising, but that first year of hospice nursing, I was like, “Wow, I didn't realize this. I didn't know.” Hence why I'm so passionate about telling people, because I didn't know.
Cynthia Thurlow: [00:47:50] Yeah, I think it's so important, and it's interesting. I certainly referred a lot of patients appropriately to hospice. We had a lot of end-stage cardiomyopathies, people with weakened heart muscles, end-stage cardiovascular disease, so we had done everything surgically and medically that we could do. What are some of the ways that patients have articulated to you that they're struggling, even though that perhaps they've made that decision to enter into hospice or their family members? Have you mentioned some of this articulation about the patient may not be mentally ready, but their body is? Do you think it's a cultural thing? I know that my father was a very devout Roman Catholic, and I know that he’d had a couple-- we used to call him the cat with nine lives, respectfully. And we used to laugh, the three of us, my brother, my father and I used to laugh about it.
[00:48:37] He’d had a couple, like bumpy hospitalizations preceding, one was 10 years ago and was five years ago where we thought were going to lose him. But it was interesting on this last hospitalization, he was much more accepting of what had happened to him, whereas before he was more fighting, fighting, fighting. This time it was definitely a different transition. So for you, “Do you think sometimes it's cultural? Do you think sometimes it's circumstantial?” Maybe a loved one doesn't want to leave because they don't want to leave their spouse that's dependent on them.
Julie McFadden: [00:49:08] Yeah. I think it can be cultural, for sure. I work in Los Angeles, where there's the cultures everywhere. I definitely notice certain cultures are a little more resistant than others. And circumstantial, I mean age plays a huge role in how things are going to go. I never want to feel like, “I'm victim. I never want to feel like I'm blaming someone for dying.” It's not, I get how hard it would be, particularly if you were young, but I do feel like that plays a role. Disease can play a role too. Some diseases are just harder to die from because you have more symptoms. So age can play a role, family dynamics can play a role. I would say most of the time, most patients eventually get to a place where they know they're dying. They can feel it. They can tell there's something that happens with them where they're like, “This is it.” Like, they can feel it. And it's more the family's resistance.
[00:50:00] So a lot of times I'll have families when I come to the door to do an admission, and the family will not let me in, and they'll come outside and they'll go, listen-- And it's usually an elderly person. “Our grandma doesn't know you're technically a hospice nurse.” So we're just sort of saying, “You're here to help, blah, blah.” And I usually say, I try to-- I'll respect them, of course, but I'll say, “If she's alert and oriented, I really can't. She has to sign the paperwork. I can't just lie to her. But don't worry, I'll talk to her, we'll get to a place, you know?”
[00:50:31] So they're like, “Okay, okay.” And usually how I start out when that happens is I have everyone sit down, and then I say, “How are you? What do you think's going on with you? Why do you think I'm here? How do you feel you're doing with this disease that I'm here for to help you?” And they will go, “I'm dying. I can tell I'm dying.” It's getting to-- then that puts the family at ease a little bit like, “Okay, she does know. She does know she's dying.” I don't know if I answered your question, girl.
Cynthia Thurlow: [00:50:56] No, you did. And I think the biggest thing that I hope for listeners is that if they have a loved one that is near end of life, or they're uncomfortable having these conversations, knowing that there are resources available. I mean, your book is so beautifully accessible and informative. Even as a clinician, I was like, these are some of these things I've forgotten about, how we have sanitized these discussions, how our own discomfort as a clinician can influence our own way that we process these kinds of things. I think with my father, which I don't mean to harp on, but just to provide some context, it provided me tremendous solitude in knowing that he was no longer suffering, that he had really suffered for a long period of time and was finally at peace.
[00:51:45] And then when you're working with family members and they're dealing with grief, whether it is situational, like they know their loved one is dying and trying to process this transition, or talking to loved ones or family members after someone has passed away. Do you have any tips or suggestions for how people-- you have a lot of great resources in the book, so I would say check out Julie's book. But what are some of your kind of higher level tips for individuals that may be processing the passing of a loved one recently or in the distant past?
Julie McFadden: [00:52:18] I think grief is complicated, and many people just to talk about this really quick, people grieve people before they're gone. So, especially in hospice, when it's this extended long period sometimes depending on the disease, where they are grieving the loss of who they were, who their loved one was, that every time their loved one declines, they're grieving the loss of their own life. Because maybe they're the main caregiver now. And one of the main feelings people feel when they've been a caregiver for a loved one on hospice when they first die is relief. And then they feel guilt for feeling relief, and shame for feeling relief. And I better not tell anybody that I felt relieved, or they'll say, “When's this going to end?” Someone's like really lingering. They'll say to me, the hospice nurse, “How long can this last? Like, I feel bad saying that, but this is really hard, right? And then they feel guilt for saying that.
[00:53:17] So just know that's normal. That's what I want to say, “know that's normal.” That's like, the number one thing my family say to me is that they feel guilty, that they felt relief. So that's very normal. And I think if anyone wants to know how to show up for someone like that, I think it's about all of us getting comfortable with being uncomfortable. You know, I'm not the first person to say that, but that is so true. It's like we're so uncomfortable. Other people's uncomfortability and being emotional and not being okay, that we try to make them okay because we need to do something. If there's anything I've learned from being a hospice nurse is that people don't want you to make them feel better or emotionally, they just want you to show up and be there. Or even if they think they want like, make me feel better. Really, what makes them feel better is someone just allowing them to say what they need to say and not change it and just sort of sit there and be with them in their sadness, whatever the emotion is. That's really hard to do, but if you can do that, I think that's the best thing to do.
[00:54:20] Just be there, don't try to say, “At least they lived 85 years.” I know it's so tempting to say, you want to say it, Cynthia [chuckles] “At least they lived.” Don't say it. Don't say it. Just be there and show them that you're comfortable with it. You know, even if you're not, just be comfortable. Be the one person that they can talk to about it, that you can talk about death and dying with them. That's what I've seen people who all of a sudden see that I'm a person in their life who is comfortable saying, “Here's what your death is going to look like, here's what your end of life is going to look like, here's how I can help.” They're instantly like, “Aha, someone here who can talk to me about this.” We need more people like that.
Cynthia Thurlow: [00:55:02] Yeah, absolutely. And just thinking about how our own discomfort as clinicians can erode those opportunities and kind of examining our own, I don't want to use the word prejudices, but our own discomfort around those conversations, because having just gone through this on the other side, I can show you the people that showed up, and they didn't even have to say anything. It was just knowing that they were there that brought tremendous comfort. I just want to kind of round out our conversation today and talk about something that I think a lot of clinicians don't talk about openly. All of us, irrespective of our background, if you work in medicine or emergency medical care or you work as a police officer, firefighter, you see things that bother you, things that stay with you.
[00:55:51] I think this is why I did not go into pediatric as a nurse or as a nurse practitioner. I could process adults and the things that I saw in the ER much more easily than I did pediatric traumas. How can we do a better job as clinicians to support one another when we go through something traumatic, whether it's in the hospital or outside the hospital with a patient? This is something that I recall from 25 years ago. When we had pediatric traumas in our ER, the ER docs would say, “Oh, the nurses are all messed up again.” And it was because so many of us were trying to process what we had just seen or experienced. And with your kind of depth of experience, what would be your recommendation? If someone's listening, they're a nurse, maybe they're a medical student, they're NP, like I mentioned firefighter, EMS, how can we help process those emotions and move through them so that we can heal? Because really, ultimately, that's what it comes down to.
Julie McFadden: [00:56:49] Girl, what a question, right? I mean, part of me wants to be like, “I don't know.” I know that the things I do now, but I would just-- to be very transparent and very honest, I didn't for many years. That's why you get compassion fatigue. That's why you get burnt out. That's why you're just totally desensitized because you have to keep moving. That's what you've learned in healthcare, specifically working in the hospital. So I think there's a bigger problem, which is our hospital system, where it's like, “You can care, but hurry up.”
Cynthia Thurlow: [00:56:24] [crosstalk] move on.
Julie McFadden: [00:57:26] Yeah, hurry up. Care, but hurry. Like, it just doesn't work that way. right? So like, “How can you care but then still have to keep it effing moving as you do?” And that I think we need to fix that problem in healthcare. Now is that ever going to happen? I don't know, but I think that's a huge problem. So it's like, “How do we as people who want to continue to care and feel and process our emotions and not just numb out and act like that didn't happen?” I think a lot of it is learning how to work the system and make it work for you, which is a whole other podcast we could do. That's what I feel like I've done in my nursing career. This whole hospice nurse Julie thing really came on a whim truly. So that's where my life is going now.
[00:58:12] But I still work as a nurse, just not full time. But prior to the hospice nurse Julie thing, even before the hospice nurse Julie thing, I worked per diem basically full time because I needed to, because I needed money. I live in Los Angeles, but I made nursing work for me. It was like, “I can't keep doing this, hurry up and care thing. I cannot be a full-time staff member because the culture of full-time nursing does not work for your mental health.” So I did things like become a per diem nurse so I can work when I want to work, take time off when I need to take time off. I work for a unionized hospital. I know that's not everywhere, but I do, and that really, really helps. So work for a company that really respects their workers and allows you to be able to take time, to have mental health breaks, to be able to say, “No, I can't take that assignment, that's too much work.” I can't physically do that.
[00:59:05] So things like that, to me, are what you really need to do as a healthcare worker, because guess what? The agency you're working for doesn't care. I don't think so. You need to care, and you need to realize that your mental health and what you're witnessing and that if you're feeling burnt down and wondering, “Why can't I do this? Why does this seem so hard?” You're not the problem. It is really hard. And for some reason, we're in a system that keeps telling us that, like, if you just worked harder or if you just did this, that's not how it works. So I think if any medical professionals are listening, “You need to learn how to make that work for you.” And I did. For me, it was working per diem, and I worked almost full time, but it still felt like I had autonomy because I could kind of come and go. I didn't have to do all the meetings. I didn't have to like be involved in the unit trauma. It felt good. That really revived me.
[00:59:55] And I also moved from the ICU to hospice. It took a while, I was an agency nurse for a while. I did pre-op, I did post-op, I did teaching for a little bit. I moved around because I was like, “I can't keep doing this. I can't keep doing what I'm doing in the ICU.” So I also think that's important, finding a spot that really helps you grow and helps you feel like, “This feels good.” I don't feel like I'm dead inside when I leave my shift and I did as an ICU nurse, I drank a lot. It's a whole other podcast too. I drank a lot. I felt dead inside, like, so you need to at least not acknowledge if that's happening to you and then try to make changes, as scary as that sounds.
Cynthia Thurlow: [01:00:40] Yeah. No, thank you for that, that beautiful share. I think what we're really speaking to is self-advocacy. Each one of us might need something very different. I know that if I had stayed in the ER more than the four years I was there, I would have really struggled because I am an empath, and it was like everything that was coming through the door, I would just absorb and to your point, it's like you're expect to care and then move on. And so it's very hard to compartmentalize if you are someone that is that way. So, Julie, please let listeners know how to connect with you. I know you have a prolific TikTok channel. [Julie laughs] Please let listeners know how to connect with you, get your book, learn more about your work.
Julie McFadden: [01:01:18] Yeah. My internet name is Hospice Nurse Julie. And like you said, I'm on TikTok. I'm on Instagram. I love my YouTube channel. So YouTube to me is where you can really find like a lot of information, where I do longer form videos. But either way, wherever you get your social media, I'm there as Hospice Nurse Julie. I also have a website, hospicenursejulie.com. That's where you can find my book. But really you can find my book, anywhere you get books, Amazon, Barnes & Noble, it's out there. So it's called Nothing to Fear: Demystifying Death to Live More Fully, and yeah.
Cynthia Thurlow: [01:01:53] So good to connect with you.
Julie McFadden: [01:01:54] It was amazing. Thank you.
Cynthia Thurlow: [01:01:59] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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