Promoting Self-Care in Palliative Care: Through the Wisdom of My Grandmother

In the post COVID-19 pandemic period, targeted efforts are needed more than ever to improve frontline nurses’ well-being. In the field of palliative care, there is recognition of the importance of self-care, but the concept itself remains nebulous, and proactive implementation of self-care is lacking. Reflective writing has been noted to have positive impacts on health care providers’ well-being. This piece brings to light the author's interest and work in reflective writing, sharing a personal account that provides a source of happiness and an opportunity to better understand her palliative care practice. Beyond the individual level, organizations are also encouraged to invest in their nurses’ overall well-being.

• Targeted efforts to improve frontline nurses' well-being are needed more than ever, to mitigate burnout, support job dedication, and improve nurses' self-rated health; this is especially true in the field of palliative care which recognizes the importance of self-care.• Nurses need to explore ways of being with the dying that serves both the health-care provider and the dying person practically and spiritually.• Bearing witness, listening, and staying present as patients tell their stories exposes health-care providers to their own vulnerabilities.
As we find ourselves in the aftermath of the COVID-19 pandemic, targeted efforts are needed more than ever to improve frontline nurses' well-being with the goal of mitigating burnout, supporting job dedication, and improving nurses' self-rated health (Aloweni et al., 2022).This is especially true in the field of palliative care, which recognizes the importance of self-care.However, the concept itself remains nebulous, and proactive implementation of self-care is lacking (Mills et al., 2018;Stilos, 2022;Stilos & Wynnychuk, 2021).

Thriving at Work
Improving one's wellness includes implementing selfselected self-care strategies that involve both the personal and professional spheres of health care professionals doing palliative care (Chittenden & Ritchie, 2011).During its annual retreat for all nursing educators and advance practice nurses at Sunnybrook Health Science Centre, Canada, facilitators introduced the group to Seligman's (2011) Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment (PERMA) Model of Practice, a theoretical understanding of achieving happiness.It outlines five pillars for thriving at work and beyond, through (1) Positive Emotions, (2) Engagement, (3) Relationships, (4) Meaning, and (5) Accomplishment.The facilitators presented each pillar and its strategies, relating them to enhancing one's well-being.Participants reflected individually on a question or scenario proposed for each pillar.Then in small groups, we went through the PERMA Model, taking turns sharing our responses to the exercises.The process helped us illuminate, through feedback and relationship building, a better understanding of how we can improve our well-being.
When my turn came, I shared my interest and work in reflective writing and its applicability to my own well-being.My journey began much earlier, but in 2021 I wrote my first article with an art therapist (Stilos & Burgoyne, 2021) highlighting the benefits of reflective writing.However, the pandemic brought my reflective writing practice to a halt, and writing was replaced with vacillating thoughts about my long-term commitment to the profession.Working as a frontline advanced practice nurse during the pandemic left me battered.I continue to be deeply troubled by the unconventional ways we cared for the dying, to minimize the spread of infection during the pandemic (Stilos et al., 2021;Stilos & Moore, 2020).The lack of humanity at end of life was in direct contradiction with the aim of palliative care, which is to improve patients' quality of life while living with a life-limiting illness, and it diminished the holistic approach of palliative health-care providers in addressing patients' physical, emotional, and spiritual needs.
Operationally, my hospital has returned to a new norm after the pandemic, and I too have taken steps to reinstate reflective writing as part of my self-care routine.Reading Nouwen's Our Greatest Gift: A Meditation on Dying and Caring (1994) sparked part of my reboot but also prompted this reflective article.Nouwen says, "People are dying.Not just the few I know, but countless people everywhere, every day, every hour.Dying is the most general human event, something we all have to do.But do we do it well?"(p.xiv).I thought of my paternal grandmother and of the countless patient deaths I have encountered over the years in my line of work.In fact, today was no exception.After witnessing another death, I returned to my office to compose my final clinical note on the person, as I sat and collected my thoughts, knowing all too well that as soon as this note was entered into the patient's hospital file, a new consult would await.

My Grandmother's Story
In 2014, the health of both my grandmothers had failed.My 83-year-old maternal grandmother in Canada was losing her battle with metastatic colon cancer.My 93-year-old grandmother in Greece was nearing the end of her of life from multiple exacerbations of congestive heart failure.My paternal grandfather had died a few years before, and I had missed the opportunity to return to Greece then for a final goodbye.This time would be different.Using my palliative care expertise, I did my best to time my trip to fulfill my own deep yearning for a final goodbye.
My grandmother was no longer living alone in her home where I had last seen her and where I have my fondest memories of us together.She had moved in with her eldest daughter who was now her primary caregiver.Her medical management included oxygen, routine opioids, diuretics, and inhalers to help manage her breathlessness.Nonetheless, her mind remained clear and our conversations during our time together were fruitful.
One morning, we decided to enjoy breakfast outdoors.With much effort, we moved our gathering to the balcony.In contrast to the sterile generic decor of the acute care hospital in which I work, this view was spectacular!From the balcony, each quarter turn brought me to a new cardinal point of the compass.To the east, Mount Olympus with its frosted tips, known as the home of the mythical Greek Gods; to the south, the energetic blue waters of the Thermaic Gulf; and to the west, the Byzantine Castle of Platamon from the eleventh century.The entrance to a luscious forest of pine and fir trees was five hundred meters from her apartment.These views encompassed all the aspects of my grandmother's life.She had labored as a seasonal fruit, cotton, and tobacco picker.As a farmer herself, she had numerous olive, fig, hazelnut, and chestnut trees; she was also an expert forager of mountain teas and oregano.Her life was the product of this land spread around us, perfectly entwined with the deep roots beneath us and the branches before us.To her, this was home.
Next to her residence was a small Greek Orthodox Church, and with our luck, that morning there was a service, complete with outdoor speakers for our enjoyment!As a devout Christian, my grandmother found enormous comfort in attending church and listening to hymns.Grandma was full of humor, stories, and memories that day.We reminisced for some time and enjoyed the chanting in the background.She recounted events of her life story, of when she was a young woman, bride, mother, and now a great-grandmother.During her storytelling, she shared a salient philosophical perspective on life: "Where you are, I was, and where I am, you'll be." Words of wisdom, I thought, from a woman who lived nine decades, including darker days of World War II and Greece's civil war that brought political and economic instability to many.Listening to her life stages allowed me to see my own life from a new perspective.Remen's Kitchen Table Wisdom: Stories that Heal (2006) provides multiple examples of the value of listening."The most basic and powerful way to connect to another person is to listen.Just listen.Perhaps the most important thing we ever give each other is our attention" (Remen, 2006, p. 112).Bearing witness, listening, and staying present as patients tell their stories exposes health-care providers to their own vulnerabilities (Tornoe et al., 2014).My conversation with my grandmother was quite emotional, encompassed with gratitude for hearing her life's journey.I am positive that this time together profoundly nourished both our souls.
Perhaps what I experienced with my grandmother mirrors the viewpoint of Zen Buddhist teacher and anthropologist Halifax (1995), that nurses need to explore ways of being with the dying that serves both the health-care provider and the dying person practically and spiritually.Nonetheless, I was left yearning for more time with my grandmother.The time came for my departure and that final goodbye which was so difficult but full of love and gratitude.Once again, Nouwen's words came to mind: "Not only does life lead to death, but death leads to new life" (1994, p. xvi).Three months later she passed.Six years have gone by since her passing, and what remains is the location we have both left behind, and her sacred words.This phrase reverberates in my heart and in all aspects of my life, even when I am sitting at the bedside of a dying patient with their family.I have come to appreciate that those words she bestowed on me have been a gift.A gift that continues to fuel the compassion I must give as a frontline nurse and that has allowed me to remain steadfast in my palliative care career.Perhaps, palliative care nurse Jocelyn Brown has a point: that love is what's needed most to help each of us come out stronger when faced with death every day (in Eggertson, 2022).
I trust that my grandmother's words today will guide me once again as I prepare to meet my new patient: a woman with newly diagnosed metastatic colon cancer and a mother of two young children.I circle back to Nowen's reflections on death, challenging me to think about "where and how I want to die?" (2014, p. xvi), but also bringing greater awareness of how one continues to live well while befriending death.I may not achieve all my grandmother's life stages.However, I am well acquainted with death and the notion that all of us are born to die, some early and some late in life-It is just what fate has in store for each of us.At this time, it feels quite selfish and a little silly to worry about the philosophical wisdom I will pass on to my children or grandchildren.Nevertheless, I hope that if and when that time comes, I too will offer them the perfect phrase that carries them forward as my grandmother's words do in me.

Closing Thoughts
This reflective writing piece is my first since the pandemic.Along with its authenticity, this piece is evidence for my fellow nursing community of how the act of engaging in personalized self-care strategies can bring meaning to one's life and work.Stories have been associated with many benefits, such as healing and soothing the body and spirit and providing hope and courage to explore and grow (Wang & Geale, 2015).Links have been drawn between the development of personal resilience and storytelling; thus, reflection can help develop personal resilience through recounting one's stories of difficulties (East et al., 2010).I encourage each nurse to find sustainable self-care practices that will allow them to keep moving forward in caring for their next patient (Rosenberg et al., 2022;Stilos, 2022).

Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.