I am so tired. Not in the usual “hard day at work,” but in a “deep-in-my-soul” tired. I am exhausted.

I am heading into my third year as system medical director, where I lead a system-wide palliative medicine program in rural health.

As in many rural systems, we have issues with broad geographic spread coupled with lower population density and limited resources.

But for those of us working in rural health, there is a passion that drives us to stay in rural health, to care for those in the closer-knit communities we serve and to engage in more creative problem-solving partnerships with area home health and hospice agencies.

Since arriving here, I have tripled consult volumes, broadened our reach across total hospital admissions, integrated teaching curriculum and elective rotations with medicine and ED residencies, and have made this program highly visible across the system with full integration into intensive care and oncology.

This is great work, but last night, I felt the toll. And for someone who prides herself on her resilience, this was a tough moment. I am a strong individual with a deep, abiding passion for my work. As the saying goes, “Do what you love, and you’ll never work another day in your life, “… but COVID has really taken a lot from all of us.

I am currently in my fourth week of covering all the COVID units for my rural hospital. We usually do this in two-week blocks to allow for each other to have an emotional “reset” in between. Why? Because as a small palliative medicine team of three providers, we must find a way to balance the needs of the organization with team preservation and resilience.

Currently, I have one provider on vacation, and my third provider, new to the job, is onboarding, having been here just three weeks. I have built a solid team of talented, caring, compassionate providers. All of whom deliver exceptional clinical care with, as Ira Byock MD encourages, an unabashed tenderness.

The sheer intensity of the COVID workload — the family meetings, the emotional lability of discussions, and family/caregiver reactions are overwhelming. My team and I jointly round with critical care medicine and nursing teams daily in the COVID unit, collaborating on pain and symptom management and primary responsibility for ongoing family meetings/goals of care and code status discussions. Where am I going with all this?

Last night, I met with the family of a young patient who was battling COVID for weeks. He was vaccinated and young, with a young wife and two children. He is loved beyond measure by family and friends. We have tried everything, but the refractory hypoxemia, high airway pressures, and multiorgan failure of COVID are winning.

We tried getting him to a higher level of care, but he was too sick. The teams caring for him feel the love and the suffering of his family. We share in this with them. We also want him to get better. They have been gracious and kind at every family meeting, asking open, honest questions — telling me, “Please, if or when it’s time to let him go, please, just tell me. Because I don’t think I can get to that decision point on my own.”

Last night, we sat down in the COVID ICU conference room with his parents, wife, nurse, and social worker.

My voice cracked, and my eyes filled with tears as I told them that it was with breaking hearts we, the medical team, feel it is time for comfort to be initiated because our technology, medicine, and best efforts are no longer helping. It is, I believe, the first time in over a decade that I have been so demonstratively emotional in a meeting.

Bolstered by a phenomenal team, we moved him to comfort care with a compassionate extubation and provided them with “heartbeat in a bottle” keepsakes, along with books for his children, imprinted with his handprint. Are these good enough? I hope so but am never entirely sure — I carry a prayer and a hope they bring solace.

This brought me to reflect on: what is COVID taking from us? Certainly not our humanity, kindness or passion to care for others in their sickest and most vulnerable times.

But it is eroding emotional reserves, our resilience, and for many, our physical well-being. We are not able to self-monitor and intervene in the heightened sadness as well as we once did, perhaps because there is simply so much of it that we are moving from one case to the next and not taking the time for us.

How do you combat this fatigue? For my team and me, we set aside the last 5 to 10 minutes of our morning IDT for a check-in with each other.

If complex family dynamics are noted to be draining someone, another one of us offers to take the case that over-sharing this workload helps amplify our bandwidth to be the best we can be for all those we serve. We provide emotional support and genuine love and concern for each other. We try to have a team lunch at least once a week because even that simple act of nourishing ourselves also nourishes each other in different ways. Those 15 to 20 minutes are often the reset we need to shore up our emotional reserves. And we are all mindful of being present in our home lives. Boundaries from work are needed to help assure those we love the most remain happy and whole.

Palliative medicine is not for everyone. Managing suffering takes time, compassion, and curiosity in our human existence, along with the willingness to be, as Dr. Byock teaches, unabashedly tender in the care we give to our patients. We excel at communication. It is our “procedure,” but it just isn’t as highly valued on the proverbial RVU scale.

COVID has brought us new challenges and a genuine opportunity to be part of the critical response to optimize the care we deliver not just to our patients but also to their families and caregivers. I am lucky, blessed to do this work every day and carry such a deep passion.

We are making a difference and impacting care in positive ways. We support not only patients, families, and caregivers but also each other, our colleagues, and other members of the health care teams.

We are all in this together — a shared commitment for assuring humanity in medicine. And each day, we hope that our eyes will see the best in people, our hearts forgive the worst, our minds forget the bad, and our souls remain ever steadfast in our faith, commitment, and love for this sacred medical work we are so lucky to do.

Patricia M. Fogelman is a nurse practitioner.

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