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Join Nurse and Naturopath Sarah Franklin as she traverses the delicate landscape of palliative care, moving beyond cancer to address the silent battles against kidney failure, liver disease, and neurological disorders.

Our episode delves into the complex interplay between medication, nutrition, and quality of life, shedding light on the often-underestimated need for personalised care and the power of effective communication during life’s most vulnerable moments, empowering you with knowledge and understanding.

Episode Highlights

  • Personalised Care and Effective Communication: The importance of tailoring care to individual needs and maintaining open, sensitive communication during end-of-life stages.
  • Involving Children in Care: Strategies to engage children in caring for their ailing parents in meaningful and age-appropriate ways.
  • Speech Therapy and Nutritional Solutions: Insights from speech therapists on maintaining dignity for patients with swallowing difficulties through innovative nutrition.
  • Medication Management: A discussion on the dual nature of medications in palliative care, balancing their healing potential against possible harm.
  • Emotional and Ethical Considerations: Sarah’s reflections on the significance of open dialogue about death, honouring patient wishes, and the emotional impact on healthcare providers.

This episode is a heartfelt exploration of the delicate artistry in palliative care, providing valuable perspectives for healthcare practitioners dedicated to improving the quality of life for their patients in their final days.

About Sarah:
Sarah Franklin is a highly qualified practitioner with  25yrs experience

Sarah started out her health career as a paramedic in the Australian Army while studying for her nursing degree at Griffith University. Once she became a qualified nurse, she went on to specialise in Oncology and Emergency.

With cytotoxic qualifications from the Australia College of Nursing,  she then went on to work in oncology and palliative care. With an inquisitive mind and a passion for understanding pharmacology,  she then went on to study Naturopathy, Nutrition, Western Herbal medicine, and Acupuncture. Sarah now runs her own clinic, combining the best of both worlds.

Sarah still works as a registered nurse in a variety of settings and presents at a range of integrative settings, including local hospitals, support groups and via podcasts for different organisations.

Connect with Sarah
Website: 
www.balancehealth.com.au
Facebook: @balancedhealthsarahfranklin
Instagram: @balanced_health_naturopathy

 

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DISCLAIMER: The Information provided in the Wellness by Designs podcast is for educational purposes only; the information presented is not intended to be used as medical advice; please seek the advice of a qualified healthcare professional if what you have heard here today raises questions or concerns relating to your health

Transcript

Introduction

Andrew: This is “Wellness by Designs,” and I’m your host, Andrew Whitfield-Cook. Joining us today is my good friend, Sarah Franklin. She’s an oncology-specialized registered nurse, a naturopath, and an academic mentor. Today, we’re talking about something a little bit different, though. Although she specializes in oncology, we’re going to be talking about nutrition and digestion in palliative care. Welcome to “Wellness by Designs,” Sarah. How are you?

Sarah: Good. Thanks, Andrew. Thanks for having me on board.

Andrew: My absolute pleasure.

Sarah: And, yeah. Looking forward to… Yeah. And looking forward to talking about this topic. It’s a topic I’m passionate about, and I think we could do a lot more work to help patients with digestion that have chronic diseases, or end-stage palliative conditions.

Andrew: Well, we certainly have an aging population. We’re all gonna get there at some stage. So, I think, first of all, we need a bit of a definition. What does palliative care involve? When is it put into place, and with what conditions?

Sarah: Well, palliative care is… Basically, palliative care is to just support someone in the end stages of their life. So, I think a lot of people hear palliative care and they think assisting somebody in dying, which is not quite the… It’s a part of that role, of the palliative care teams, to assist them with that process, but palliative care is basically supporting a patient socially, mentally, physically, through that end stage of life. So, it’s not just that final dying process, so… And I think, again, when people think palliative care, they think of cancer, so they focus in on cancer because they’re used to, a patient had cancer and went to palliative care, or a palliative care unit.

But palliative care extends to people with kidney, kidney failure, liver failure, congestive heart failure, your neurological conditions, like MS, Huntington’s, Parkinson’s, dementia. So, all of those conditions are a life-ending condition, that will require palliative care at some point. And the conditions can vary a lot, so, from condition to condition. So, you know, people with end-stage liver failure will have a lot of bloating and ascites. People with dementia will struggle with cognitively being able to eat, or all those things. And I think the other complex thing with these palliative patients is, you know, they’re still on a lot of medications to try to support their quality of life, so they’re still on a lot of medications, which then have an impact on nutrition, on their digestion, and although those medications might not be life-extending, they’re there to try to provide further quality life. So, for example, with congestive heart failure, they might still be on medications for fluid retention, to help reduce the fluid load on the heart, as a measure to improve their quality of life. But it’s not going to extend greatly that. But, in coming with that, you have these nutritional issues that you come across with these medications, where they strip you of particular minerals, or we have particular medication interactions, so… And that’s where today I guess we’re looking at, you know, there’s a few products here that we can use to help patients in that end stage, because we have complexities when it comes to digestion and swallowing and all those sort of things.

Andrew: Okay. So, is there… I know this is a piece-of-string question, but is there an expected life expectancy where they move people over into palliative care, like, for instance, 12 months, 24 months?

Sarah: No. No, not really. It just depends on how the patient’s deteriorating. So, you can normally tell when the patient’s deteriorating, and that’s, for some diseases, that’s a very slow process, and for others, that’s quite rapid. But normally, when you start to see, you know, increased pain, a lesser level of consciousness, because these diseases affect their ability to think, through calcium or different things, so, you know, progressive cerebral changes, where they can’t cognitively look after themself anymore. Obviously, with pathology, you’ll start to see the kidney function, the liver function, in some cases, the bone marrow is starting to fail, where you’ll start to see changes in bone marrow production, as far as from a hematology point of view. So, no. There’s no piece of string, because a patient with pancreatic cancer might be in palliative care within three months. A patient with Alzheimer’s could have it for 10 years.

So, and some of these diseases are very slow. Generally, as a clinician, we’re often treating these patients for a period of time before they reach that palliative phase. I think the problem is that naturopaths are not good, or nutritionists are not good enough at spotting when that change occurs in the patient’s care, management of care. So, you’ll know because you’ll start to see changes in medication rapidly, or you’ll start to see the patient come in and say that, you know, “They’re talking about referring me to the palliative care team.” So, that should be your first sign that, okay, they’re now withdrawing treatment. And then what tends to happen is, their medical team becomes smaller. So, normally, you know, if you looked at a cancer patient, they’ve got an oncologist, they’ve got radiation oncologist, they’ve got their GPs, they’re having blood tests and scans.

And then all of a sudden, it’s like, “Oh. Okay. I don’t need to go. I’ve been discharged from the oncologist.” And they can have a sense of abandonment, which isn’t true. They haven’t abandoned them. It’s just that there’s no, they can’t provide any more treatment for you anymore, so, generally, they then get moved on to either back to the GP, or back to the palliative care team. And that’s often when a patient will come to you and want you to perform a miracle, which you won’t be able to do, and that’s where you need to have that integrity around having an honest conversation with your client about not offering hope when there’s not hope there. It’s more, “I’m here for you. I’m here to support you. I’ll follow you through this journey or process.”

And then looking at what you can do to help support them in a palliative way, which might be pain, it might be digestive, it might be sleep, it might be anxiety, that all these things that you, there’s lots of stuff that we can provide for these patients, but it’s being able to spot it early enough. Otherwise, what happens is you just end up getting…they think there’s nothing more you can do for them, so they stop seeing you. And then, all of a sudden, you’re, like, three months or six months down the track, going, “I wonder what happened to so-and-so,” when there was a part there where you could have kept treating them, and you could have improved their quality of life, and you could have supported their carers and the people around them to have an active role, to support this person emotionally and physically through this process.

Andrew: Part of what you spoke about before, about the medical team shrinking, because there’s nothing more they can offer them, I do believe that part of that issue has got to do with communication. I was reading a story on “Australian Doctor” recently, and it was saying… Now, forgive me, I think this was…I’m gonna get this wrong, but regional Queensland, and there was some huge amount of patients who were discharged from hospital without discharge planning, without effective communication to other healthcare practitioners, whoever they may be. So, it is an issue. You know, who do you blame? Everybody’s overworked. Everybody’s under extreme pressure. There’s not enough staff. I get it. The fact of the matter is, the patient’s in the center of this, and they need care so. So, should it be part of our care to maybe take the baton, and say, “I’m not gonna wait for this to happen. I’m going to say, ‘Hey, guys, I noticed, you know, Mr. oncologist, Mr., Mrs. GP, whatever. I’ve noticed that patient X has, you know, been discharged. I haven’t received any communication,’ or ‘Here’s some communication to you. I’d like to be part of this healthcare team, blah, blah, blah.'” Is that part of what you do? Like, you’re used to this as an RN, working in the hospital system. But working outside of that, do you communicate with these doctors and other healthcare professionals at all?

Sarah: Yeah. I mean, I’m lucky enough in that I’ve got relationships with the medical team, because I’ve come from that industry, so I’ve got relationships there. But do I think, as a naturopath or a nutritionist, you have a responsibility to support that patient? Absolutely. So, and I think if you don’t, you’re not doing your job that you should be. So, I think the buck does stop with everybody. I think if you’re a part of that healthcare team, if you feel like the patients doesn’t have the support services, and if they don’t have those things there, then I think you do have a responsibility to know who those services are and how to refer them, who they are, and how to make it happen. You don’t need to be a doctor to go, “Maybe you need to get back to your GP and discuss a referral for a palliative care team, or community services, so that you don’t have that carer burnout.” So, I think that’s a part of your role as a clinician, to know when to refer, who to refer, and how to refer. And I think, you know, you brought up the rural thing before. Absolutely. There’s complexities in both. I think in the urban environment, it’s complex. It’s a far more complex system to navigate. People are busy. People, you know, support structure don’t have time and finances to look after each other. Often they’re more isolated in a urban environment.

One of the advantages of remote is that those guys tend to stick together, and they have a better support structure around them and around the town. They tend to look after each other in a rural setting better than a urban setting. So, urban settings have more services, but it’s a more complex system to navigate, where rural have less services, but they’ve got these benefits of a sense of community, and a better social, generally, a better social support, because they’re used to probably having a lack of services, that they’ve learned how to navigate that better. Whereas in an urban environment, where we’ve got that expectation that we can just present to an ED that’s gonna have a specialist available, which they don’t.

Andrew: Let’s face it, they’re just tougher.

Sarah: Yeah.

Andrew: It’s just tougher.

Sarah: And and respect to the rural, shout out to the rural naturopaths and nutritionists, because they do a lot of heavy lifting out there, because they really do bridge the gap between, there’s some huge gaps out there, and they really do bridge those gaps out there. So, rural naturopaths and nutritionists really do do a lot more heavy lifting. You know, they’re counselors, they’re, you know, they play a much more physical role in, you know, checking blood pressure and everything. So, they definitely do…you know, and they’re a part of the community, so they’re…it’s harder for boundary-setting, all those sorts of things, so, you know, huge respect for guys that work in those rural communities, with the services that they’ve got.

Andrew: What are the issues with the activities of daily living that you see and you treat? You’ve mentioned pain. You’ve spoken about swallowing. Can we delve into these a little bit more?

Sarah: Yeah. So, often, what you start to see is, you know, with some of the neurological conditions, etc., you definitely get those digestive issues. So, you know, you might have the patient with throat cancer, or you might have a patient with, you know, throat cancer with radiation…

Andrew: Stroke.

Sarah: …you might have a patient with stroke, yeah, that can’t swallow effectively. You might have a patient with dementia or Alzheimer’s that doesn’t know how to swallow, cognitively. So, I think, when you’re looking at these palliative care that’s why I guess I’m grouping them a little bit, because we tend to, in geriatric care, see a lot of the same conditions as palliative care, because we tend to see more palliative conditions in the aging community. So, the main things we sort of see is, like, oral health. So, a lot of these older people, or, you know, depending on what’s going on, they might have, you know, dentures, or they haven’t got dentures, or they’re not able to chew their food properly. So, you’ve got oral issues. You’ve got digestive issues, where you’ve got, you know, strictures or narrowing of the esophagus, so they’re an increased choking risk. So, then you’re needing to use thickened, or you know, you’ll have speech pathologists involved to review what you can use.

You’ve got poor appetite, because they’re not moving as much. They’re more sedentary, they’re losing muscle mass, their metabolism’s slowing down, so they’re often not hungry. They’re often dehydrated. They’re often nutrient deficient. They tend to wanna eat foods that are crap, that are high-calorie, but, you know, low nutritional content value, so there’s a lot more education around what type of foods would be beneficial. And then, if they are in a aged care facility, or if they’re in a palliative care unit, then it’s the obstacle for us, is how do we communicate that, so that that can be implemented in a environment that you’re not in control of, because it’s all governed by, you know, those institutions. So, then, how can you communicate to the charge nurses or the family or the doctor, so that you can implement nutritional changes, or implement supplementation that’s safe, because you’re not going to be able to get anything through without the family or the doctor basically ticking off on it on the end, so that’s communication.

Andrew: So, with regards to things, I mean, you could start with appetite, and oral health, indeed. So, we’ve got anywhere from, as you say, dentures, you get atrophy, atrophication, atrophy of the jaw. So, the dentures that once used to fit well now don’t. They can cause ulceration, pain, lack of chewing. There’s a whole sequelae that comes from that. You’ve got the changes in, just the appetite, and as you say, you know, they tend to crave the sweet things, the sweet sensation… The sense of taste of sweet comes back in, if you like.

Sarah: Yep. Yep.

Andrew: So, they like their desserts. But this is at a time when they’re very often suffering from sarcopenia, so you really need to look at protein. So, these are real big issues, and there’s so, you know, defecation, lack of control of defecation, incontinence, urinary and fecal. You mentioned before about, you know, as they get older, as these patients get older, you know, they’ve got a lack of mobility. So, you haven’t just got things like bone mineralization, things like that, you’ve gotta say, okay, well, what happens to that calcium? Because it goes out. So, there, have you got a kidney problem? Have you got bed sores? Have you got vitamin D, lack of vitamin D? This…

Sarah: Yep.

Andrew: There’s so many rabbit holes. Your mind must be like Swiss cheese, Sarah.

Sarah: Luckily, I love it. I love it. And I love, as much as it’s an area that people go, “Oh, that’s really odd that you’re passionate about that,” but you really can make an impact on these guys, and you can really improve their quality of health. And you can really help the family to feel supported, because they often feel lost, and they don’t know if what they’re doing is right or wrong. So, just having someone to help them run alongside them, to give them a purpose, and to keep that connection. You know, it’s complex. There’s role changes. There’s, you know, partners becoming parents. There’s, you know, you’ve got so many social issues. You’ve got kids that are, you know, you might be navigating a palliative care with a child that’s involved, so you might be navigating how does a child process a parent passing away, or getting them prepared and ready, ready for what they need to do, or, you know, how can you keep the child involved with the palliative care? You know, can you give them a little task that they could do with the parent, to keep a connection there that is purposeful, but, at the same point, appropriate for that child, depending on their personality and their age development of how you can sort of… You know, because often, you don’t wanna just exclude them out of the picture, but it needs to be done in a way that’s appropriate for that child.

Andrew: That’s very thoughtful of you. I’d never, ever would have thought of that. Absolutely brilliant. Can we go through, Sarah, what this instigation of your care with palliative care looks like? Like, what sort of things do you actually say, with regards to, let’s say, poor nutrition, multivitamin, or vitamin D, when they’ve got, say, a swallowing risk? A swallowing issue?

Sarah: Yeah. So, if there’s a swallowing issue, normally, they’d be referred to by a speech…normally, you’ll have a speech therapist involved. And the speech therapist role is to assess their swallowing, to make sure that… Because there’s a risk, as they start to lose that swallowing effect, or you can’t chew your food properly, there’s a risk that you’ll choke on your food, and then you’ll aspirate, and the food will go into the lung, and then you’ll have pneumonia. So, that’s our biggest risk, is aspiration. So, generally, if the patient’s coming in, or the family, and saying, oh, that we’re noticing when they’re drinking, they’re coughing, or when they’re eating food, they’re coughing a lot, it’s usually because they’re choking. So, then you go, well, again, your responsibility is to go, “You need to get back to your GP, because we probably need a speech therapy review, to check the gag reflex,” which the GPs or specialists will refer off to. And then what happens is the speech therapist will come back and give you a grading. They’ll give you a thickening grading, because they’ll be able to assess the swallowing, to show you what’s important.

So, I guess that’s where, with supplementation, you know, you might go, well, you know, if you’re trying to increase their absorption of their food, and their tummy’s not very well, and they’re nauseous and they’re bloated, so, what liquids could you use, or what powders, or liposomal forms could you use? Because these people are going to be deficient in B12, folate, and they’re probably not eating any green leafy stuff. They’re not eating enough protein. They’re probably vitamin D deficient, because they’re sitting inside all day, and there’s some medications that decrease vitamin D, as well as B12, folate. They’re probably magnesium deficient, which would then increase cardiac risk. So, what powders could you use? Or liposomal or liquids could you use, because you’re gonna have to mix it in, whatever that swallowing…whatever you’ve been approved for. So, but it’s also, if the patient is, yeah, describing those issues, swallowing water. Water’s normally the main one that you see, so you’ll often go, you know, you’ll see them drinking water, and then they’ll start coughing. That’s usually a sign that it’s too thin, and the muscle reflex is just, it’s not fast enough to register with the brain, and they’re choking on the water, so…

And that’s where you’ve gotta think outside the box, and go, “Okay, we’ve got a nutrient deficient person. They’re not gonna be able to tolerate a lot of supplements, so what can I do in a powder or liquid or liposomal form that’s going to be able to have an impact, but be able to tolerate, because tablets will usually become something that you can’t use, or tablets or capsules at this point, or if it is a capsule, can you open it up and use it?

Andrew: Yeah. Do you tend to look for, you know, let’s say, for instance, there’s some great-tasting protein powders nowadays, you know, whey protein with a good nutrient profile. Do you tend to sort of look at that?

Sarah: I do.

Andrew: I guess, you know, naturopathically, we tend to like to avoid dairy products, but in some it’s…I’m not that scared of whey. I actually like it.

Sarah: Yeah. And I think you just gotta be a bit realistic at the end stage. You’re not, oh, you know, we gotta be totally on point with nutrition and sugar. So, yeah, absolutely. There’s some really good, nice protein powders out there. If you’re younger and you’re healthier, you can be a bit more, “Yep. This is what I want you to eat, and let’s be stricter around sugars and processed stuff.” Like, obviously, we’d all prefer patients to use less processed stuff, because we know that it’s not good for you, and the risks associated. But, when you’re a palliative patient, it’s like being, “Oh I don’t wanna take more things. I’ll get addicted.” It’s like, “Well, that’s the least of your issues, being addicted to more things.” So, it’s the same thing with the sugar. I think you’ve gotta be realistic that sticking to your guns on some of this stuff isn’t gonna work, so… But absolutely, could you, you know, try chia puddings with protein powder? Or could you do smoothies with vegetables and juices, and then somehow blend them into, you know, like, basically like children, where, can you make them into little ice blocks or, you know, you’ve gotta probably be prepared, you know. Could you do a jelly, with some gelatin, some collagen powder, and make, like, a little jelly or something, where you can make some fruit juices, or blend something up and put a bit of collagen powder to thicken it up, and, you know, you do these little things along the way, to help build their nutrition, but in a way that’s healthy, but it’s also being realistic about, you know, that you’re there to help their quality of life at this point. You’re not there to extend it.

Andrew: Sarah, moving on from swallowing, when we’re talking about mobility, muscle mass, institutionalization, lack of appetite, do you tend… And indeed the swallowing issues as well, do you tend to utilize, in a maybe, a whey protein concentrate or something, with a good nutrient profile, what do you tend to favor?

Sarah: I think, you know, when you’re at this point, or at the palliative point, it really comes down to texture, and it comes down to taste. So, they’re not gonna be hungry. They’re not really gonna wanna do anything. They’re going to be depressed to a degree, so, you know, you’re also got the challenges of someone who’s really struggling at the moment, so asking them to take a really yucky powdered drink, is gonna, it’s not gonna go well.

Andrew: Yeah. No way.

Sarah: So, yeah. So, to be honest, at this point, yes, do I look for something but basically, we almost move into that, I guess, you know, it sounds terrible, but you just start really looking at the, how much protein, how many calories, how much carbs have you got in it, how much fat’s in it? So, you really start breaking down to, what nutrition is in there? So, and what vitamins and minerals are in there? So, has it got enough of what we want? So, definitely, a look at whey protein. But I also look at, you know, yes, it’s nice to use, you know, rice-based or soy-based or different pea proteins, whatever. But, generally, your whey proteins are the better tolerated on taste. So, if a patient prefers to have a whey protein, with banana in there, and honey, and you might be able to put some other things in there to help build it up, you know, your collagen. You know, you could put liquid iron in there. You could put, you know, B vitamins. Whatever. You could put different things. Magnesium. So, you can put little bits in there. Obviously, you’ve gotta do it around taste, but…

Yeah. So, that’s where I’d be going. I, you know, to be honest, it’s really, I’m looking at the nutritional panel, and I’m trying to, you know, it’s almost, look, I’m gonna use a protein powder that I would use for a bodybuilder who wants to gain muscle mass. So, I’m gonna be using something that’s as strong as… What’s the most I can get in the smallest amount of volume, because they’re not gonna be able to tolerate much. So, that’s where, again, you’re looking at your, you know, your protein powders. You know, there are other formulas on the market that are high-calorie, what we call very high-calorie-dense liquids, that we obviously use in the hospital sector, and that’s what we use with tubes, NG tubes. And some of these patients might even have a nasogastric tube or a PEG feed in their stomach, and sometimes even these things, as long as you okay it with the doctors, they’re happy.

As long as you’re blending it down properly, you can use these things, you know, particularly through PEGs, that you can sort of supplement through the PEG feed with your liposomals and your magnesiums and your bits and pieces, so you can, if they are eating through another mean other than through their mouth, again, that’s something that you can discuss with your medical team, to go, well, if we make it up, and if the family are comfortable to do it, and it’s all dissolved and it’s all broken down, and it’s all soft, and there’s no risk of it blocking the tube, then is that something that we could sort of look at all the same with your liposomal products, you know, you… Liposomal, different nutritions that you can get with magnesium, or your other, you know, there’s lots of liposomals available, is, you know, they would be fine to put down a NG tube, or, like, a thinner tube, because you’re using such a low volume that that’s something that you could do as well.

So, there’s lots of ways if you can think outside the box. But again, all of these things need to be done around communication and discussion, and that everybody’s happy with what you’re doing, because you’re, generally, these patients are going to be in an acute setting, and if they’re not in acute setting, they’re at home, and they’re being managed by palliative care nurses, so then it’s communicating with that palliative care team, to go, are the nurses happy with what we’re doing, because you don’t wanna be doing something that creates an issue because you didn’t know, and then the medical team are a bit perplexed as to, something’s changed, or something’s deteriorated, or something’s gone wrong, and it’s like oh, you know?

So if everyone knows what each other’s doing, then everyone can, work around that. And I think naturopaths are starting to build a better role in that allied health sector, so I think we’ve been the, you know, the poorer, you know, the very poor sibling in the healthcare sector. But we’re now seeing a lot more naturopaths and nutritionists in GP clinics, and playing a bit more of a role, so, and I think, through the formal education system that we’re under, where now it is a four-year bachelor degree, or they’ve got master’s degrees, that I think that they’re starting to take us more seriously. So, I think, in time it’s only gonna, our role in that is going to increase, where we’ll continue to work with dietitians and nutritionists, or, you know, whatever that may be, speech therapists, to have input on… Because, you know, our view is so holistic in their care. It’s not just, you know, like, a dietician, they might be more focused on the macronutrients, or… We’re not focused on one little bit, we’re focused… The beauty of what we do is we’re so holistic in our approach that we can really pull together lots of different allies that they’re using, psychologists and speechies and OTs, and there’s so many allies that we can communicate with, to bring together, if you can see a deficit, that we can really play that role if we have more time in the teepees.

Andrew: True holistic care.

Sarah: Yeah.

Andrew: Yeah. Okay. So, earlier on, you mentioned medication issues. Let’s go through these. What do the, what’s the typical sort of thing that you see? I think we mentioned, you know, swallowing a tablet earlier, but obviously there’s other medication issues with, oh, gosh, leaky blood-brain barriers as we age, and toxicity, if your liver isn’t functioning correctly or your kidneys aren’t functioning correctly with regards to biotransformation of medications. Tell us what you see in your clinic with regards to this.

Sarah: Probably the main things I see are either… Yes, definitely, like, potassium, magnesium, like, I definitely see a lot of magnesium deficiency, because of chemotherapy,  oncology patients. So, there’s certainly a lot of medications that drop your magnesium down. You also see the magnesium drop in a lot of autoimmune, like some of your rheumatoids and those guys, because of the medications that they’re using can drop magnesium. Calcium is another one, and obviously, when your magnesium/calcium goes out, then you can, you know, from a nursing perspective, you can end up with some pretty serious medical emergencies in regards to the heart, that happen quite quickly. Your potassium, with your, you know, some of the medications that you’re using for fluids, so, your congestive heart failure patients, and those guys, or your, some of your livers might be on medications that affect the potassium level, so, do you need to then be increasing, you know, potassium, and yes, there are medications to increase all these things, but there’s also foods, and you know, yes, you can supplement, but, you know, you can try and increase potassium through diet as well.

Vitamin D is a big one that we see, just because a lot more people are spending a lot more time inside, and we’re now understanding the key role that vitamin D plays, you know, genetically, how integral it is in how we synthesize things, and how things work. The same with your B vitamins, you know, your methylation pathways, and if you’ve got a genetic variant on there, that, how much, you know, I wouldn’t say it, I’m obsessed with methylation, MTHFR, but I certainly acknowledge that it plays a big role. So, if you do have that, then that’s something you definitely need to consider as well, so, because, you know, people are definitely not eating enough green leafy stuff. I think protein. Protein is definitely a big one, that you’ll see on their pathology. When you’re reading the pathology, you’ll see that continual drop in protein, and then once you get that down, then you have a whole catabolic effect in the body, where, once it starts digesting itself, you have all sorts of troubles with the kidney and the liver at that point, because it’s doing something it shouldn’t be doing. And then, obviously, nutritionally, if you don’t have enough iron, if you don’t have enough B12, if you don’t have enough folate, if you don’t have those essential nutrients, the bone marrow can’t produce white cells and red blood cells, and the bone marrow can’t do its job. So that’s when you’ll see that, in their pathology, you’ll start to see that the hemoglobin and the white cell count and the platelet counts, and then when you start to see them all out of whack, you then know that it’s probably an upstream issue, that it’s not that they’re being damaged in the blood, they’re not being produced in the first place.

So, again, the kidneys can affect the bone marrow. So, the kidneys talk to the bone marrow on how to produce these things, so then, if you’ve got a patient with kidney disease, you’re going to see changes in hematology, because of the way that they all talk together, or the same with the liver. Once the liver starts to fail, then can it actually metabolize the medications? You know, a lot of cardiac medications that we use for congestive heart failure impact on the kidney and liver, so, you know, I know in the nursing world, it’s a common debate between the cardiologist and the renal specialist on, you know, finding that fine balance between the heart and the kidneys, because they, you know, they definitely have impacts on each other, and trying to get the balance right is very difficult, but any patient with any of these, COPD, any of the neurologicals, you know, your neurological patients are gonna be magnesium deficient, zinc deficient. Zinc for everyone. You know, magnesium’s a big one for the nervous system, for that myelin sheath, and what’s the…you know? And I guess, with your brain, it’s, you know, when you’ve got some of these inflammatory brain conditions, what actually does cross the blood barrier, or not, and understanding that, and how can you support that neural inflammation when there’s chronic disease as well?

Andrew: Can I ask about, you know, when we’re dealing with palliative care, we’re talking about moving towards the end of life. So, with regards to that, do you have hurdles, resistance, by the healthcare team, even the family, to say, “What’s the point?” You know, how far do we go with this sort of thing? How much money do we throw at this? Do you ever have that sort of, or have to have an uncomfortable conversation about, “Listen, this is worthwhile, but this, actually, you’re not gonna get much bang for buck from it. We can give it to you, sure. But it’s not gonna change… It’s not gonna have a great impact on their activities, their daily activities of living.”

Sarah: Yeah. I think there’s probably two answers to that question. One is definitely, yes. So, if there’s products that we’re using that aren’t of benefit, why would we use them? We’re just increasing load, we’re wasting money and they’re, you know, what they’re gonna be able to tolerate is gonna be minimal. So you’ve really gotta condense what you’re doing. So, absolutely, do you need to scale back anything that is not going to improve their quality of life? Needs to go. So, definitely, yes. The other part of your question is, have I ever had to have discussions around patients feeling like it’s not a benefit? Never. Because, generally, it’s more the other way, that it is such a under-assessed, undervalued part of what we do, that, to be honest with you, I’d say 90% of naturopaths and nutritionists don’t take an active role in palliative care. So…

Andrew: Wow.

Sarah: And that’s purely because they didn’t know that they could. And that’s probably because the practitioner didn’t let them know that they could. So, to be honest with you, I’ve never had anyone go, “What’s the point of seeing you in palliative care?” They’re all like, “Yeah, what can I do to help this person through this last stage?”

Andrew: Okay. So, is this then… Do I be brazen, and say the word “failing?” Is this a failing of naturopathic teaching institutions, in that they’re not teaching it as an important part of naturopathic care? And therefore people don’t know, da da da?

Sarah: Right. I do. Yep. I do.

Andrew: That’s why you’re an academic mentor.

Sarah: I do. So, I, you know, as a palliative, you know, oncology nurse, and a nurse that’s done palliative care, and worked in palliative units, being a part of someone’s death is like being a part of a pregnancy or birth. It can be a really beautiful thing, that you can make really beautiful, and everyone can be supported and valued. But often, that’s not the case, and I think that is a failing on our education and awareness, in that people don’t know when to recognize it. They don’t know how to have the hard discussions, and to have that communication. And I think, at the end of the day, you have to be comfortable with your own immortality and belief systems around that, to be comfortable to work with this. So I think you need to be, you know, you really need to be comfortable where you are. You know, what do you think about your own immortality? And I know that, you know, I know, for me, I struggled with it initially, working in palliative care as a nurse. It took me a long time to be comfortable with this, and fortunately I had colleagues that were able to…you know, I guess I had that support structure around me, to help me process that. And I guess when I became a naturopath, and I had kids, I had a lot of anxiety around working with people dying again, because you’re like, “Oh, my god. Everyone I see is dying,” and you get a distorted perception on reality.

And then, for me, I had to really sit there and go, “What was that about for me? Where was that anxiety coming from for me?” And for me, it was purely ego, that I thought that if I died, my children wouldn’t be okay, which was not true. So, for me, that’s, once I was able to nail it down and go, “Actually, my kids would be okay. That’s my own ego, that I think I’m so self-important that they wouldn’t just thrive,” when, yes, of course, they know that they would be upset, and of course that would have an impact on them. But I also know that they would have been okay, and there’s lots of kids that have lost their parent that thrive, and they grow from it, and it’s not the end of the world. So, once I was sort of able to move through that, and acknowledge that, then I was…and you know, going to be comfortable with my immortality, that once you surrender to that, you can be quite comfortable, and have open discussions around all those fears that those patients have, which is, what’s gonna happen when I die? Is it gonna be painful? And what’s gonna happen? So, and part of that is understanding the dying process and these different diseases.

So, if a liver patient said to me, “What’s gonna happen?” I’d say, “Well, you’re probably gonna get ascites, and you’re gonna build-up of fluid in your tummy, and, you know, they’ll try to keep that down as much as they can, but then it will press on the lungs, and you’ll get shortness of breath, and you might get, you know, more confusion, so, if you… And they all have a different process. They’re not all the same. So, the way that a liver patient dies is different to a way a person with chronic kidney disease dies, where they, you know, loss of appetite, increased confusion, drowsiness. You know, they’re all different, because their pathology’s different. So, I think that’s, again, understanding, if you have a palliative patient, do some research on what the pathology is like at the end, because how you would treat them, and preparing the patient, and the family, for when these things come on. I remember reading a… They did a big, a coroner study, and they were talking about just that preparation of when people were identifying deceased people for coroner’s reasonings, and they had one study where they really explain to them what’s gonna happen. So, you’re gonna come in the room. This is what it’s gonna feel like. It’s gonna be cold. This is what’s gonna happen. We’re gonna come in, the person will be in… You know? And, I mean, they talk through the whole process before the person, the family member went in the room to identify the body.

And then they had a group where they didn’t so much, and it was huge. It was huge, the difference. When people are prepared for something, and they know what’s coming, and what that experience is gonna be like, it’s not so scary, and it’s not so… They’re ready for it. Versus going, “Oh, my god. What’s happening? This is all out of control,” and the family become distressed, and “is that normal?” and, you know, they’re just, they’re not prepared for it, and, you know, it’s not just a failing on our industry. It’s a failing on the healthcare sector, how many palliative patients are not managed well, and then they end up at home, and then it ends up becoming a disaster, and it ends up being a really traumatic thing family…

Andrew: Out of their control. Yeah.

Sarah: Yeah. Rather than pre-empting it, and going, “Okay, we need to put these things in place, so that we’re ready for this.”

Andrew: Sarah, I’m gonna have to put up in the show…

Sarah: Sorry, that was a bit heavy, wasn’t it? Sorry.

Andrew: Oh, but, you know, yeah. But you know what? It shows your care. You had me teary there for a tick, but I’ll get over it. One of the interesting things I’m gonna put up in the show notes is, it was a podcast that was on ABC Conversations. This one was done by a woman, led by a woman, but she was speaking with an oncologist who openly discusses death very early, and talks about that very early in the meetings with her patient, to say, “What would you like to happen if and when this should eventuate?” And it’s a beautiful podcast. So, we’ll put that up in the show notes, and I’m blinking. So, Sarah, I can’t thank you enough for taking us through what you do every day, but when I see you doing it, I am just inspired, I am all inspired by your care. Oh, damn it. Of your human…

Sarah: Sorry, Andrew. If I could give you a I would.

Andrew: …of your… Not just your patients. Well, you’re only three Ks away, but… But I am truly honored to know you, because you are a caring individual, who really is there for your patients. And I thank you so much for sharing your expertise, and that care, indeed, with us today.

Sarah: You’re welcome.

Andrew: And thank you, everyone, for joining us. Sorry, teary moment. I’m a bit of a sook. But we’ll put up as much information as we can in the show notes. Obviously, you can find all the other podcasts on the Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”

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