photograph by lisa buser
Dr. Jeff Nelson directs the palliative care team at Regional One Medical Center.
The small, windowless conference room in the Regional One Health Trauma ICU was crowded, the air close. At the table were seven family members of Mr. C., who had arrived the night before at the Trauma Center downstairs; he’d been hit by a car as a pedestrian. He had massive head trauma when he arrived, and the situation overnight had gotten worse.
Dr. Jeff Nelson spoke in a soft voice; this was going to be a difficult conversation. He asked what the family had heard from previous doctors, and was careful with his questions. “Sometimes they don’t remember,” he said later, “and I don’t want them to feel stupid or uninformed.”
One family member said that she knew “he’s gone.” Sniffles started from the end of the table.
Nelson explained to them what happens when a brain is severely injured and the measures doctors had taken up to this point. Another physician on Nelson’s team outlined the tests he’d just done to assess whether Mr. C. was actually brain dead; the news was bad. He explained that the ventilator was breathing for their brother and when that was removed, his heart would stop.
But one family member wasn’t having it, which Nelson said is common in these emotional situations.
He listened, then said, “I can’t imagine how hard this is.” They could try one more test, and she wanted to “watch the doctors do it.” Sure, said Nelson. Mr. C already had many tests, and he offered to share the results.
Another family member left the room abruptly, saying, “Don’t let them pull the plug on him” on his way out. The meeting broke up soon afterward.
“We’re not about dying here,” Dr. Jeff Nelson said as he approached another trauma patient’s room. “We’re about how you live with what’s happening.” In a healthcare world that often approaches life-limiting illness with test after test that includes scant interpretation or context, that philosophy can be transformational, for patients, families, and medical staff alike.
It’s probably not your best day ever, the first time you hear about palliative care.
Maybe you’ve had a devastating cancer diagnosis, one that may be terminal. Or the chronic heart disease you thought you could live with has taken a turn for the worse. Perhaps your elderly father has had a bad fall and hit his head or broken several bones. Or a loved one has been in a serious automobile accident, one that sends her to Regional One Health, our region’s only Level 1 Trauma Center.
At Regional One, you may meet Dr. Jeff Nelson, who leads the hospital’s year-old palliative care service. In the crowd of white-coated physicians, nurses, and other professionals in the Trauma ICU, Nelson, who favors khakis and polo shirts but no white coat, can blend in. But make no mistake: He’s a well-regarded leader in this rapidly growing medical discipline.
Nelson is board-certified in palliative and hospice medicine as well as family medicine, and is also an assistant professor at the University of Tennessee Health Science Center. At Regional One, he works with a team that includes a nurse practitioner, a social worker, a practice manager and — always — a gaggle of fellows, residents, and medical students. More than his credentials, though, Nelson is an empathetic, gentle practitioner who seems born to do this work. His approach to patients and their families is helpful, open, and comforting.
“We’re not about dying here,” he said as he approached another trauma patient’s room. “We’re about how you live with what’s happening.”
In a healthcare world that often approaches life-limiting illness with test after test that includes scant interpretation or context, that philosophy can be transformational, for patients, families, and medical staff alike.
photograph by lisa buser
Dr. Jeff Nelson confers with his team, including (from left) medical student Claire Cohen, social worker Tonya Arnold, and nurse practitioner Nakesha McCollins.
Nelson and his team are acutely aware that their work is easily misunderstood. “I think one of the biggest misperceptions about palliative care is that it’s about dying,” he said as we navigated the maze of hallways at Regional One on the way to his next consult. “I think it’s about how you live despite circumstances you don’t want.” And they never talk about “pulling the plug.”
Many people, including some healthcare professionals, confuse palliative care with hospice, which involves ceasing all disease-directed therapies — chemotherapy and radiation, for example — and concentrating on comfort, peace, and dignity for the patient. Sometimes palliative care leads to hospice care. Sometimes it doesn’t.
Nakesha McCollins, a nurse practitioner on Nelson’s team, was challenged one day by a nurse on the cancer floor at Regional One. “Why are you here?” the nurse demanded. “This patient isn’t on comfort care.” The nurse thought McCollins and her partner, social worker Tonya Arnold, were hospice staffers.
“We talk through major life changes with our patients,” McCollins explained. “She’s had a major life change.”
The palliative care team works with other medical professionals to augment all the standard treatments for people with a serious — or even terminal — illness, focusing on quality of life for patients and their loved ones. “It might be treating physical symptoms, it might be helping with depression or anxiety, it might just be having that therapeutic alliance with people that helps them feel better and less alone,” Nelson told a Regional One podcast interviewer last year.
“Hospital time is different from human time. In the hospital, everyone wants the patient to go on to the next thing, because the alternative is end-of-life care. We help families and patients think about whether the ICU, a ventilator, and more surgery is right for them. Where can we truly provide support? How can we help define the way our patients want to live?”
— Dr. Jeff Nelson
Working at Regional One is a special subset of palliative care, given that many patients there have recently experienced life-changing traumas. “We have quite a number of severely ill and injured patients at Regional One Health,” said Dr. Martin Croce, the hospital’s chief medical officer. “In addition, we provide top-notch cancer care. We knew that palliative care was needed to provide all the care our patients need. Sometimes, the best care is the alleviation of suffering rather than prolonging the inevitable.”
Nelson sees palliative care as an extra layer of support that can help patients and their families understand what has happened, where they are in their medical journey, and what options are open to them. “Palliative care conversations are different in trauma because the shock of what’s happened is so great for the family members,” he said. “They can’t really hear everything and make decisions about the long-term at the beginning.”
Another family meeting focused on an aging matriarch from a rural area outside Memphis who had been struggling to breathe. Her adult children knew the end was near.
During their conversation, Nelson asked who his patient was and what she might want as her health declined. She already had a breathing tube and he was trying to help the family understand the next steps. “I wouldn’t choose to be on a ventilator,” he said, and they all agreed. “But we don’t want her to suffer,” said her daughter.
“We don’t allow that here,” Nelson responded, while he outlined what would happen as the patient’s breathing became more labored.
“Hospital time is different from human time,” he said later. “In the hospital, everyone wants the patient to go on to the next thing, because the alternative is end-of-life care. We help families and patients think about whether the ICU, a ventilator, and more surgery is right for them. Where can we truly provide support? How can we help define the way our patients want to live?”
In addition to helping families cope with their loved one’s serious illness, Nelson and his palliative care team support the staff at Regional One as well, especially coming out of the Covid-19 pandemic.
“What you saw [with the older woman and her children] — we usually do that a couple of times a week, but during the pandemic, we did it a couple of times a day,” said Dr. Ian Molyneaux, an anesthesiologist and critical-care physician. “From an emotional standpoint, it was extremely difficult.”
Nelson launched the palliative care program at Regional One in July 2022, and Molyneaux said it was a huge relief to the medical teams — as well as the patients and their families. “The palliative care folks take care of families but also take care of the staff,” he said. “If you’re experiencing emotional burnout, it affects the way you take care of patients. I can’t tell you how much that service means to the hospital and the community. They are a very important part of how we do our jobs.”
Carolyn Mallett, a registered nurse who works in the Trauma ICU, agreed. “If I see a patient where the family doesn’t understand how serious the situation is or if they need to understand their options for end-of-life care, I can call palliative care,” she said. “I hear all the time from my families, ‘I didn’t understand that. One team says he’s looking better, one team says it’s not good.’ Palliative care is looking at the whole picture. It’s very helpful because they can clear up any confusion.”
Was the hospital leadership surprised at how quickly the palliative care service has taken off? “Honestly, I always thought the service would be successful,” said Croce, the chief medical officer. “Dr. Jeff Nelson has done a phenomenal job. He built his team with outstanding people who care about the patients, and he is an exemplary physician. When patients are seen by Dr. Nelson and his team, the caring and empathy is palpable.”
The Burn Unit at Regional One is a hard place to be, and Nelson thinks so, too. It’s easy to understand why: Patients are in a lot of pain, there’s a high chance of infection, and burns are often fatal. The unit is kept warmer than the rest of the hospital.
Nelson and his team visited a woman from Arkansas who was burned in an accident. Because of her age and other health issues, doctors couldn’t operate to prevent infection.
“I’m going to be really direct with you, okay?” Nelson said after a few minutes of small talk with the patient’s family. He explained to them that, without surgery, her burn would certainly get infected. The patient was coughing; she may have inhaled smoke, too. In short, he said, “This is a fatal injury.”
It took a few minutes for anyone to react. A family member began to sob. It was unclear what the burned woman heard or understood, though it’s obvious that she was the pillar of her family.
Nelson sat quietly for a while, then asked if the family understood or had any questions. It was an excruciating moment.
It’s hard not to wonder what attracted Nelson to palliative care, and how he gets through days filled with sick and dying patients and their distraught families. His answer was both practical and philosophical.
He might reschedule a difficult family meeting if he needs to. And he concentrates on finding things outside of work that make him happy. “I find the things that ground me,” he said. “I’m a dance mom for my daughter’s recital soon, and we have horses that we enjoy riding. This work certainly gives you perspective.”
He is also dedicated to helping physicians and other healthcare providers change the narrative around end-of-life care. “Medicine has a narrative of death as a loss, right?” he said. “Which really means, well, you’re going to end up with a zero batting average. I want to empower physicians and other providers to change that narrative so that death is not a loss; it’s a part of life that we can make beautiful if we treat our patients well.
“My patients will be dying with or without me. Maybe I can make a bad process into a positive thing. I can give them hours, days, weeks, or months without dehumanizing treatments or severe pain. I can help.”
How Palliative Care Came to Regional One
In the early days of the Covid-19 pandemic, the Community Foundation of Greater Memphis led what came to be called the Mid-South Covid-19 Regional Response Fund. It was a lightning-speed effort that ended up raising nearly $15 million from corporate, foundation, and individual donors that went to 212 area organizations to help with relief, recovery, and resilience.
A $1 million grant from that fund — the money had to be spent by a certain time and for a cause related to Covid — went to Regional One Health to launch the palliative care service, which premiered in July 2022.
“The healthcare industry gave so much to our community during Covid, we wanted to honor their resilience and help the hospital come back stronger,” said Sutton Mora, executive vice president and COO of the Community Foundation. “The need for palliative care existed before Covid, was worsened by Covid, and exists post-Covid.”
In the future, Regional One hopes to move into outpatient palliative care. “Regional One is going through a metamorphosis, with new clinics, especially cancer clinics,” said Dr. Jeff Nelson, head of the palliative care team. “Outpatient palliative care is part of that. Your primary care physician refers you or you can ask for it. You find it just like you’d find any other specialist.”
Leanne Kleinmann is a Memphis-based writer and communications/fundraising strategist whose company, Leanne Kleinmann Communications, serves nonprofit and for-profit clients in Memphis and across the country to help them tell their story more effectively. LEANNEKLEINMANN.COM
