Spotlight series – PAs in palliative hospice care
Specialist palliative care and hospice medicine require clinicians to be committed to improving a patient’s quality of life when they are facing a progressive, life-limiting condition. While physician associates (PAs) are already working in palliative medicine, Jovy Giles is the first PA in the UK to work in a hospice environment.
In 2018 Jovy qualified from the University of Liverpool and went on to work in the care of the elderly as her first place of work post-qualification, followed by stroke medicine. Now having worked in a hospice since late 2020, Jovy shares insight into her role and how it enriches her life and offers a greater appreciation for humanity.
What made you decide to become a PA?
I was exposed to healthcare while young, as my mum worked as a housekeeper in nursing homes and hospitals. I studied biomedical science as my undergraduate degree in 2012 and volunteered at Kingston Hospital in a dementia specialist ward during my course. Volunteering was a good opportunity for me to gain exposure to working in a hospital environment, which ultimately led me to look for a patient-facing role. I went on to work as a healthcare assistant (HCA) for the Royal Hospital for Neuro-disability in 2015, which receives the majority of its funding from charity alongside part-NHS funding, supporting people with irreversible neurological disabilities. It was working there that gave me a deeper appreciation for life in general, and the value of supporting people during what can be the most difficult time of their lives – and when they need to depend on someone else and be cared for the most.
I considered studying medicine before becoming a PA, but I value flexibility and did not want to be too restricted in my role. Having already gained some work experience in hospital, I was aware that medicine can have a more regimented programme than other jobs. While working as a HCA, I attended an RCP Updates in Medicine conference, which highlighted a new medical role – PAs. Once I learned more, I thought it sounded ideal for me. Having the opportunity to select my workplace based on my preferred specialty at any given time without being locked into a training programme really appealed to me, as well as being able to offer continuity of medical care and a more attractive work–life balance. Once I qualified, I returned to London and worked in both care of the elderly and stroke medicine to broaden my general medical knowledge and skillset.
Can you tell us more about your experience working as a PA in palliative care hospice medicine?
Working in hospital wards, I was involved in a lot of emotionally challenging conversations with both patients and relatives surrounding severe illnesses, including lifelong disability, death and dying. Sometimes clinical environments distract from the impact these experiences have on patients and their families; when they feel truly supported, the benefit of their hospital experience can’t be overstated. This motivated me to take ownership and have these sensitive conversations with patients and their families early on in my career. The feedback I received was consistently positive, rewarding and humbling. I knew sometimes we couldn’t change the outcome of their circumstance, but I could deliver that information with sensitivity, honesty and compassion. It was then that I recgonised an interest in palliative medicine.
As a PA, I was able to utilise the consistency of my role to further develop my clinical and emotional intelligence. It was another reminder of why the PA role was suited to me, and the reasons I entered healthcare, as I wanted a job that would broaden my lived experience but that maintains humility. I started to engage more with the hospital palliative care team and was hoping to complete a secondment with them, but unfortunately was unable to due to the start of the pandemic. I was recommended by a palliative medicine consultant to consider the European Palliative Care Certificate, which I completed during COVID-19. It provided me with additional insight into palliative medicine as a specialty and allowed me to build upon my existing knowledge.
Palliative medicine is an extension of general medicine that focuses heavily on compassion and empathy in everything you do, including clinical decision-making – something that I found very rewarding working in the care of the elderly and stroke medicine. Working through the pandemic affirmed my desire to work in palliative care, but unfortunately I was unable to find a role in palliative medicine for PAs after searching for several months. That was when I saw a role advertised at St Raphael’s Hospice and the job sounded ideal, so I applied. I was very lucky to hear back from them and after further discussion, was offered a completely new role there working as a PA. Hospices also gain the majority of their funding through charities with part-NHS funding, so I know the decision to employ an unfamiliar role was not taken lightly. I am very grateful to be in this position and am so glad I took the chance to progress my career in this way.
What diagnostic/investigation/procedural skills have you gained?
Hospice palliative medicine is a specialty that – alongside medical management of complex conditions and social/psychological emergencies – highlights humanity, compassion and acceptance by affording the time to care for each patient as an individual. It is an extension of general medicine that encompasses the core beliefs of individualised holistic care for both patients and staff. One of the most valuable skills I have developed in this specialty is advanced communication, which sounds easy, but is full of nuance and tact, and is not always gained with experience unless you specifically nurture it. In a hospice environment, being able to offer psychological safety through good communication can never be underestimated, especially when our patients are having experiences that many people struggle to comprehend. Good communication is just as important as good medicine and distinctly enhances our practice.
Although my particular hospice is less intervention-focused, I take bloods, place complex catheters and send patients into the hospital for scans, IV therapies, or emergency/elective interventions where appropriate. Other hospices are more intervention-focused and can offer paracentesis, rehabilitation and transfusions etc, so this is another aspect of variability in this specialty for PAs to consider. I enjoy the practical procedures in my role as much as other elements of my practice, including supporting my patients in emotionally and psychologically. I am also very fortunate that the St Raphael’s consultant team maintains a strong emphasis on education, and I am privileged to have multiple sessions of regular protected study time to complete audits, research and grand rounds/journal clubs, allowing to me progress both personally as well as professionally in my role.
How would you describe the impact of your role as a PA?
Being a consistent medical team member as a PA, I have a comprehensive awareness of specific local systems and procedures. I’m also able to support the training of rotating specialty doctors and assist with inducting and teaching GP trainees. In addition to this, I have been working closely with the hospice education team to deliver teaching sessions for clinicians both in the hospice and for the wider specialist community services, alongside supervising the training of clinical procedures for HCAs and nursing associates. I enjoy this aspect of my role, as it offers me variety while allowing me to share my specialist and generalist knowledge to benefit colleagues. This ultimately has a positive impact on our patients and staff – which is the outcome I always hope for in whatever I do.
In March this year, I presented a poster at the Palliative Care Congress about the impact of the PA role on my hospice; my consultant team also gave an oral presentation about the new hospice PA role at Hospice UK Conference in late 2021. To support my poster, I collected data from clinical staff regarding my role as a PA. After 3 weeks, 75% of staff knew what a PA was, and by 6 months, this improved to 100%. More than 90% of staff found the addition of my role beneficial after just 3 weeks, with over 80% of those surveyed rating the benefit as moderate or higher. 33% felt the PA role had helped 'a great deal’, with comments such as: ‘more admissions undertaken by PA to share the medical workload’ and ‘approachable and able to clarify medical plans’. I was delighted with these findings and the ability to showcase the impact my role had over 6 months, including taking on more autonomous working style to support my patients as my clinical acumen improved over time.
What do you find most enjoyable and rewarding about being a PA?
I enjoy being able to improve people's lives in the way we do and share their life stories, which is genuinely humbling. I don’t think there are many spaces, even within healthcare, where you experience a job that is so enriched by the lives of others that it enhances your own, or one that encourages such reflection on your own humanity, compassion and sacrifice.
I remember one particular patient who illustrates this point well. They were admitted for complex symptom control after a prolonged stay in hospital following a diagnosis of cancer that was not appropriate for further anti-cancer therapy. On admission to the hospice, they were struggling with all the recent trauma, as well as trying to support their child. As their symptoms and quality of life improved during the hospice stay, they wrote daily motivational quotes on the whiteboard in their room. On ward rounds, just before they were discharged, we were reflecting on the admission and how far they had come in terms of symptoms and mindset – they left on less medication than when they had been admitted, and their physical and emotional pain had improved so much that they were now caring independently for themselves, and they were able to have well-supported honest discussions with their child. The patient wanted to write a quote with me to sum up their experience at the hospice. They left feeling much more accepting of the future as opposed to the ‘death sentence’ they felt they were given in hospital, and wrote: ‘people don’t just come to the hospice to die, they can come to learn to live.’
This patient still comes to visit us on the ward regularly, occasionally with their child, after spending time each week in our wellbeing center and café. They have commented that when the time comes, they would like to spend the end of their life with us at our hospice. The honour of being part of a patient's life and celebrating life with them is difficult to put into words, and the patient being so clearly grateful for how they have been treated is humbling. It’s patients and experiences like this that made me want to enter specialist palliative medicine and what makes me so passionate about the work we do.
What challenges do you face as a PA working in palliative hospice care?
Being the first PA to work in hospice medicine, I have been contacted by multiple hospices since presenting my poster. I have found that many hospices are keen to hear about developing the PA role. As the PA role is still new, especially in the hospice environment, there are some common misconceptions, including people wondering when ‘I might become a doctor’. I am proud to be continuing to drive forward the PA role in a hospice environment and will continue to educate others who might be thinking of employing PAs in the future.
Like working in hospital medicine, working in a specialist hospice ward can be emotionally and mentally draining. The difference I have found is that because people expect a hospice to be challenging, the teams are much more aware of compassion fatigue and are extremely supportive, including taking time to debrief and offering protected time for team reflections for particularly complex cases.
Palliative medicine is often misunderstood or mistaken for meaning ‘the end’ or ‘no further treatment’, but it is so much more than that. We offer patients a safe, controlled, comfortable environment, in which our priority is to help manage physical and emotional pain, suffering and severe specialist symptoms alongside treatment of reversible conditions with their background diagnosis. We discharge the majority of our inpatients home or to a facility that can support their ongoing care needs. Where they may be too unwell to be discharged from the hospice, we continue to support patients & those important to them with care, compassion and without judgement until the end of their lives. It is important to understand that although we may not be able to cure, we can still provide patients with quality that they did not have before, and which allows them to prioritise enjoying the time they have with those important to them.
What does the future look like for you as a PA?
I thoroughly enjoy working in hospice palliative care and I have hopes to encourage more hospices in the future to hire PAs and understand the benefits the profession can bring. I am enjoying my role and I am not sure another job will be able to offer the same level of respect, dignity and appreciation to myself, my patients and my colleagues. Palliative care in a hospice environment is unique – it allows me to care for patients and their families at a particularly vulnerable point in their lives and be able to guide and support them in a very human way. However, if I do wish to pursue a different career path in future, as a PA it is easy to move jobs to a different specialty.
What advice would you give to a PA looking to work in palliative hospice care?
Ensure that you are in medicine not because you can be, but because you want to be. Being a PA isn’t an easy job, but it is so worthwhile if you continue to develop your role to suit your values and the values of your organisation. Specifically for hospice palliative care, know that you can’t always ‘fix’ things, as much as you may want to, and let yourself feel challenged; it keeps your management plans individualised and creative. Developing your emotional intelligence can never be underestimated either, no matter how long it might take – it will really help you to understand your patients and build positive relationships with their families as well as in your daily life.
I would personally try to gain as much experience as possible before you commit. The PA role isn’t always easy and it is very fast-paced. Gaining experience volunteering or working as an HCA or similar will help you understand what demands healthcare involves, and you’ll gain an appreciation for the wider workforce. Thank you for reading.
We’re always looking for qualified PAs who are FPA members to share their stories. If you’re interested in sharing yours, get in touch using the contact details below. If you’re thinking of a career as a PA, you can learn more about how to begin your journey here.
Get in touch to share your PA story:
Jenna Donaldson – FPA communications officer