FROM DECEMBER 2022 ISSUE OF WEST END PHOENIX

In the daytime — from 7:00 a.m. to 5:00 p.m., Monday to Friday — the home-care doctors of Mount Sinai’s Temmy Latner Centre for Palliative Care work as a team. Each physician is assigned a slice of the city to cover and they travel within it, doing everything from routine checkups on long-term patients to facilitating medically assisted deaths. But late at night, when their colleagues are sleeping, one doctor from the team works the on-call shift. Sometimes nights are quiet, but more often, there’s work to do. People don’t stop dying just because the hospital is closed.

Late-night calls can come in from anywhere in the city. A switchboard operator pages the doctor, who stops whatever they’re doing — or, in some cases, hauls themselves up from the depths of 3:00 a.m. sleep — and phones the caller back to find out what they need. These conversations can be charged. “Nights and weekends are mostly for urgencies and emergencies,” says Dr. Russell Goldman, the director of the centre. The doctor grabs their bag, packed with as many different kinds of supplies and medications as possible, and gets in their car.

Unlike day shifts, with their carefully delineated territories, the night can take you anywhere. On-call doctors might find themselves inching through crowds of partygoers downtown, or navigating the maze of residential streets in an unfamiliar neighbourhood, squinting to make out house numbers in the dark. But no matter what part of the city they’re in, they always end up in the home of someone who is likely experiencing one of the most emotionally complex and difficult moments of their life.

This kind of medicine attracts a different type of doctor than you might find working in a more traditional hospital environment – someone like Joshua Wales. He came to palliative care through an unconventional path, after pursuing a degree in opera. When he realized there might not be a career for him in that field, he switched to medicine because it offered an opportunity to meet different people. A palliative care rotation in medical school made him feel like he’d found his place; it’s a rare corner of medicine in which patients dictate the trajectory of their own care and doctors can take the time to closely listen and respond to their needs. “I’m interested in highly affective experiences,” says Wales. “Intensity of emotion. I’m not an emergency department adrenaline person. I want a different intensity.”

Here Wales describes the life of an on-call palliative care doctor in his own words. His interview has been edited and condensed.

“In the hospital, people might tell you stories about their lives, but those lives don’t actually become real until you see them. When someone’s just sitting in front of you in the hospital, disconnected from any context, you don’t know what kind of art they have on their walls, what kind of cereal they like to eat. You don’t know whether they’re messy or tidy, whether they live with a huge extended family or in a very solitary place. I understand something about you by seeing the books you keep next to your armchair, by the size of your television and what you’re watching. When you visit a patient in their home, you’re confronted right away with their reality — both the limitations and the opportunities of it.

The night’s such a funny time. When you’re on call, you’re travelling around the city and doing visits with people you’ve maybe never even met. And at night, everything seems much more acute, more intense. I co-parent these two young children, and I think a lot about how they emotionally regulate themselves. Something about daytime provides a kind of reassurance that everything’s okay, but when you wake up at 4:00 a.m., problems seem insurmountable. We’re all just more ourselves in a primal way. I find that I’m also my gentlest and most vulnerable at night. When you’re talking to someone on the phone at 3:00 a.m., you speak differently; there’s this mutual understanding that we’re both awake at a bizarre time, having a weird conversation. Night has this way of dissolving all your protective veneers; things get inside you more.

But it’s also a pleasurable time to be awake if you lean into it, if you can deal with all that complication. The other night I was on call, and at 3:30 I ended up having to go deep into the East End. I drove all the way along Queen Street, and there was no traffic. It was so nice to just drive across the city in the middle of the night like that. You get to see it as more of a landscape, and less of a video game.

The other big difference is that you do feel like you’re on your own. If I’m in someone’s house in the middle of the night, it’s often because there’s a crisis. You’re walking into an unfamiliar environment, and your job is to regulate it while you’re also possibly exhausted, or irritated, or anxious about what you have at your disposal.

During the day I feel like an agent, connected to this broader network: I can call the nurse, I can call the pharmacy, I can order supplies if I don’t have exactly what I need. At night, you’re really just yourself, at the mercy of all these different factors. You just bring yourself and whatever you have in your bag. Honestly, so much of the stress of the job has to do with creating a small hospital in your car. Whenever I have panic attacks about work, it’s about whether I’ve ordered enough of a medication that a patient might need, or whether I have the right supplies. I’m always trying to think three steps ahead: It’s Friday, what are all the things that could happen over the weekend? Or tonight?

In the first few years of practice, I trusted the system would be there more. I’d think that if I needed a nurse I’d just call them and they’d come, or if I didn’t have the right medications, I could just call the pharmacy. Those services are still supposed to be available to you at night. But eventually you realize that there’s the way the system’s designed, and then there’s the way it actually functions. Right now, especially, we’re in a systemic collapse. Before, if someone needed an injection at 2:00 a.m., I could still call a nursing agency. But now we’re in a situation where you just have to go yourself, because nurses are completely decimated in terms of their capacity. I do actually feel much more capable now; I can adjust pumps, I can put in lines. You learn to do things that you didn’t think you could do. You’re your own hospital and social worker and pharmacy and nurse and doctor. It can be empowering in a way, but also terrifying. And so much of it hinges on the presence of tiny objects. Like, ‘Oh, I don’t have a syringe, of which there are billions in the world. This moment could be saved if I only had this tiny piece of plastic.’ Someone’s end of life can hinge on the availability of these things we take for granted. We forget how important these small things are.

When I tell people I do palliative care, the most common response I get is ‘Oh, geez. Yikes.’ And some moments are extremely emotionally hard. But they can also be very meaningful. You’re invited into some very intimate moments in people’s lives. You develop some very intense connections to people that are quite time-limited but valuable. Bad things are going to happen regardless. But to be there with people while that happens is a privilege.”

This piece was originally published by The Local in its “Toronto at 3A.M.” issue, released December 2023. To read it on their website visit https://thelocal.to/palliative-care-home-care-death-at-home.