Palliative care found Juliane Samara before she was qualified to practice it. Now a Nurse Practitioner on the New South Wales South Coast, she says the job is about far more than what's in her prescription pad.

Juliane Samara was in her final semester of nursing when her father-in-law relapsed after being diagnosed with non-Hodgkin lymphoma several years earlier. He had become seriously ill while visiting his daughter in Switzerland, and Juliane flew over to bring him home to Australia.

“I had to go to Switzerland to bring him home from hospital to die,” she recalls. “The trip from Geneva to Australia was absolutely terrifying, because I knew I had a man who was dying, and it was my job to get him home to his family.”

“We got off the plane and went straight to the emergency department,” she says. Ten days later, he died in Canberra Hospital.

In those final days, one of the last things he said to her was, “You must do palliative care,” a mandate of sorts, and his way of telling her “This is what you’re good at”.

Finding her way to palliative care

While palliative care wasn’t something Juliane went into straight away, it was something that ran alongside her work from the beginning.

She spent years in oncology first, running a chemotherapy day unit then as a specialist nurse working with people with advanced cancers. Juliane says she became increasingly frustrated by seeing patients continuing treatment at all costs, when, in her view, care could be “so much better” if clinicians were more open and honest about death, dying, and what quality of life really looks like.

Juliane trained as a Nurse Practitioner while working there before joining Canberra's specialist palliative care unit at Clare Holland House, providing outreach to people living in residential aged care homes. Today, she works with the specialist palliative care team across the Eurobodalla region on the New South Wales South Coast, where there is no permanent palliative medicine specialist.

Helping people ‘get home’

One of the strengths of Juliane's role is being able to act quickly when time matters. That often means helping people leave hospital and return home, where most Australians say they would prefer to spend their final days.

Last year, a referral came through for a man in his nineties who had been admitted to hospital with what looked like a stroke. Juliane went to see him the next morning. “I realised very quickly that this was a man who had a metastatic lesion in his brain that had bled,” she says.

He was in the final stages of life and all he wanted was to go home.

Within a day, Juliane and her team had organised a hospital bed, a syringe driver and medications, coordinated discharge planning, and linked in community services so he could return home with his family around him. He died at home the following day.

“Just to be able to support that family to meet his wish to die in his own home, I think really speaks about what we bring to palliative care.”

The role of a nurse practitioner

In palliative care, timing changes outcomes. One of the biggest advantages of the Nurse Practitioner role is being able to act without unnecessary delays.

“We're in between doctors and nurses,” Juliane explains. “We have the advanced practice experience, knowledge, and skills that give us a more in-depth understanding of disease processes, diagnosis and treatment. But we bring with that our nursing values, and the nursing philosophy of looking after the whole person rather than just the disease process.”

A Nurse Practitioner is a registered nurse who has worked at an advanced level for years before completing a master's degree. This expanded scope of practice allows them to diagnose, prescribe, order diagnostic imaging, refer and manage a person's care from start to finish. That includes choosing and initiating medicines for symptom control, adjusting doses as symptoms change, and managing how treatments are delivered at home.

That expanded scope of practice allows Juliane to assess a person, prescribe medicines, organise equipment, and adjust treatment as symptoms change, without waiting for someone else to authorise the next step.

Part of that is making sure the right medicines are in a person's home before they're needed. Juliane says that as symptoms change, she's constantly reviewing whether pain, nausea, agitation or breathing distress are being managed effectively, adjusting medications and treatment plans accordingly.

“We try to preempt all of that,” she says, “rather than scrambling at the last minute because someone has uncontrolled symptoms.”

More than prescribing

In her work, Juliane often returns to a line from palliative care pioneer Dame Cicely Saunders: ‘How a person dies remains in the memory of those who live on’.

She has sat with many families in those final days. What stays with her, long after, are the things that didn't go so well. Getting the clinical side right is only part of it. The rest is about shaping how families remember those final days, in what she recognises is “already a highly emotional and vulnerable place to be”.

Trust is a huge part of this. “A lot of the time it’s just sitting and being with the family,” she says. “It’s not necessarily about the talking. Sometimes it’s just sitting in silence, acknowledging that this is a distressing time.”

She also follows through, checking back to see whether a dose worked and whether a family is coping, and adjusting the plan when something isn’t right.

“That in itself builds trust,” she says. “And being open to change.”

Whether it’s getting medications into a person’s home before symptoms escalate, coordinating support services, or simply being present with a family during an incredibly difficult time, the focus is always on making sure people receive the care they need when they need it.

“When we have a job to do, we get in and we get it done,” she says. “Without a lot of the messing around that often happens when the focus is medical treatment rather than values-based, person-centred treatment.”