There is only one guarantee in life, and although we may not know when it will come, we will all die one day. Some will consider it morbid to talk about death, so much so that it has almost become a taboo. The taboo subject has increased our fears of dying and maintained the mystery that surrounds it. Many of us are unprepared.
In the movies, the dying person often speaks in a hushed tone, as they reveal some important information, or their dying wish, and then they take one last gasp of air and it’s all over. An unrealistic portrayal.
Millenia of death experiences and more recently, scientific research, has allowed us to build up a picture of what death is really like from the perspective of the dying.
Death has changed in the past few decades; this is because of the advancement of modern medicines. We were much more likely to die from rather sudden, tragic death such as accident or a quick but severe illness in times before. This is not to say that this no longer happens, on the contrary, but many of us are likely to experience death as a gradual process. A slow downward hill, that speeds up towards the end.
The Gradual Decline
One of the most difficult parts for us as the living to understand, is how the body’s desire for those necessities such as food, drink, and the need to use the toilet, are suddenly no longer a priority as death approaches. As if the body itself recognises that those things are not important now. My patients often loose interest in food, or report a low appetite to begin with, then in the days that follow, they struggle to chew and swallow, before they stop eating all together.
In conjunction with this, there is a similar pattern that happens with the energy levels, they become weary, easily tired, spend more time in bed, then finally they slip into a state of deep sleeping. The changes are subtle, in most cases this time is generally peaceful, like a gentle winding down to life that happens over a period of several days.
The moments before death are not thought to be painful. Mostly as at this point the brain has set itself into a comatosed state, and therefore much of the normal awareness we possess in our awake states is lost. As if they are half sleeping, half awake, feelings of pain, hunger, thirst are all put on the back burner as the brain now sees this as low priority. Although the brain sacrifices complex thought processes, our senses such as hearing remain. This means that the dying person can still hear you right till the last moments. Studies have also shown that just before we die, there is a sudden surge in brain chemicals, which many have interpreted as a euphoria moment. A moment of brain excitement and perhaps a pleasant feeling before the body stops. The brain chemicals will continue to fire long after this.
The Travelling Woman
This memory was not my first experience of death, nor my most recent, but one that was imprinted on me for what ever reason. It was 4:30pm on the district, I would be leaving in half hour. I rang my line manager; I had completed all my cases for the day – a rare moment- and wanted to see if I could help. She gave me the address of where she was at.
I remember it was raining that evening. It could not have been the summer as it was cold and dark outside. My line manager met me at the front door, she briefed me that she had met this lady last week, she was dying, and the daughter had called to say things were moving along.
The house was filled with family members who scurried off to busy themselves as we set to our work. She lay in a hospital bed, a large cross framed above her bed. She breathed gently, completely still, her eyes fixed and looking nowhere. She did not acknowledge us there, but we spoke to her as if she had. We carried out our checks. When we were finished, my line manager turned to me and simply said “she’s travelling”.
This phrase is one that has stayed with me since. It made perfect sense. Whether you believe in a life after this one or not, she was between life and death, travelling between two existences, with her destination nearby.
The breathing was slow and shallow, the pupils did not react. Suddenly there was a long pause where she did not breathe, then, after what felt like the longest moment, she breathed again.
“Cheyne-Stokes” I murmured, looking up at the nurse who had mentored me since my graduation. She nodded.
Breathing patterns change just before death occurs. Cheyne-Stokes breathing is a pattern where the individual may stop breathing for a few seconds or even as long as a minute before starting to breathe again, and signifies that death is near.
My line manager went off to find the family, while I made her comfortable. There was little else we could do, and she deserved to be surrounded by those who loved her most.
Most people die just like this, peacefully and gradually, not dramatic. There are of course certain conditions that can make the lead up to death very painful, this is particularly the case with cancer. However, this does not mean by any case that the person dying of cancer should be forced to endure some prolonged and painful death, instead this is managed with a good comprehensive pain regime.
The syringe driver
For Many in the terminal phase (but not limited to) will benefit from a syringe driver, to help keep them comfortable and to control pain. This is a handheld device, that pumps a continuous unbroken delivery of medication into the persons fat tissue, that is then slowly absorbed into the body’s system. There is no way that this hastens death but avoids peaks and troughs in levels of medication.
I had received a very vague referral from the GP, a woman in her 90’s was moving toward the end of life, and I had been asked to visit to see if there was anything I could help with. I was met by a kind, but rather proud daughter. She worked in television, and lived in a flat with her elderly mother, who had once been a typist in Parliament. The daughter was aware that her mother’s days were limited, she had been seen by the palliative team earlier in the week (specialist team who care for the dying) and she felt confident that all was under control.
At the time I was still a reasonably junior nurse, but perhaps looking back there was no way to have predicted what would come next. I asked if I could see her mother, and she led me to the bedroom, where a frail slither of a woman lay in bed. She looked tired and restless. I asked her if she had any pain, which she did not, she was sleepy. The daughter told me how the medications had been delivered from the pharmacy in anticipation, and I proceeded to check these. I left my telephone number with her, and the number for the night-time team before leaving.
A couple of days later, I received a call from the daughter to say her mother had died in the night, and whether I might be able to come. The daughter was distraught when I arrived. I sat her down, where she began to relay the events that unfolded since we last met. She told me how her mother became unsettled during the night when the carers were attending to her, the night nurse had been called out. The nurse had administrated a sedative drug by injection to help her feel calm, and recommended inserting a syringe driver, but the daughter had refused. From the daughter’s perspective, I can understand, the injection had worked, and her mother was able to sleep without distress. She had not seen the purpose of a syringe driver or anticipated her continued need for more medication. Unfortunately, her symptoms worsened the following night, she began to call out, shouting and screaming when the carers turned her in bed. She moaned and grimaced each time she was touched. Eventually the daughter had called the night-time team. The sad truth is that at this point in the night there are very few staff working and they are often busy, by the time the nursing sister reached them, the mother had already died. Should she have had a small dose of sedative delivered slowly by the syringe driver infusion, this would of in no way hastened death, but would have brought relief from distressing symptoms and allowed her to die peacefully.
When I was working on the twilight team, I was called out to a man who was in his final days. He was in a semi reclined position in his bed, propped by pillows, taking slow deep breaths that were drowned away by the noise of the hissing oxygen machine. When I approached closer, I could hear a gurgling, and bubbling sound as he breathed. This rattling noise is distinctive and is known by the rather unpleasant name of “death rattle”. When we are close to dying, we are no longer able to cough or swallow well enough to clear our own saliva, so it tends to pool a little. There is absolutely no evidence to suggest that this is painful, distracting or distressing to the dying person, in fact they do not seem to be aware of it at all. He was peacefully resting.
A syringe driver had been connected the previous evening, and as they tend to run over a 24-hour period, I was there to replace the medication. He was receiving a small amount of morphine to keep him comfortable. He did not respond to me as I went about my work. My colleague reports that he died on the following evening during her shift. Gradual and peaceful.
Caring for the dying is not as depressing as it might sound, it’s certainly moving, but something that has felt like a huge privilege. Even when an individual has lived a meaningful and fulfilled life, it has never been the case where it has been easy to help them pass on. In many cases the path of the dying goes through some very predictable patterns, clear stages in a sequence of events. I have learnt to recognise these stages, in the same way that a midwife identifies the patterns of childbirth.
Death is a natural process, a steady decline as we exit this life. This should not be a taboo, a myth, but something we learn to recognise and can feel somewhat familiar with, so that we may take the most of the last moments we have with our loved ones.

Yesterday, I was sat in a waiting room where the TV was showing the Prime ministers’ questions. Mr Johnson said something that immediately drew my attention…” whether they have Alzheimer’s OR dementia” …Incorrect I thought to myself. Alzheimer’s IS dementia. He should have said Alzheimer’s or any other form of dementia. Was our Prime minister misinformed, ignorant or was it just that he had incorrectly phrased what he said?

Chances are, you’ve heard of dementia. Maybe you know someone personally who has lived with it. Perhaps that person was someone you love(d). Yet, despite the growing impact dementia is having on our society, there remains so much misunderstanding of the disease and its many myths.

Understanding Dementia can be difficult, mostly because those who are affected by the disease are all unique individuals, with their own life stories, preferences, like, dislikes, values, and experiences that will impact of their story. Additionally, symptoms are also going to vary depending on what type of dementia the individual has and how long they have had it for.

Let’s get down to facts…

Dementia is simply an umbrella term of a type of brain disease, perhaps a more controversial term to explain it, but ultimately that is what it is. There are 106 types of dementia which all affect the brain in different ways, however, Alzheimer’s is far the most commonest form, making up for about 70% of all sufferers.

Dementia is NOT a normal part of ageing and is NOT limited to the older generation. I can recall when I was 19 years old, as a student nurse, caring for a woman in her 40’s with a form of dementia. This form had a quick progression, meaning that within a year she had lost the ability to walk, talk and eat. It was soul destroying to watch her two daughters, similar age to myself at the time, come to visit her. The youngest of the two, a high school student, broke down in tears almost each time she came, whereas the oldest tried to be the strength of this troubled family. That could have easily been my own mum.

The devastating truth is anyone can develop dementia, its linked closely to our genetics and lifestyle choices. Some forms of Dementia, such as Alzheimer’s, have an increase in risk of developing the disease as we age. This is a significant concern in an aging population.

There is currently no cure for dementia, mostly because the cause is poorly understood. In my early nursing days, I was taught it was down to changes in the brain, however, more recent research has found the same changes can occur in the brains of those without dementia. There are treatments available on the market, which are generally limited to a group of drugs called “anticholinesterase inhibitors” you may have heard of Donepezil and Rivastigmine, which fall into that family. The downside of this medication is that you need to remember to take it each day, which is difficult in a disease that impacts on memory, but also it is only going to be effective in mild Alzheimer’s, it works by helping slow down the progression. This leaves other dementias and for those who were diagnosed too late without treatment, an issue that current research is trying to tackle.

As I have mentioned, and likely you are aware if you have knowledge of demenits, that memory is heavily associated with the condition. You may have also heard of terms such as “short term” and “long term” memory, but this is a rather simplistic view of memory loss. We have various areas of memory stored in our brains, specific to the type of memory being stored. Dementia does not take all that memory. For example, our procedural memory is our “how to knowledge”, think about when you go to the toilet, or brush your teeth each morning, we do this on autopilot. There is no one standing over us giving step by step instructions, because as a child we learnt how to perform these activities, this was then stored in our brain and now we just do it without much thought.

In dementia, the procedural memory is often impacted, which means those activities that were once simply done, become increasingly difficult. This would be the equivalent of having a task to perform with half of the instructions available, or none at all.

Semantic memory is where we find our meanings or understandings for life, this will be made up of various experiences acquired in school, our career, the rules and regulations of society, general knowledge, hobbies, and passions. This ability to apply meaning and understanding is what aids us in being logical and provides us with capacity to make decisions. Dementia destroys procedural and semantic memories; this is often a gradual process over time, meaning that those living with dementia are aware that this process is happening.

Our episodic memory is mainly accessed through a part of the brain called the hippocampus, and in some part, this is relatively reserved in dementia, allowing that person to shift back to another period in their life. Primarily, for whatever reason, those living with moderate dementias will return to somewhere between 10-30 years of age, and we term this the “reminiscence bump”. Everyone is different, they may find themselves somewhere outside of that 20-year timeframe, regardless it is real to them.

I remember caring for a 93 year old recently, who recalled her recent retirement, that had in fact been nearly 40 years earlier.

This means that the rest of their lives becomes a kind of twilight, as if they have not lived that life yet. You may have observed this if you have known someone with dementia , an older person living with dementia, who does not recognise their own child, a heart-breaking experience to watch. This is simply because in their mind they are living as the 20-something version of themselves, and that child may not be born yet, or is certainly cannot be of the age that they actually are. You cannot bring them back to reality because they are stuck in their own reality where they are trying to make sense of that world around them. To try and orientate them is a messy thing, it causes fear, anxiety, and confusion.

The person with Dementia may confabulate stories, this may be where the brain has used older memories to plug a gap in more recent memories, creating an explanation or a situation that has a sense of reality for the person telling the story (confabulation). I often have conversations with those living with dementia talking about having spent the day with a relative you know to be dead, and there is no way that this could have happened. This occurs when the person has no recollection of what has just happened and uses memories to create context; its not that they are lying to you, this is them trying to make sense of the reality they find themselves in.

The most significant characteristic that is relevant to all dementias is communication difficulties – to lose ability to communicate and to understand is a tragic loss. Some people lose verbal communication, this is true of Alzheimer’s, words start to escape them, gradually at first, and then as they progress into more severe stages, where they will be reduced to repeating 1 or 2 words. Therefore, you will find that often they are repeating the same words over and over, or words that you can’t make sense of, or even they will forget what they are saying mid-sentence. In Vascular dementia, another type of dementia, the person tends to retain words but lose understanding of visual communication, the nonverbal communication, which means they lose the ability to read facial expressions, or body language. (everyone and everything will become a threat)

Once those living with dementia have lost the ability to use language to communicate, behaviour becomes a powerful form of expressing needs and feelings. When they have lost the ability to express themselves in a rationale manner, that the people around them will understand, it must make one feel vulnerable and be frustrating ,imagine how isolated and lost you would be to the outside world. When those feelings are not acknowledged by others, then it is likely those behaviours can then intensify, and we, the outside world, will deem these behaviours “challenging” or “disturbing”, so instead of responding in a way that acknowledges the attempt to communicate, that the person feels valued and listened to, we may respond negatively.

There are many other common symptoms and others less common that are specific to types of dementia or even to individuals. The most important thing to remember, in my opinion, is that those living with dementia, may not be in our reality, and rather live in their own version. They are trying to make sense of a world that the brain is no longer aiding them to do. They need to find understanding, compassion, and a sense of being acknowledged by those of us who are not experiencing this cruel disease. This becomes difficult, especially when we lack understanding of dementia, how do we adapt our own approach if we do not understand what is required of us? The more we understand, and the more we can share our knowledge with others, it is more likely that the needs of those living with dementia will be met successfully and any potential distress avoided.

During my clinic one day, I recall feeling mildly insulted when an ageing patient was surprised to learn that nurses are required to attend universities for their education. I remember thinking to myself , it was not by sheer luck that I was in my role, it was years of study and learning. Some while later it dawned on me how nursing has changed, the more we have learnt about health and medicine over the last few decades, nursing has had to adapt with it, including the level of education. Nurses were only taught in universities since the late 1980’s (before I was born) it was not until 2002 that nurses could prescribe their own medication (as I commenced high school) and it was not until 2009 that nurses were educated at degree level (as I entered university).
Nursing education has been a journey, that has intertwined with my own journey. I’ve been in this gig for about 10 years now, before I entered healthcare, I really wanted to be a journalist. I loved writing, and researching facts, and was so set on this goal that I had selected my college education based on the idea that this was where I was heading. Somewhere and somehow, this did not transpire, unsurprisingly, as making career decision at the young age of 16 is not exactly wise.
I was ambitious enough to know that I wanted more than my waitressing role at the local pub, and had decided I would look for a job as an office administrator. I envisaged myself chatting away on the phone (I was good at talking) and I liked the idea of my acrylic nails going tap, tap, tapping on the keyboard as I would frantically type important stuff.
There was an advertisement for an apprenticeship reception position in a GP surgery, the pay was terrible, but it meant I could complete a qualification alongside working, so I went for that. It turned out to be a good move, you might even say life changing, as this swayed me in a completely different direction. At 17 years old, I had a lot to learn, and looking back now, it was a huge responsibility for a young person, I had access to thousands of pieces of confidential data and held the keys to the public in their ability to reach a healthcare professional. I loved it! The team that I worked with were wonderfully kind.
For the first time, I found myself fascinated by the nurses working there, all the skills and knowledge they possessed blew my young mind. The doctors were great, don’t mistake me, but I loved that nurses could equally prescribe medicines, I loved the diversity of the role, I was so enthused by them, I found myself sitting around the family dinner table, talking about what I was observing. My mum, being an awesome mum, really encouraged me to take a role at the local community hospital as a Healthcare Assistant (Nurse’s Aide/ Auxiliary Nurse). At first, I was a bit reluctant having no experience, but finally I applied.
At the Hospital, the Sister in charge conducted the interview, it was reasonably short, I remember her looking me up and down, I was wearing false eyelashes, fake nails, fake tan, everything all a bit fake, with lots of makeup on. Hardly the sort of impression she was expecting of a budding nurse. After studying me for a couple of moments, I think she may have even sighed at the sight of me, or at least she might as well of. “Look,” She said, “if you are willing to remove all the nails, and make up, then there is a role here for you”. And that was it- A journey began.
I will tell you now, that I had absolutely no idea what I was doing. I sometimes feel like that now, when I look around for the more nursier nurse, the senior one, then I realise as of present day, that that is me. Luckily for me, back then, I shadowed a woman who’s name completely escapes me, but I remember how she looked. She was a stout woman, short hair, and probably in her late 40’s. She gave me a 5-day induction inside the hospital before I was left to my own devises.
On day 1, I had turned up at the early shift, it started around 7am, so I ensured I was there a little before that. The woman supervising me had be talking with hushed tones to another colleague before approaching me. “Stephanie”, she began “Have you ever seen a dead body before? Maybe a relative?” I had not. “One of the patients has died. About an hour or so ago. The night staff have not had the time to see to the body, I wondered how you felt about assisting me to perform the last offices?”. Last offices, or laying out of the body, is an incredibly respectful practice of caring for the body after death, which usually includes cleaning, dressing, and positioning the body ready to be transported to the funeral directors. Of course, back then I had no idea what that entailed and simply replied “okay”.
Despite an unusual first day, it had not put me off, and after another 8 months at the community Hospital, I applied to do the Diploma of Higher Education in Adult Nursing. At the time, the Degree program was new and not very popular, the Diploma was fully funded by the Government, meaning I could study without incurring lots of tuition fees. I recall so little of my student nursing days because it was so hectic. We spent 7 weeks inside the hospitals and clinics, trying to grasp what felt like this mystifying world, followed by 7 weeks in the university having lectures and seminar all day, every day. We were required to write assignment after assignment and perform in assessments at least once a year.
For the first year, I was completely bewildered, but gratified with all that I learnt. By the second year, I thought I knew stuff, I had made it through a whole year after all, but rarely understood how to apply my newfound knowledge into practice. Knowing the statistical data of the prognosis of lung cancer off by heart was very little use on my respiratory ward placement. Instead, what I took from that ward was that holding the hand of the person dying of lung cancer, to ensure they would not die alone, was far more important. By the third year, I had accepted that I knew very little in the grand scale of things, there was so much more to continue learning, and I was eager to have it all, I spent much more time with my head in books and research papers. There was little time to rest, or even to pause, then finally I qualified in the summer, still feeling like I knew more than I did but not enough to enter the world of a registered nurse. I was ready whilst still being so unprepared.
I proceeded to register with the nursing and midwifery council, a professional body that protects the public by enforcing standards upon nurses. I took my first role on a nursing district team, visiting those at home. The first 12 months of my career I really learnt at a speed like never before! I encountered porta catheters for chemotherapy for the first time, inserted Catheters into the bladder without a mentor to guide me, and did post-graduation courses in blood sampling, wound care compression therapy, and intravenous drug therapy. I worked with a team of fantastic nurses (many who I call my friends today) and we worked hard, often visiting 30 homes in a single day, it was unrelenting and constantly busy.
After 2 years, I left the Nursing team on the district and I ventured into many other roles in the years that followed, maintaining my place as a community nurse. One of my favourite positions was as a General practice nurse in GP surgeries, the same nurses that had inspired me 10 years before.
The passion for nursing becomes addictive, despite the work being exhausting both physically and mentally. You are constantly analysing and assessing often complex situations, while on your feet all day. No time to pee, no time to drink. The demand is huge, patients often vulnerable and relying on your abilities. Your feet will hurt. Your brain will ache. Yet you will go back and do it all again the next day because its somehow still so satisfying.
Today, all nurses are required to have a degree, and I welcome this, with the view that nurses are not the handmaids of the doctor, but autonomous practitioners in their own rights, who call upon their own knowledge and expertise to help shape the care of patients. To do so, they are required to be educated to a much higher level than ever before, the skills they perform are far too advanced in today’s modern healthcare system to be anything but highly educated. Many have poopooed this idea away, saying it will scare off those who have the other qualities of a good nurse ,such as caring, empathy and kindness, but who are not academic enough to complete the course. I disagree, everyone can be taught, but its hard work, that requires a huge commitment both emotionally and financially. Those that possess these nursing attributes would be perfectly suited to health care assistant roles. These are much needed to bridge the gaps in care provided.
More recently, the introduction of the nursing associate saw a position arise that sat between a health care assistant and a registered nurse, which provides another opportunity to progress into nursing, without perhaps such a large commitment of the 3 years degree programme, and often is fully funded for those who put off the higher education due to cost implications.
I do not feel educating nurses contributes to the nursing shortage, it only makes care safer and more efficient, what is probably more realistic is that there is a shortage of degree level professionals who are willing to work for much less than the national average salary. Especially when they have forked out over £ 14,000 in tuition fees (not including accommodation, books, and other equipment) to study to become a nurse in the first place (not to mention that they will continue to pay £120 a year to maintain their nursing registration for as long as they practice). There is also a shortage of those who will put themselves through a gruelling and hard level of study to be undervalued in their role.
Despite this, anyone looking for a lifelong career that will bring great job satisfaction, diversity in your role, and opportunities to progress and develop, then a Nursing career is waiting for you.

The last 18 months have arguably been one of the most historically significant of my generation. I certainly don’t recall any other Pandemics catching us out like COVID-19 has. This disease has made it obvious that our wonderful and pioneering National Health Service (NHS) as brilliant as it is– pride of the British- its not ready for a Pandemic of any proportion. The NHS is struggling, in my 10 years of service, it’s always been struggling, which may explain in some ways why our healthcare system is failing those living with obesity.

Likely, the sad truth is that as a society we have already failed the battle with obesity because of a general misunderstanding. I’m sure you know someone, or perhaps you are someone with a higher BMI than is recommended for the stature, and what comes with this is a belief that the person is greedy, glutenous, lazy and choosing to be this way. Obesity is a disease, but because of this misconception it is not being treated as a medical condition in the same way that other diseases are.

If someone had any other medical condition, let’s say they have Diabetes, or a heart condition, we understand that there is an underlying physiological cause, obesity is no different. There is plenty of science that tells us that obesity is brought about by an impairment in the metabolic pathways- quite simply the metabolism is not working properly. The same way that a heart condition is when the heart is not working properly.

Studies have found more than 200 different gene variations that have an influence over the way our bodies regulate weight, and nearly all of these are related to appetite regulation. Those who are obese are being told by the chemical signals in their bodies that they are hungry, there is a lack of satiety or feeling of fullness. To clarify, obesity is not a lifestyle choice such as greed, but instead it is caused by genetic and environmental factors.

Despite the science supporting that being overweight is a serious condition, one that carries considerable risk factors for hundreds of other conditions and disease. Living with obesity is estimated to reduce life expectancy by 3 to 10 years and living with more severe forms of obesity can be seriously debilitating, such as feeling breathless, experiencing joint pain, feeling tired all the time, and poor mental health.
Still, even with knowing all of this, the widespread stereotyping exists and is so ingrained into our daily lives that it is rarely even challenged. The negative messaging from the media is so blindingly obvious, and even out own government perpetuates that message that shames and ridicules larger body sizes. They are considered undesirable, ugly, and creating low self-esteem. Even those living with obesity just assume it is all their fault, and why would they not feel that way when they are attacked by society, and where this stigma is encouraged.

What is most disappointing of all, is that this active bias exists in healthcare, the very same system that champions science. How will those living with obesity ever understand that this condition is out of their control, and instead it is related to the genetic makeup they were handed, when the healthcare education they are being given is to move more and eat less, even the attitudes and language used by professionals is enough to make me cringe. Interestingly, Weight is the most common form of discrimination in the UK, outweighing ethnicity, sexual orientation, and gender.

So then, why don’t they just eat less and exercise more, I hear you say. Let’s explore this…

Firstly, I want to explain the set point theory. Although still considered a “theory”, this is very well acknowledged in the scientific community. In adults our weight is generally maintained at a stable level, you may have experienced this yourself, I know I certainly have, I seem to always bounce back to roughly the same weight, this is where my body seems comfortable. Our hypothalamus in the brain is in control of this, it sets a preferred weight, and uses a feedback mechanism to maintain that certain level of fat within the body. When you suddenly start to eat less, your metabolism slows down, the chemicals in the brain reduce those feelings of fullness and signals the need to eat. This is evolutionary survival, to stop us from starving to death, our body responds in this way.

Most people living with obesity are able to lose weight, in fact they probably work harder at this and do very well with it, more than most of us are able. However, because of the body’s feedback mechanism to prevent starvation, they will only be able to temporarily alter their body weight, before the body fights to return it to its set point. Which means they often end up putting all the weight back on, and even more than before.

This weight cycling adds to the individuals feeling of failure, most will be living with low self-esteem. Which takes me to understanding the psychological implications connected with eating.
In several cases, labels will begin as early as childhood. Those suffering with mental health problems such as anxiety and depression, perhaps related to weight although this is not always the case, may find solace in food. Emotional eating can result in overeating, which then will impact on weight gain, and self-esteem. The cycle will continue. Food provides us with a natural reward and a feeling of pleasantness, it releases dopamine (our happy hormones) that activate pleasure centres within the brain. Science supports the link of mood, food, and obesity, but this is a complex process, and other factors such as cost, income, and availability will also influence food choices.

Many will feel they are unworthy and will not reach out for medical help, and when they do, they are met with the stigmas of the healthcare service, or when they do meet a caring and compassionate professional, they will struggle in getting access to appropriate treatment. Being offered weight loss surgery on the NHS is near impossible, because of this many individuals living with obesity is opting to go abroad or even privately within the UK to be operated on, people are willing to spend this money whether it is really within their affordability as it will inevitably change their lives.

The NHS takes a sensible approach to treating obesity, which is reasonable, it works on a TIER system that tries to apply the appropriate treatment to individual dependant on the severity of the condition. The makes sense, if I have diabetes, but it is well controlled, I would not be expecting a pancreas transplant anytime soon, so from this point of view it all sounds good and what we would expect from a public funded service, but when this is put into practice, the results are not so wonderful, mainly for 2 reasons:

Firstly, most will need treatment but can’t get access to it, as sadly some doctors have this misconception that you must go from TIER 1 to TIER 4 like climbing a ladder, which is simply not the case. The TIER most appropriate to that person will be based on the assessment of which category would fit their needs, for example if they have a higher body mass index and have been living with obesity for some time, it would be appropriate to refer them straight in at TIER 4, unfortunately because of this misconception they might instead be offered TIER 2, so by the time they reach TIER 4 they are getting the treatment far too late.

Could you imagine if this happened in any other condition where they did not receive the appropriate treatment for their stage of the condition? Take cancer as an example, and you went to see your doctor, and they have told you that your cancer is far spread and you need surgery, but they will not be providing you with the surgery until you have reached that stage of the ladder. There would be absolute outrage, but as cancer is innocent and obesity is full of blame, this is entirely acceptable within our society.

The other issue with access, is that the TIER 3-4 weight management services, which is where you may potentially access surgery, where you can be offered weight loss medications, and will receive an whole intense medical team approach; there will be nurses, psychologists, dieticians, doctors all working together within this service. Again, sounds great as a plan, but the reality is these services vary, depending on where you live in the country, in many areas a weight management service is simply not available or just does not exist, this is a prime example of health inequality, or simply put a game of “postcode lottery”, where you can just hope to land on Mayfair.

One positive impact the pandemic has brought about for those living with obesity, is that all sudden they are being given a focus, and this increase in attention is welcomed. I welcome the new policies that aim to help those living with this condition, this is very much needed. The problem is they haven’t improved any access to treatment, which I have just highlighted as needing change. What these polices are strongly focused on is prevention- which is again welcomed, prevention is better than cure after all. Even so, where does that leave the 35 million people living with obesity in the UK who many are already needing treatment?

Rather than focusing solely on individual responsibility to do something about obesity, there needs to be a systemic change, starting with how we view the disease. We need to change the narrative so those living with this condition feel supported to seek help. We need to ensure when they do seek help, they have somewhere they can access for what they need, when they need it

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As a trained and experienced sexual health nurse/ Cytology sampler (that’s a smear taker if your wondering) I have had a fair share of unusual questions and concerns from those that have come under my care. Most of these questions come from women and are heavily focused on their vaginal discharge. Yes, that’s right- ladies are very concerned with what it looks like and even what it smells like. I get asked everything from “Nurse, does it smell funny to you?” (whilst in-between legs of said questioner) or “nurse, is it meant to look like that?” “is it too white?” “is it too sticky?” “how can I produce less of it? “does everyone have it like me?” “does it mean I have an infection?” “why does it smell more after my period” “why does it smell differently after sex” …

Women are curious about their vaginal discharge. And why shouldn’t they be? This is a rather taboo subject; I am not sure how many of you sit down on a Friday night and compare vaginal discharge stories with your “Gal Pals” but this for sure has never been my experience- and I have some pretty weird friends. The truth is vaginal discharge is very seldom talked about (unless you have a similar role to mine).

Your vagina is rather impressive (assuming you have one), it has this rather complex relationship with the communities of bacteria’s that live in it (like tiny little villages of microbes!). We often term this microflora, imagine it to be an ecosystem, that when undisturbed, is beneficial to the health of the vagina. Bacteria that is healthy for our vagina sounds as if I just totally made it up, but its true! Our resident microflora helps us from being made home to other less friendly bacteria by competing for territory.

Vaginal discharge plays an important role in this, as it helps to keep you clean. The mucus that the vagina produces comes from various glands, which remove any debris and old cells being shed. Ultimately every woman is unique and so is her discharge. I’ve often considered what does it mean to be “normal” when explaining this to women, some women have it every day and others don’t, and not to mention that vaginal discharge changes throughout the menstrual cycle. Discharge production is linked by our sex hormones, oestrogen, and progesterone. This controls the “type” of vaginal discharge by altering in response to the rise and fall of hormonal levels, as we work our way through the monthly cycle.

For most of this cycle, progesterone is the dominant hormone, creating thick and creamy mucus, a bit like Diarylea triangles (bet you will never eat them again!). This type of discharge is designed by the body to try and stop you from becoming pregnant, by hindering the sperms movement towards the egg, like trying to swim through treacle. It’s the bodies way of saying its not ready to get pregnant yet, so back off spermys!

If you have a 28-day cycle, somewhere around day 14, ovulation occurs (when an egg is released) at this point it is likely the discharge will become clearer, wetter, and if you fancied to take some in your hand (likely you don’t) but you would be able to stretch this out like some sort of strange kids slime putty toy…And this is entirely normal. We can blame this on rises in Oestrogen, it has the complete opposite effect of the Progesterone hormone, it is allowing the sperm to move easily and even assist it in reaching the egg that is now available to be fertilised! Your body is ready to get pregnant.

In terms of smell, vaginal discharge is not meant to smell like DOVE soap, it more resembles an attic that has not been opened for a while- musky! A strong foul smell, like gone off steak sitting in the fridge too long, are often a sign that things are a bit off balance. Odours do differ from women to women, we all have our unique smell. You may notice a slightly different smell to discharge following a period, this is because there will be some endometrial (womb) lining mixed in with the discharge, this is entirely normal and will resolve itself as you move through the cycle. Sometimes, semen interacts with vaginal fluid, along with sweat that is produced during intercourse, so again, it is entirely normal for it to smell differently after sex, and even up to 5 days later if he has ejaculated inside you.

If you are using artificial hormones such as contraceptive pills, implants, injections and coils, your levels of hormones are relatively consistent, this is because the contraceptive is tricking your body into thinking its already pregnant, so the discharge tends to be thick and creamy all the time as there is a consistent level of progesterone being delivered to the body.

When you are sexually aroused you become “wet”, this is different from vaginal discharge, and is known as transudate, that’s basically there to save you from the discomfort of friction burn during intercourse and gives the sperm an idea of which direction they should be heading. (“its this way lads, follow the slippery road”

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What about when its not normal?
One of the most common issues that changes the vaginal discharge are caused by imbalances in the vaginal microflora. When there is a sudden strong and foul smell, a change in colour or consistency, this may be our vaginal discharge trying to tell us something.

This may be a fungal infection known in the medical community as Candida (Albicans), you probably know this better as “Thrush”. It is pretty normal to have the fungus candida, a type of yeast, living in and around the vagina on any given day. When this grows out of control, because something has changed in the environment to encourage it to multiply, this will result in an infection. If you’re experiencing this or have had this in the past, you’re not alone- 70% of women have also experienced it, with either mild or severe symptoms.

Thrush causes some rather unpleasant symptoms of itching and burning of the genitals, they become very sore and red, and discharge will often look thick and white and lumpy (like cottage cheese) The good news is that it is easily treated, in most cases you can self-treat by buying “over the counter” (no prescription needed!)

If your self-treating, I would recommend both using a pessary (inserted into the vagina) such as clotrimazole and to use oral medicine such as fluconazole alongside it for the higher chance of cure, especially if it’s been particularly tricky to get rid of.

If your having symptoms of the outer vagina, chuck in some clotrimazole cream to treat that area too. These days you can get the pessary and the cream in a duo pack, but the cream is known to make the burning sensation worse in the beginning of the treatment, which you may not enjoy, so it’s perfectly fine to stick to the oral treatment instead- the end result is usually the same and either way you are less likely to get treatment failure.

Another problem that is often seen is known as “Bacterial Vaginosis” or just BV for short. This is another example an overgrowth of bacteria leading to infection. There is usually a reduction in the careful balance of how acidic the vaginal environment is, this allows those microbes the take over the territory once owned by other bacteria, and they then become the dominant strain, pushing everything out of balance. Typical symptoms are a strong unpleasant odour- I would describe it as smelling fishy- discharge is usually greyish white colour, and it may cause itching, soreness, or other discomfort. This is easily treated with antibiotics, generally Metronidazole is used, although it’s not superior to any other treatments, we just like it. Not every case will need treatment, as the vagina is able to self-correct the problem and get back the fine balance.

You may have heard it before but over washing does upset the vagina, you only need to wash the external vulva and meatus – nothing needs to go inside the vagina to clean it. Doing so can cause the imbalances I have described. Your vaginal discharge is there for a reason, so trying to eliminate it by washing it away leaves your vagina vulnerable and open to infections.
Another message your vaginal discharge may be trying to tell you, is that you have a sexually transmitted disease. This may present as pain, unusual bleeding, unpleasant smells, and yellow green frothy discharge. Sometimes there are no symptoms at all. No matter how much washing you do, or how clever your vagina is, this is not going to go away. Left untreated can cause serious damage, such as infertility. I know it takes away some of the pleasure, but everyone should consider using condoms when having sex with new or “open” partners, don’t let anyone pressure you into thinking otherwise.

What I would like to end on is some caution, as most issues with vaginal discharge can be easily treated, we do not need to worry too much about this, just get to know what’s normal for you. Post-menopausal women and girls before puberty should not be having issues with vaginal discharge, you should not have vaginal discharge at all, this is because they don’t have much oestrogen and progesterone floating around to really be producing it. Therefore, if you’re no longer having a menstrual cycle, or too young to have started one, you need to see a doctor if you are experiencing issues with vaginal discharge, it is very likely to be caused by infection, but sometimes it can be something far more serious.

There comes a point in your nursing career, where you genuinely feel like you have heard it all, and it is no different when it comes to the strategies patients employ, and swear by, to build up their immune system. A spoonful of Turmeric, a daily multivitamin, Vitamin drips, B12 injections at the local salon, 5 Almond nuts soaked in water one hour before breakfast…There is an entire industry who are making these recommendations to us, or selling us these products, with the promise that it is going to improve the workings of the immune system, to make it stronger and more effective in its role.
Now here is the truth- you can’t build the immune system, certainly not in the same way you can strengthen a muscle in the gym, because that’s not how the immune system works. As an overall system it can become supressed or weakened, this can happen just from aging or becoming pregnant, it can also occur after taking certain medications, or from having various health conditions. The opposite, super strength, is not possible, and I can provide you with the supporting evidence as to why you are wasting your money and efforts in trying. I am generous enough to also let you in on a BIG secret of how you can help your immune system…for free!
To understand why we can’t just take a magic pill and get the superman effect, we need to start with truly understanding the immune system and how it works for us. The immune system is extremely coordinated and is made up of a vast network of cells, tissue that are all working together with one common purpose- to protect you! Imagine this is how an army serves to protect its country. There is not one simple soldier or platoon that is working in this role, an army is made up of lots of different components, different teams, and the immune system is the same.
Let’s explore…
One of the most important parts of our immune response is your Leucocyte cells (white blood cells) who are literally living their entire cell lives on the lookout for anything suspicious going on in the body. This is the frontline of your army, patrolling around ensuring no foreign invasion is going on.
As soon as anything foreign is noted (basically anyone looking a bit dodgy) the alarm bells are rung, which is responded to by a specific type of Leucocyte known as a Macrophage. He’s like the cell version of Rocky, I imagine him to be full of muscles and wearing a headband in army print. Rocky the Macrophage gets down to the area where the suspicious guy is. What makes Rocky Macrophage super terrifying is that he’s not there to ask questions, he is there to destroy, he just eats that foreign invader right up. So, perhaps our very own version of Hannibal Lecter and not so Rocky. Feeling quite pleased with himself, the Macrophage reports back the intel to base. He tells the army headquarters what this foreign invader looked like (i.e., which antigen was on the surface)
Next, this new information is passed onto the special operations part of the army, known as the T-cells. These guys are slightly more sophisticated in their approach to killing, compared to the Macrophages. I imagine the T-cells to all have incredibly posh British accents. Anyway, they go out on a scout for any foreigner who is wearing the specific antigen that Macrophage Rocky has told them about, they probably sit on the top of a building and sniper out each invader one by one. This becomes their core mission.
Back at headquarters, B cells, who will most definitely be wearing a lab coat and goggles, join with other members of the T cells gang, and work on designing a secret weapon, which we call antibodies. Based on the information they have received from the Macrophages, and what they know about the Antigens on the surface of the invader, they can look for its own opposing antibody
The whole function of the Leucocyte army is to stop the escalation of the foreign invader- Viva la resistance! But, as you can see its quite a lengthy process and going through these stages each time gives the invader an advantage, like taking over the whole body and …well we would become very sick or even die. So, the Leucocyte army have developed an effective strategy, once they create a secret antibody weapon in response to an antigen, they pop it in the cupboard for when it might next be needed, which they can deploy it straight away once the invader comes back. They are ready.
This is just one segment of the immune system.
Which brings me back to the idea of what do we really mean by boosting the immune system? Which cells are you looking to strengthen and how exactly are you going to do that without throwing it all off balance? Give Rocky the Macrophage too much strength and likely he will start eating his comrades.
Take the example of using Vitamins to improve immunity. I passed through Westfields shopping mall a couple of weeks ago, where I saw a stand advertising Vitamin drips. You could literally select what vitamins you would like to have pumped into you at a hefty cost. I could not work out if this was stupid or dangerous (unless you have an ACTUAL severe B12 deficiency as diagnosed by blood sample) this is going to make absolutely no different to your overall immune response, and not increase your B12 levels either, since your body has a limited capacity for storage. You will inevitably end up providing your toilet bowl with the excess B12- yes, you paid for expensive urine. More concerning than this, would be an excessive intake of vitamins such as Vitamin A, as a minor reaction to these increased levels you can cause dizziness, headaches and at the more worrying end comes comas and death! We even have a term for this- hypervitaminosis (too many vitamins!) Which tells you that you don’t need loads!
Remember that your immune system is doing its thing each day, on average we are exposed to literally billions of bacteria, virus, fungal spores. All these challenges, you may consider, could make the immune system a bit tired – but, believe me, that there is no Vitamin drip out there that money can buy, not for all the Turmeric in the world, that is going to be a miracle immune boosting cure.
The good news is that refuelling your immune system is free and simple.
Our greatest superpower is …. wait for it…sleep!
Yes. Sleep.
There is sufficient scientific evidence that tells us this is the tool we need to restock the immune system, so that when you wake up each day, its more robust and ready to go. When we start to pull apart the studies, we can see that even less than 7 hours sleep each night increases the risks of catching a cold; less than 5 hours sleep could mean more serious infections such as pneumonia. The greatest man-made tool we have for boosting our immune response is vaccination, but even the effectiveness of this is also closely linked to the amount of sleep we get, for example, less than 4 hours sleep each night would result in 50% less antibodies produced in response to a vaccine, compared to someone who was receiving more hours at night.
Along with eating a well-balanced diet, not smoking and getting vaccinated- plenty of sleep is the scientific answer to strengthening the immune system. You’re welcome.

Listen to the Vegan.

Plant based diets have quadrupled in recent years, surely you have not missed the celebrities, sports stars and social media influencers all commending this Vegan way of life. Thanks to Greta Thunberg the importance of the planet’s sustainability has heavily been placed upon everyone’s shoulders; Vegans will tell you that their diet choice has a significantly lower carbon footprint than a non-vegan diet and on top of that, claim that their diets come with a multitude of health benefits, such as being less likely to develop long term health conditions -high blood pressure and diabetes- meaning that they will live longer and stronger. It all sounds a bit good to be true doesn’t it?

Are vegans living longer with exceptional health? Does the science support this exceptional claim?

Traditionally people adopted vegan diets in most parts out of necessity rather than choice, people ate the diet that they could easily obtain, and often it was more difficult, and usually more expensive, to obtain animal products. So, when you start to look at the data that we have around vegan diets, particularly in these populations, it is easy to find examples where there is deficiency, rather than convincing evidence that it’s a superior diet for health.

Yet there is science that supports the potential benefits from a plant-based diet that we could all take heed from, such as eating more fruit and vegetables.

It’s no secret that as a nation our diets are appalling, copious amount of highly processed, high salt, high sugar and high fat are consumed daily. I’ve already had two fizzy drinks and three chocolate bars to make it through the school run- that’s by 9am! There is plenty evidence, that is well known about, that supports eating more fruit and vegetables has wonderful benefits for our bodies. One of the greatest examples eating more fruit and vegetables has for us in the link with reducing the risk of bowel cancer. Other supportive evidence tells us that if we ate more wholegrains, soy and nuts it would have protective factors for the heart. Avoiding meat and cheese can help lower cholesterol and blood pressure. We can safely say there is evidence that supports that vegan diets can be healthy, but are they healthier?

The truth is that the diet does not come without risks, the main one being nutritional deficiencies, such as calcium, vitamin b12 and vitamin D. Its not an unfamiliar occurrence that a patient sits in front of me, and as I look at their latest blood test results, I see the B12 levels are well below the expected range, if I am lucky, there will also be the result of an “intrinsic factor” blood test to review, this will give me a clue to the cause of the deficiency. But it does not appear autoimmune, or due to any other condition. I flick through the electronic prescription on the computer in front of me- nope- not on any medication that might be causing it. “Are you following any plant-based diets?” I ask as a last resort. “yes nurse, I am vegan”. Mystery solved.

Going Vegan does not necessarily mean you will have a healthy diet. Instead, it requires a lot of extra time spent, carefully planning nutritional intake to ensure that the much-needed nutrients, such as protein and iron, are consumed at the right level. Unplanned vegan diets will result in the same risk of long-term health conditions as their meat-eating counterparts. Planning will need to include conscious effort to ensure enough vitamins are consumed. So ultimately, how healthy a vegan diet is will depend on the individual’s approach. Complicating the planning further, there has been almost an explosion of Vegan cafes and alternatives food choices propping up for Vegans to eat out, all cashing in on the rise in those choosing the plant-based diet. Unfortunately, many of these are just as high in sugar, salt, and fat as the non-vegan options. For example, some Vegan burgers contain more salt content than that of a meat burger, a high salt diet being a major risk factor for high blood pressure, leading to heart problems. The greatest issue is that many opt to a plant-based diet without sufficient understanding and knowledge of the nutritional implications and how to plan a safe diet.

Perhaps more worrying than poorly planned Vegan diets, is the research that points to this dietary decision being driven by the need for food restriction in some individuals, there is probably a vast amount of those with an eating disorder steered by veganism that wont even realise this is what it is. It’s important to be able to tell the difference between an eating disorder driven veganism to a true veganism.

Vegan ideology can feel persuasive but let’s not forget that people can die from diet beliefs. There is anecdotal data from clinicians treating those with anorexia nervosa, a serious mental health condition where the sufferer feels they need to keep their weight as low as possible, are wanting to follow a vegan diet. Interestingly, eating disorders are more common in adolescents and young adults, which is also where veganism is becoming most popular, research has linked veganism to eating disorders, but there is insufficient evidence to suggest that what starts out as veganism will develop into an eating disorder, and there is of course no suggestion that all vegans have some form of underlying eating disorder. Veganism is often not just a diet, but a moral baseline that extends beyond food, to clothing, cosmetics and even the type of loo roll they choose, so it may worth being cautious of those only interested in the restrictive eating part.

As it stands, vegans are still dying, meat eaters are still living well past the average life expectancy, Vegans still get diabetes and other various health conditions. Is there enough data that takes individuals following a well-planned vegan diet and compared it to a well-balanced diet that includes meat, for several people of the exact same age, sex, height, weight, same environment, non-smoker, non-drinker, exact same genetic material to give us a conclusive result that vegans are healthier? Absolutely not. That sounds almost impossible to achieve such data.

The best balance for us all would be to listen to the Vegans and eat more fruit and veg and less meat and dairy. To reap those benefits though does not need to be an everyday restriction, in fact just going one less day a week without meat – especially fatty red meats (Goodbye daily dose of lamb…sob..sob..) could provide benefits without the need for all the planning and risk associated with veganism. Look instead for leaner sources of protein by switching to more chicken and fish and avoid processed meats like they are drenched in Salmonella.

You can also have a positive impact on the environment by cutting back on meat, this will reduce carbon footprint without having to go entirely vegan – not to mention there are lots of other ways to protect the environment. Wasting less food would also influence how we can cut back on greenhouse gases, likely this alone would have a huge impact.

Perhaps the biggest lesson to be taken from the research is that we need to be listening to the Vegans who may be indicating they are trying to cover for an eating disorder. This is an upsetting side to veganism, which requires specialist input. Those with an existing eating disorder – I strongly advise you away from veganism.

I caught myself typing it, but It was too late. The post was published to the cyber community. In one swift action I had erased the hard work and commitment of thousands of my colleagues over years of duty and service. I had called myself “just a nurse”. How shameful!
Let me explain…
The role of the nurse predates the 19th century, the term “nurse” comes from the Latin word “to suckle”, when mothers traditionally outsourced breast feeding to another woman, known as a “wet nurse”. From the 16th century the term was used to refer to those who cared for the infirmed. Florence Nightingale arguably was the most famous nurse of all time, forming nursing into meaningful career move forever more.
I was 17 and a half when I entered the NHS, I owe so much of my knowledge and career to the practice of other nurses. I sat in awe of advanced nurse practitioners who prescribed medicines and interpreted blood test results, no different from their doctor counterparts. I watched on, inspired by the nurses who wrapped blankets with such tenderness to our frail and impaired members of society and ensure they sipped on warm drinks in the winter months. I desperately wanted to be like the nurse who warmly embraced the gentleman who had just lost his wife. I fought back tears of emotion as a 3rd year student on the district, watching this moment unfold, as his wife lay peacefully in the bed where we had just finished her last offices. More than a decade on, I remain motivated and dazzled by the remarkable work of my nursing colleagues.
The nurses of today are delivering care that is more complex that it’s ever been. Most service users receiving healthcare will rarely turn up with a simple case of “well controlled diabetes”, they come with a multitude of issues. The nurse will understand that the diabetes is being impacted by the pancreatic cancer, that is now affecting the existing lung condition, for which they are getting side effects from the medications but can’t be switched to another prescription because the diabetes has damaged the kidneys, meaning that another medication would damage it further. And this is just the physical impact. I haven’t even started on how this might affect them from a psychological or social perspective. These are the customers that nurses will dutifully care for.
Nurses are specialists in their fields, in addition to the traditional care giver role, they educate and plan for the best possible outcomes. Their passion is improving the quality of the lives of those under their care, often doing so in a toxic, under resourced and poorly staffed environment. A nurse is a compassionate friend who has the skills to switch your mentality from helpless and broken, to a state of healing. You will make it through some of your most difficult and vulnerable moments in life thanks to the compassion of a nurse. They will advocate for you, and on many occasions save your life. They are the heart and soul of the health care system.
Nurses fill a huge array of essential roles, nurses are everywhere, they work in hospitals, schools, prisons, people’s homes, care homes, research labs, cruise ships, clinics, and universities. Yet, there is a complete misunderstanding of the role, that results in devaluing nursing as a profession. The realities and complexities are poorly understood by those outside of the nursing family. To fulfil these roles, nurses of today are university educated, highly competent, knowledgeable, skilled professionals leading in care.
As a nation, we are surrounded by notable and influential nurses who are occasionally recognised by an MBE or some other sort of award. The rest have the simple job satisfaction of knowing that in the words of LL COOL J they are “doin’ it and doin’ it well.”
How can we influence public perception of nurses, when even I am not shouting from the rooftops of what the profession is? Its no wonder people would rather take healthcare advice from their friend who once did a first aid course in 1996 than the nurse standing in front of them. So, let me say it NURSES ROCK!
Everyone will need a nurse one day. When you do, if you haven’t already, you will appreciate that we are NEVER just a nurse. I am a nurse, and I am proud of the profession.

#notjustanurse