The Evolving Roles and Expectations of Inpatient Palliative Care Through COVID-19: a Systematic Review and Meta-synthesis

Abstract

Background

Palliative care performed a central role in responding to the systemic suffering incurred by the COVID-19 pandemic. Yet, few studies have elucidated the inpatient palliative care specialists’ experiences and perceptions.

Objective

Systematically review and synthesize the evolving roles and expectations of inpatient palliative care specialists in response to COVID-19.

Design

A systematic review and meta-synthesis informed by Thomas and Harden’s framework and Pozzar et al.’s approach was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Data Sources

MEDLINE, EMBASE, CINAHL, and PubMed were systematically searched for articles published between December 2019 and March 2023. We included all peer-reviewed qualitative and mixed-method literature studying the roles and expectations of inpatient palliative care specialists. A mixed-method appraisal tool was used for quality assessment.

Results

Of 3869 unique articles, 52 were included. Studies represented North American (n = 23), European (n = 16), South American (n = 4), Oceanic (n = 2), Asian (n = 2), West African (n = 1), Middle Eastern (n = 1), and inter-continental settings (n = 3). Most were reported in English (n = 50), conducted in 2020 (n = 28), and focused on the perspectives of inpatient palliative care clinicians (n = 28). Three descriptive themes captured the roles and expectations of inpatient palliative care specialists: shifting foundations, reorienting to relationships, and evolving identity. Two analytical themes were synthesized: palliative care propagates compassion through a healing presence, and palliative care enhances the systemic response to suffering through nimble leadership.

Conclusion

Inpatient palliative care specialists responded to the COVID-19 pandemic by establishing their healing presence and leading with their adaptability. To develop institutionally tailored and collaborative responses to future pandemics, future studies are needed to understand how inpatient palliative care clinicians are recognized and valued within their institutions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-023-08564-y.

INTRODUCTION

The COVID-19 pandemic devastated the lives and livelihoods of millions of families globally.¹ Beyond its immediate health impacts, COVID-19 tested healthcare providers and systems in their ability to deliver optimal care amidst unpredictable workloads, insufficient support, and exceptional uncertainty.^2–4 Given that palliative care specialists are professionally trained in managing clinical uncertainty and providing individualized support in challenging emotional situations, palliative care may have been uniquely positioned to support patients, families, and interdisciplinary teams in the pandemic context.^3–6

Emerging evidence investigating the effectiveness of inpatient palliative care during COVID-19 has demonstrated a multitude of positive outcomes. These benefits ranged from increased hospital efficiency to decreased uncertainty for patients and families during the end-of-life period.^4,7–10 Moreover, core aspects of palliative care, including adequate symptom management, sensitive communication, and aid in complex decision-making, are now recognized as fundamental to healthcare provision more broadly.¹⁰ Despite acknowledgment of the importance of integrating palliative care into pandemic planning, very few studies have elucidated the roles and expectations of inpatient palliative care teams during a pandemic.^{2,3,7–9,11–13} Therefore, illuminating a holistic picture of inpatient palliative care’s role in a pandemic setting remains a priority.

This study aims to use a sociological lens to systematically review and synthesize how the roles and expectations of inpatient palliative care clinicians have evolved through the COVID-19 pandemic. By triangulating perspectives across individual, interpersonal, and institutional levels, we hope to better understand the impact of the pandemic on palliative care clinicians, characterize palliative care’s effectiveness amidst a pandemic, and facilitate palliative care integration into future pandemic responses.

METHODS

Registration

The study has been registered on PROSPERO, an international database of systematic reviews (CRD42022346213).

Search Strategy

Informed by Thomas and Harden’s methods,¹⁴ we conducted a systematic review and thematic synthesis of articles published between December 2019 and March 2023 while following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.¹⁵ We chose December 2019 as the index month in alignment with the index case of COVID-19. In collaboration with our institutional research librarian (CW), we searched MEDLINE, EMBASE, CINAHL, and PubMed for potentially eligible articles (Table 1). We conducted the original search in August 2022, and an updated search in March 2023. We included articles for review and synthesis if they (a) were original peer-reviewed manuscripts, (b) employed qualitative or mixed methods, and (c) had findings related to the experiences or perceptions of inpatient palliative care specialists (Table 2). Three authors (DWZ, SGR, ZJ) independently screened article titles and abstracts to identify potentially eligible articles, and then assessed full-text articles for relevant findings (Fig. 1).

Table 1.

Database Search Strategy and Results

Database | search strategy	Records retrieved; August 2020	Records retrieved; March 2023
MEDLINE   1 COVID-19/ or exp COVID-19 Testing/ or COVID-19 Vaccines/ or SARS-CoV2/   2 (coronavirus/ or betacoronavirus/ or coronavirus infections/) and (disease outbreaks/ or epidemics/ or pandemics/)   3 (nCoV* or 2019nCoV or 19nCoV or COVID19* or COVID or SARS-COV-2 or SARSCOV-2 or SARS-COV2 or SARSCOV2 or SARS coronavirus 2 or Severe Acute Respiratory Syndrome Coronavirus 2 or Severe Acute Respiratory Syndrome Corona Virus 2).ti,ab,kf,nm,ot,ox,rx,px.   4 ((new or novel or "19" or "2019" or Wuhan or Hubei or China or Chinese) adj3 (coronavirus* or corona virus* or betacoronavirus* or CoV or HCoV)).ti,ab,kf,ot.   5 (longCOVID* or postCOVID* or postcoronavirus* or postSARS*).ti,ab,kf,ot.   6 ((coronavirus* or corona virus* or betacoronavirus*) adj3 (pandemic* or epidemic* or outbreak* or crisis)).ti,ab,kf,ot.   7 ((Wuhan or Hubei) adj5 pneumonia).ti,ab,kf,ot.   8 1 or 2 or 3 or 4 or 5 or 6 or 7   9 limit 8 to yr="2019 -Current"   10 (pandemic* or epidemic*).ti,ab.   11 Palliative Care/ or "Hospice and Palliative Care Nursing"/ or Palliative Medicine/   12 (palliative* or hospice* or "end of life").ti,ab.   13 disease outbreaks/ or epidemics/ or pandemics/   14 9 or 10 or 13   15 11 or 12   16 14 and 15	1534	590
EMBASE   1sars-related coronavirus/   2(coronavirinae/ or betacoronavirus/ or coronavirus infection/) and (epidemic/ or pandemic/)   3(nCoV* or 2019nCoV or 19nCoV or COVID19* or COVID or SARS-COV-2 or SARSCOV-2 or SARS-COV2 or SARSCOV2 or SARS coronavirus 2 or Severe Acute Respiratory Syndrome Coronavirus 2 or Severe Acute Respiratory Syndrome Corona Virus 2).ti,ab,kw,hw,ot.   4((new or novel or "19" or "2019" or Wuhan or Hubei or China or Chinese) adj3 (coronavirus* or corona virus* or betacoronavirus* or CoV or HCoV)).ti,ab,kw,hw,ot.   5(longCOVID* or postCOVID* or postcoronavirus* or postSARS*).ti,ab,kw,hw,ot.   6((coronavirus* or corona virus* or betacoronavirus*) adj3 (pandemic* or epidemic* or outbreak* or crisis)).ti,ab,kw,ot.   7((Wuhan or Hubei) adj5 pneumonia).ti,ab,kw,ot.   81 or 2 or 3 or 4 or 5 or 6 or 7   9limit 8 to yr="2019 -Current"   10pandemic*.ti,ab.   11palliative nursing/ or palliative therapy/   12(palliative* or hospice* or "end of life").ti,ab.   1311 or 12   149 or 10   1513 and 14   16limit 15 to exclude medline journals	454	666
CINAHL   1 (MH "COVID-19+")   2 (MH "Coronavirus+") OR (MH "COVID-19 Pandemic")   3 (MH "Disease Outbreaks+")   4 TI ( 2019-nCoV OR 2019nCoV OR COVID-19 OR SARS-CoV-2 OR coronavirus* or pandemic* ) OR AB ( 2019-nCoV OR 2019nCoV OR COVID-19 OR SARS-CoV-2 OR coronavirus* or pandemic* )   5 S1 OR S2 OR S3 OR S4   6 (MH "Hospice and Palliative Nursing") OR (MH "Palliative Medicine") OR (MH "Hospice Care") OR (MH "Terminal Care+")   7 TI ( palliative* or hospice* or "end of life" ) OR AB ( palliative* or hospice* or "end of life" )   8 S6 OR S7   9 S5 AND S8   10 S5 AND S8 Limit 2019-current   11 S5 AND S8 Exclude MEDLINE records	942	419
Pubmed   COVID-19 [mh] OR COVID-19 Testing[mh] OR COVID-19 Vaccines[mh] OR SARS-CoV-2[mh] OR spike glycoprotein, COVID-19 virus [Supplementary Concept] OR ((Coronavirus[mh:noexp] OR Betacoronavirus[mh:noexp] OR Coronavirus Infections[mh:noexp]) AND (Disease Outbreaks[mh:noexp] OR Epidemics[mh:noexp] OR Pandemics[mh])) OR nCoV[tiab] OR nCoV[tt] OR 2019nCoV[tiab] OR 2019nCoV[tt] OR 19nCoV[tiab] OR 19nCoV[tt] OR COVID19*[tiab] OR COVID19*[tt] OR COVID[tiab] OR COVID[tt] OR SARS-CoV-2[tiab] OR SARS-CoV-2[tt] OR SARSCOV-2[tiab] OR SARSCOV-2[tt] OR SARS-COV2[tiab] OR SARS-COV2[tt] OR SARSCOV2[tiab] OR SARSCOV2[tt] OR SARS coronavirus 2[tiab] OR SARS coronavirus 2[tt] OR Severe Acute Respiratory Syndrome Coronavirus 2[tiab] OR Severe Acute Respiratory Syndrome Coronavirus 2[tt] OR ((severe acute respiratory syndrome[tiab] OR severe acute respiratory syndrome[tt]) AND (corona virus 2[tiab] OR corona virus 2[tt])) OR new coronavirus[tiab] OR (new[tt] AND coronavirus[tt]) OR novel coronavirus[tiab] OR novel coronavirus[tt] OR novel corona virus[tiab] OR (novel[tt] AND corona virus[tt]) OR novel CoV[tiab] OR (novel[tt] AND CoV[tt]) OR novel HCoV[tiab] OR (novel[tt] AND HCoV[tt]) OR ((“19″[tiab] OR “19”[tt] OR “2019”[tiab] OR “2019”[tt] OR Wuhan[tiab] OR Wuhan[tt] OR Hubei[tiab] OR Hubei[tt]) AND (coronavirus*[tiab] OR coronavirus*[tt] OR corona virus*[tiab] OR corona virus*[tt] OR CoV[tiab] OR CoV[tt] OR HCoV[tiab] OR HCoV[tt])) OR longCOVID*[tiab] OR longCOVID*[tt] OR postCOVID*[tiab] OR postCOVID*[tt] OR postcoronavirus*[tiab] OR postcoronavirus*[tt] OR postSARS*[tiab] OR postSARS*[tt] OR ((coronavirus*[tiab] OR coronavirus*[tt] OR corona virus*[tiab] OR corona virus*[tt] OR betacoronavirus*[tiab] OR betacoronavirus*[tt]) AND (outbreak*[tiab] OR outbreak*[tt] OR epidemic*[tiab] OR epidemic*[tt] OR pandemic*[tiab] OR pandemic*[tt] OR crisis[tiab] OR crisis[tt])) OR ((Wuhan[tiab] OR Wuhan[tt] OR Hubei[tiab] OR Hubei[tt]) AND (pneumonia[tiab] OR pneumonia[tt])) AND   2019/10/31:3000/12/31[Date – Publication] AND   palliative: "palliative"[All Fields] OR "palliatively"[All Fields] OR "palliatives"[All Fields] OR   "hospice's"[All Fields] OR "hospices"[MeSH Terms] OR "hospices"[All Fields] OR "hospice"[All Fields] OR "hospice care"[MeSH Terms] OR ("hospice"[All Fields] AND "care"[All Fields]) OR "hospice care"[All Fields] OR   "end of life"[All Fields]	843	417
Preprint	37	N/A

Table 2.

Characteristics and Relative Contributions of Synthesized Publications

Perspectives and sampling timeframe	Author	Year of publication	Research question(s)	Recruitment setting	Recruitment strategy	Qualitative data collection	Methodological orientation/approach to analysis	Percent of all coded quotes
Inpatient specialist palliative care providers (physician, nurse, nurse technician, chaplain), 2020–2021	Boger	2022	To know the multidisciplinary palliative care team’s perception about stressors in the death and dying process	Brazil, hospitals	Convenience sampling	Semi-structured interviews	Content analysis	1.12
Inpatient specialist palliative care providers (physicians, nurses, healthcare assistants, senior manager, clinical manager) 2020–2021	Bradshaw	2022	To explore the experiences of and impact on staff working in palliative care during the COVID-19 pandemic	UK, organizations providing specialist palliative services	Purposive sampling	Semi-structured interviews	Thematic analysis	3.45
Inpatient specialist palliative care providers (physicians, nurses, nursing assistants), not reported	Butkeviciene	2021	To understand professionals’ attitudes, experiences, and suggestions concerning end-of-life (EOL) dignity to provide knowledge upon which efforts to improve EOL care can be grounded	Lithuania, members of the Lithuanian Society of Palliative Medicine	Purposive sampling	Semi-structured interviews	Phenomenology, thematic analysis	1.95
Inpatient specialist palliative care providers (physicians, nurses, medical social worker, spiritual care provider, other), 2020	Chan	2021	To examine the mental health of palliative care professionals in Hong Kong during the COVID-19 pandemic, the relationship of mental health with socio-demographic factors, and the impact of the pandemic on palliative care services	Hong Kong, public hospitals	Snowball sampling	Online survey	Thematic analysis	0.53
Inpatient specialist palliative care providers (chaplain, social workers, advanced practice nurses), 2020	Currin-McCulloch	2021	To describe an innovative social work and nursing approach to brokering patient and family care amidst the social distancing and visitation restrictions of COVID-19	USA, level 2 trauma center	Purposive sampling	Open-ended journal prompts	Thematic analysis	1.95
Inpatient specialist palliative care providers (nurses and nursing technicians) 2020	deAzeredo Siqueira	2021	To identify the main stressors of the nursing staff in assisting patients in oncology palliative care with suspicions and confirmed for COVID-19 and to provide subsidies for measures of psychological interventions during the pandemic by COVID-19 and in the future	Brazil, hospital unit specialized in palliative oncology care	Convenience sampling	Semi-structured interviews	Psychodynamics; Christophe Dejours	2.03
Inpatient specialist palliative care providers (nurses, physician, psychologists, physiotherapists, spiritual support workers), 2020–2021	DeLuca	2023	To understand the experiences of palliative care professionals deployed in supporting emergency and critical care staff during the COVID-19 first and second pandemic waves	Italy, urban hospital	Convenience, purposive, and snowball sampling	Semi-structured interviews	Thematic analysis	3.67
Inpatient specialist palliative care providers (physicians, nurses, social assistants), 2020–2021	Figueiredo	2021	To capture the performance of the palliative care team in relation to patients with COVID-19	Brazil, tertiary public hospital	Purposive sampling	Semi-structured interviews	Bardin’s thematic categorical analysis	1.81
Inpatient specialist palliative care providers (physician, nurse practitioners, nurses, fellows, social workers, chaplains), 2020	Finuf	2022	To investigate how job resources and personal resources reduced perceptions of burnout and increased perceptions of well-being in palliative care teams	USA, urban academic hospitals	Purposive sampling	Anonymous electronic survey	Not reported	0.26
Inpatient specialist palliative care providers (physicians), 2020–2021	Fish	2022	To explore the narratives of palliative care doctors working during the pandemic to understand their experiences at a personal and professional level	Scotland, hospice providing specialist inpatient and community-based palliative care	Convenience sampling	In-depth narrative interviews, video calls	Paradigmatic narrative analysis	4.08
Inpatient specialist palliative care providers (chaplains), 2020	Galchutt	2022	To qualitatively capture the perceptions of inpatient palliative care chaplains and the patient–family experience as the pandemic emerged	USA, urban hospital	Convenience sampling	Semi-structured telephone interviews	Thematic analysis	1.93
Inpatient specialist palliative care providers (mesothelioma clinical nurse specialist), 2021	Gardiner	2022	To explore perspectives of Mesothelioma clinical nurse specialists on their role in providing palliative care for patients with mesothelioma and their families	UK, Mesothelioma UK	Purposive sampling	Focus groups, interviews	Thematic analysis	2.65
Inpatient specialist palliative care providers (administrative, physician, nurse practitioner, consultant, spiritual worker), N/A	Holdsworth	2022	To understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the dynamic sustainability framework	USA, tertiary academic hospital	Not reported	Semi-structured interviews	Thematic analysis	1.62
Inpatient specialist palliative care providers (nurses), 2020	Johnson	2023	To explore the caring experiences of palliative care nurses during the COVID-19 pandemic	Qatar, tertiary academic hospital	Purposive sampling	Semi-structured interviews	Content analysis	2.10
Inpatient specialist palliative care providers (nurse), not reported	Kirby	2021	To identify the main psychological influences on the perception of the Nursing staff in oncological palliative care during COVID-19 pandemic	Brazil, hospital specialized in oncological palliative care	Purposive sampling	Semi-structured interviews	Psychodynamics; Christophe Dejours	1.13
Inpatient specialist palliative care providers (physicians, nurses) 2020	Luckett	2021	To solicit descriptions of, and responses to, ethical issues experienced as a result of COVID-19 related circumstances from the perspectives of nurses providing palliative care	Canada, specialist palliative care services (hospital, hospice, long-term care, community)	Purposive sampling	Video conferencing interviews	Thematic analysis	0.22
Inpatient specialist palliative care providers (nurses, nurse practitioners, practical nurse), 2020	McMillan	2021	To solicit descriptions of, and responses to, ethical issues experienced as a result of COVID-19 related circumstances from the perspectives of nurses providing palliative care	Canada, specialist palliative care services (hospital, hospice, long-term care, community)	Purposive sampling	Video conferencing interviews	Thematic analysis	2.39
Inpatient specialist palliative care (physicians, nurses, social workers), 2021	Okyere	2022	To explore palliative care providers’ perspectives on delivering PC services in the era of COVID-19	Ghana, tertiary teaching hospital	Purposive sampling	Online survey	Content analysis	3.30
Inpatient specialist palliative care providers (residents), 2021	Pfieifer	2022	To streamline clinical care and communication and improve patient and family experience through the integration of a Palliative Care Practitioner to a COVID-19 specific internal medicine physician team	USA, tertiary acute care teaching hospital and level 1 trauma center	Not reported	Semi-structured interviews	Not reported	0.10
Inpatient specialist palliative care providers (unknown), 2020	Pastrana	2021	To explore how the COVID-19 pandemic has impacted palliative care workers around the world and describes the coping strategies they have adopted to face their specific situation	Global, IAHPC members	Purposive sampling	Free test questions — survey	Thematic analysis	1.88
Inpatient specialist palliative care providers (palliative program leaders), 2020–2021	Rogers	2023	To explore palliative care program leaders’ perceptions of the future viability of their programs in the context of the pandemic and inform future educational and program development	USA, any specialist palliative care setting (hospital-based, home-based, other)	Purposive sampling	Online survey	Content analysis	1.35
Inpatient specialist palliative care providers (physicians, physician assistants, social workers, nurse practitioners) 2020	Rosa	2022	To explore the experiences of an interdisciplinary palliative care team in meeting the holistic needs of oncology inpatients via telehealth over a 10-week period during the first COVID-19 surge	USA, urban comprehensive cancer center	Purposive sampling	Semi-structured interviews	Thematic analysis	4.39
Inpatient specialist palliative care providers (physicians, physician assistants, social workers, nurse practitioners) 2020–2021	Rosa	2022	To explore the experiences of a multidisciplinary palliative care team delivering tele-palliative care for oncology inpatients during a 10-weeks COVID-19 surge in New York City	USA, urban comprehensive cancer center	Purposive sampling	Semi-structured interviews	Thematic analysis	2.90
Inpatient specialist palliative care providers (physicians, nurse practitioners, social workers, chaplains, advanced practice nurses), 2020	Rowe	2021	To qualitatively explore the challenges presented by the COVID-19 pandemic from the perspective of palliative care clinicians. Specifically to (1) describe the strategies adopted by palliative care clinicians to cope with new challenges including patient and clinician isolation, prognostication of an emergent disease, and rapidly rising numbers of severely ill patients and (2) identify additions or adjustments to in-person and system-related palliative care training, methods, and tools made during pandemics	USA, specialist palliative care services (palliative care clinical sites, hospitals, academic medical centers)	Purposive sampling	Semi-structured interviews	Thematic analysis	2.57
Inpatient specialist palliative care providers (physicians, nurses, spiritual support counselor), 2020–2021	Sena	2022	To explore palliative care health professionals and physicians perceptions of end-of-life care management in COVID units during the first two waves of the pandemic	Italy, hospitals	Convenience sampling	Semi-structured interviews	Thematic analysis	3.23
Inpatient specialist palliative care providers clinicians (physicians, nurses, physiotherapist, psychologist, pharmacist), 2020	Tavares	2021	To explore the main challenges in providing PC during a pandemic and describe the strategies to be adopted to solve the identified difficulties	Portugal, urban academic hospital	Convenience sampling	Open-ended survey questions	Content analysis	0.51
Inpatient specialist palliative care providers (physicians, volunteer palliative care consultants), 2021	Tong	2022	To understand the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge	USA, urban academic hospital	Purposive sampling	Semi-structured interviews	Thematic analysis	4.20
Inpatient specialist palliative care providers (physicians, nurses, consultants, residents), not reported Non-inpatient palliative care clinicians (nurses, physiotherapists, acute medicine consultants, respiratory consultants), not reported	Wenzel	2022	To explore the experiences of healthcare workers providing non-invasive advanced respiratory support (NARS) to critically unwell patients with COVID-19	UK, acute national health service trust across two hospitals	Purposive sampling	Semi-structured interviews	Thematic analysis	1.29
Inpatient specialist palliative care providers (medical or nursing directors, other), 2020 Non-inpatient palliative care clinicians (medical or nursing directors, other) 2020	Bradshaw	2021	To describe the challenges UK specialist palliative care services experienced regarding advance care planning during COVID-19 and changes made to support timely conversations	UK, services providing specialist palliative care (inpatient palliative care, hospital palliative care, home palliative care, home nursing)	Purposive sampling	Cross-sectional online survey	Framework analysis	3.08
Inpatient specialist palliative care providers (physicians, nurses) 2021 Non-inpatient palliative care clinicians (family members), 2021	Collier	2022	To investigate the experiences of any person — for example, patients, families and clinicians of restrictions to hospital visits for people with palliative and end-of-life care needs during COVID-19 restrictions in New Zealand	New Zealand, tertiary hospital	Purposive and snowball sampling	Semi-structured interviews	Not reported	1.32
Inpatient specialist palliative care providers (medical directors, lead medical clinicians, nursing directors), 2020 Non-inpatient palliative care clinicians (medical directors, lead medical clinicians, nursing directors), 2020	Dunleavy	2020	To map and understand specialist palliative care services innovations and practice changes in response to COVID-19	Global, services providing palliative care (inpatient palliative care, hospital palliative care, home palliative care, home nursing)	Purposive sampling	Online survey	Framework analysis	4.95
Inpatient specialist palliative care providers (physicians), 2020 Non-inpatient palliative care clinicians (physicians), 2020	Gips	2022	To describe the perceived qualities of successful palliative care (PC) providers in the emergency department (ED), barriers and facilitators to ED–PC, and clinicians’ perspectives on the future of ED–PC	USA, urban academic EDs	Homogenous purposive	Semi-structured interviews	Two-step rapid analysis	0.366
Inpatient specialist palliative care providers (physicians, nurses, social workers, chaplains, resident), 2020 Non-inpatient palliative care clinicians (nurses, consultants), 2021	Hanna	2021	To explore health and social care professionals’ experiences and perceptions of providing end-of-life care during the COVID-19 pandemic	UK, range of clinical settings (hospital care-home)	Purposive sampling	Semi-structured interviews	Thematic analysis	1.63
Inpatient specialist palliative care providers (social workers), 2020 Non-inpatient palliative care clinicians (social workers), 2020	Latimer	2022	The main objectives of this study were (1) to assess palliative and hospice social workers’ experiences of moral distress during COVID-19 and (2) to identify and describe participants’ most morally distressing scenarios	USA, social work hospice palliative care network members	Snowball sampling	Online questionnaire	Thematic analysis	1.13
Inpatient specialist palliative care providers (nurse, palliative consultants), 2020 Non-inpatient palliative care clinician (infection control nurse, consultant, anesthetist), 2020	Mitchinson	2021	To identify barriers to delivering end-of-life care, describe attempts to deliver care during the COVID-19 pandemic, and understand the impact this had on staff	UK, large teaching hospitals	Purposive sampling	Semi-structured interviews	Framework analysis	0.647
Inpatient specialist palliative care providers (physician, nurses), 2020 Non-inpatient palliative care clinicians (pharmacist, supply chain and environmental service workers), 2020	Navuluri	2023	To understand the contours of distressed work faced by healthcare professionals during COVID-19	USA, quaternary referral hospital	Purposive sampling	Semi-structured interviews and participant observations	Thematic analysis	3.96
Inpatient specialist palliative care providers (physicians, nurses, administrative staff, other), 2020 Non-inpatient palliative care clinicians (physicians, nurses, administrative staff, other), 2020	Oluyase	2020	To study the response of and challenges for palliative care services during the COVID-19 pandemic	Global, specialist palliative care services (hospital, community-home based, nursing home)	Purposive sampling	Free-text questions in survey	Content analysis	0.278
Inpatient specialist palliative care providers (physicians, nurses, psychologists, medical managers), 2020 Non-inpatient palliative care clinicians (nurses), 2020	Seibel	2022	To explore the experiences of stakeholders and staff in implementing and operating an ad hoc unit delivering acute palliative care	Germany, urban academic hospital	Purposive sampling	Semi-structured interviews	Content analysis	1.13
Inpatient specialist palliative care providers (unknown), 2020 Non-inpatient palliative care clinicians (unknown), 2020	Singh	2022	To explore health professionals’ perspectives of the role of palliative care during the COVID-19 pandemic by analyzing their views and experiences expressed in articles and blogs located via Twitter	Twitter	Convenience and/or snowball sampling	Online opinion articles (Tweets)	Content analysis	1.09
Inpatient specialist palliative care (physicians, internists), 2020–2021 Non-inpatient palliative care clinicians (physicians) 2020–2021	Wentlandt	2022	To explore the facilitators and barriers to palliative care integration in the care of patients with COVID-19	Canada, primary, secondary, tertiary hospitals	Purposive and snowball sampling	Semi-structured, open-ended interview	Thematic analysis	3.54
Inpatient specialist palliative care providers (physician), 2020–2021 Non-inpatient palliative care clinicians (physicians) 2020–2021	Wentlandt	2023	To describe physician experiences with (restrictive visitor) policies and reflections of their effects	Canada, primary, secondary, and tertiary hospitals	Snowball sampling	Semi-structured interviews	Template analysis	4.45
Inpatient specialist palliative care providers (physician), 2020 Non-inpatient palliative care clinicians (physicians, nurse practitioner) 2020	Wiebe	2021	To document how the experience of providing medical assistance in dying (MAiD) changed during the COVID-19 pandemic	Canada, MAiD providers and coordinators	Convenience, purposive, and snowball sampling	Semi-structured interviews	Abductive reasoning	1.41
Inpatient specialist palliative care providers (physicians, nurses, consultants, residents), not reported Non-inpatient palliative care clinicians (nurses, physiotherapists, acute medicine consultants, respiratory consultants), not reported	Wenzel	2022	To explore the experiences of healthcare workers providing non-invasive advanced respiratory support (NARS) to critically unwell patients with COVID-19	UK, acute national health service trust across two hospitals	Purposive sampling	Semi-structured interviews	Thematic analysis	1.29
Non-inpatient palliative clinicians (physician), 2020	Aaronson	2020	To evaluate emergency department (ED) clinician’s experiences on embedding palliative care (PC) in the ED during COVID-19	USA, urban academic ED	Voluntary response sampling	Survey	Inductive thematic analysis	1.32
Non-inpatient palliative clinicians (general public), 2019–2020	Back	2021	To understand public perceptions of serious illness care to inform greater public engagement	USA, general public	Third-party recruitment	Focus groups	Not reported	0.154
Non-palliative clinicians (hospice medical directors, hospice directors of nursing), 2020	Constantini	2020	To examine the preparedness for, and impact of, the COVID-19 pandemic on hospices in Italy to inform the response in other countries	Italy, hospices	Purposive sampling	Telephone interview	Descriptive analysis	0.281
Non-inpatient palliative care clinicians (hospice staff, family members), 2020	Cross	2022	To explore how hospice admissions staff and caregivers of hospice patients perceive the hospice admission process and the transition to hospice at home	USA, hospice organization	Purposive sampling	Semi-structured interviews	Thematic analysis	2.44
Non-inpatient palliative care clinicians (directors of nursing), 2021	Ninteau	2022	To capture how nursing homes addressed palliative care needs during the pandemic	USA, community nursing homes	Snowball sampling	Semi-structured interviews	Thematic analysis	1.87
Non-inpatient palliative care clinicians (physicians, nurses), 2020	Schallenburger	2022	To examine challenges and possible solutions for general palliative care inpatients in relation to the care of seriously ill and dying patients and their relatives	Germany, primary, secondary, tertiary hospitals	Convenience sampling	Focus groups	Content analysis	1.23
Non-inpatient palliative care clinicians (physicians, hospital leader, spiritual care provider), 2020	Vesel	2021	To explore the utilization, perceptions, and understanding of palliative care among critical care clinicians, hospital leaders, and spiritual care providers during the pandemic	USA, tertiary academic medical center	Purposive sampling	Semi-structured interviews	Thematic analysis	3.39
Non-inpatient palliative care clinicians (general public), 2020	Vihvelin	2022	To gain insight into preferences for the end-of-life and end-of-life care from people experiencing homelessness	Canada, general public	Purposive sampling	Semi-structured telephone interviews	Thematic analysis	0.179
Non-inpatient palliative care clinicians (clinical oncologists), 2021–2022	Wang	2022	To explore the current status of palliative care practice for cancer and the influence of COVID-19 from the perspective of oncologists	China, various settings (medical centers, palliative care institutions)	Not reported	Semi-structured interviews	Thematic analysis	0.578

^*Voices we abstracted for our study

Figure 1.

PRISMA flow diagram.

Quality Appraisal

The methodological quality of the studies was assessed independently by two co-authors (DWZ and SGR) using the Mixed Methods Appraisal Tool (MMAT).¹⁶ The MMAT is a 5-item assessment tool that allows for concurrent assessment of qualitative, quantitative, and mixed-method studies. The authors (DWZ, SGR) independently assigned quality ratings of high (***, 4–5 criteria met), moderate (**, 2–3 criteria met), and low (*, 0–1 criterion met) (Suppl Table 1). We neither weighted nor excluded articles from the review based on article quality as we extracted primary quotes for our independent analysis. We assessed the relative utility of each article to the purpose of the review and synthesis by calculating the percent of all coded data derived from each article¹⁵.

Data Extraction and Analysis

The data extraction and analysis process was informed by Thomas and Harden’s framework and Pozzar et al.’s approach.^14,17 While Thomas and Harden provided a sequential, staged outline,¹⁴ Pozzar et al. provided the protocols and strategies for thematic analysis.¹⁷ The first stage was understanding the context of each study. Using Covidence,¹⁸ two authors independently (DWZ, SGR) extracted the main characteristics of each study: study type (qualitative, mixed method), research question, recruitment setting (country, setting), recruitment strategy, and relevant primary quotes. Additional details on study design were collected for qualitative studies and the qualitative arm of mixed-method studies (data collection strategy, methodological orientation/approach to analysis). Any disagreements were resolved through discussion or with a third reviewer (ZJ).

The second stage involved qualitative data analysis using a six-step thematic analysis approach.¹⁹ One author (DWZ) imported each manuscript into NVivo 12.²⁰ In the first step, two authors (DWZ, SGR) read and reread the included articles to become familiarized with the primary quotes. Second, two authors (DWZ, SGR) performed inductive, line-by-line coding on all primary data that pertained to the perception and experience of inpatient palliative care specialists. Third, we developed a codebook using deductive (i.e., the socioecological model) and inductive approaches (open coding 100% of the transcripts). The fourth step involved two authors (DWZ, SGR) independently coding and recoding the primary data using the finalized codebook. During the coding process, authors met weekly to debrief and resolve conflicts, outliers, and refine codes and code definitions. We critiqued our application of these codes across studies through constant comparison.¹⁴ In the fifth step, similar codes were combined into descriptive themes. The sixth step involved generating analytical themes. We first considered the abstract concepts represented by the descriptive themes. We then generated a set of analytical themes by returning to the data and identifying the antecedents and consequents of each identified concept. With this approach, we aimed to ensure that our findings would expand upon (rather than simply summarize) the primary data.¹⁴ Our final set of analytical themes represents the relationships between concepts that were consistent across studies. No study was excluded based on quality as we extracted relevant primary data for thematic synthesis (Table 3).

Table 3.

Themes, Subthemes, and Example Quotes

Theme	Exemplary intrapersonal quote	Exemplary interpersonal quote; converging	Exemplary interpersonal quote; diverging
Theme 1: shifting foundations
Subtheme 1.1: Systemic changes disrupted routines of palliative care	“…when compare[d] to the year before, Our PCU had been 15 beds, we are now 10. We gave up 5 because we couldn’t fill them… And even the 10 that we had there was a reasonable balance. There was a while it was hard to fill even 10 ….” — Palliative Care Clinician, North America, Wentlandt et al., 2023	“This means I may be faced with choices that, in my 20 years of clinical practice, I have never had to make .. . . These will be devastating decisions for all involved, including my colleagues.” Non-Palliative Care Clinician, Global, Singh et al., 2022
Subtheme 1.2: Disruptions in clinical routines created confusion and misunderstandings of roles	“I feel we did not know what to expect and had no plan of how we were going to do our jobs on a daily basis. We were reprimanded for not doing enough but had no direction on how to be helpful ... It added to the stress with an already difficult job. We are not expendable, it has left me feeling ambivalent about this job…” — Palliative Care Clinician, North America, Finuf et al., 2022	“I found it difficult in part. In the sense of palliative thinking and working, it’s simply different from normal wards and surgery. And I sometimes had the feeling that the palliative care unit wanted you to work the way they know it and that they sometimes imposed their palliative thinking and acting on you.” — Non-palliative Nurse, Europe, Seibel et al., 2022	“Well I don’t think [my perception] evolved. I said, ‘thank heaven we have that service running’… I think had it not been built up to the degree it was, I think we would have lost some ability to help some of these patients.” — Hospital Leader, North America, Vesel et al., 2021
Subtheme 1.3: Lack of presence spurred feelings of clinical ineffectiveness	“[I] don’t feel comfortable prescribing something or making a recommendation for an opioid or medication … is it safe to escalate these medications when you’re not physically seeing the patient? And how do we know what we’re doing is right…” — Palliative Care Clinician, North America, Rosa et al., 2022	“I mean, there’s no substitute for being in person with someone. When you’re with someone and they’re not there, you’re basically doing it blind when you’re on the phone, you’re robbing yourself of one of the most important senses, which is your visual, your body language. And body language gives off an energy where you can connect with someone you. It’s easier to empathize with someone when you can see what they look like and over the phone you just can’t, it’s a voice...” — Internist, North America, Wentlandt et al., 2023
Theme 2: reorienting to relationships
Subtheme 2.1: Nimbleness and thoughtful risk-taking were essential for bridging relational gaps	“I felt that it was really mean. The lady had two daughters and was unfair for them to decide who gets to see their mum before she died. I told them both to come and just blame it on me when they got to the hospital door.” — Palliative Care Resident, UK, Hanna et al., 2021	“It’s not fair to treat everybody the same, it’s not reality. Reality is that there are certain family members and situations where they are essential to the wellbeing of that person...I’m willing to have more grey, more trying to work with exceptions” — Hospice Nurse, North America, McMillan et al., 2021
Subtheme 2.2: Palliative care clinicians and enhanced interprofessional efficacy through compassionate presence	“ED clinicians .. . said the reason they did not feel morally distressed is because we [palliative care clinicians] had their back. And that was really powerful.. .it just made me realize how many places there are in the institution that could benefit from partnership with us. I always knew they were there.” — Palliative Care Clinician, North America, Rowe et al., 2021	“[There were] times when I disagreed with the family but palliative care was instrumental in advocating for them and listening in longer conversations that I would not have had time for, and they make me feel more confident that the clinical decisions are in line with the patients and families’ goals of care.” — Emergency Physician, North America, Aaronson et al., 2021	“I found it difficult in part. In the sense of palliative thinking and working, it’s simply different from normal wards and surgery. And I sometimes had the feeling that the palliative care unit wanted you to work the way they know it and that they sometimes imposed their palliative thinking and acting on you.” — Non-palliative Nurse, Europe, Seibel et al., 2022
Theme 3: evolving identities
Subtheme 3.1: Rapid evolution of roles created emotional anguish for palliative care clinicians	“I am the only member of the palliative care team at the hospital and I have resigned under the strain of the program. Currently, there are no plans to open the position and replace me.” Palliative Care Clinician, North America, Rogers et al., 2023	“I was emotionally broken. I remember crying at the end of that weekend. I was, I was like ‘Oh my God’ and I had to, I had to actually reach out to my [palliative] consultant colleagues to say, ‘I feel broken’ and they were like, ‘that’s normal.’” Acute Medicine Consultant, Europe, Wenzel et al., 2022
Subtheme 3.2: Decentralizing and expanding the tenets of palliative care	“Palliative care is the medical specialty, but it’s also a set of principles and approaches to serious illness that are not consigned and should not be consigned to those who practice palliative care as a medical specialty. There are things that everybody should be doing... by hospitalists and cardiologists and oncologists and intensivists and surgeons and all of the different specialties.” — Palliative Care Clinician, North America, Rowe et al., 2021	“All doctors are palliative care doctors now.” — Non-palliative clinician, Global, Singh et al., 2022

RESULTS

Of the total 3869 unique articles, we assessed 246 for full texts and included 52 for the final analysis (Fig. 1). From the included articles, we extracted 877 primary quotes for analysis. Each article contributed between 0.11 and 4.95% of all coded data. The articles were then categorized based on the perspectives represented, geographical location, and timeframe of data collection. Most articles focused solely on the perspectives of inpatient palliative care clinicians (n = 28), some had mixed perspectives with non-inpatient palliative care clinicians (n = 14), and others solely focused on the perspectives of non-inpatient palliative care clinicians (n = 10). In terms of geographical representation, studies were conducted in North American (n = 23), European (n = 16), South American (n = 4), Oceanic (n = 2), Asian (n = 2), West African (n = 1), Middle Eastern (n = 1), and inter-continental settings (n = 3). Studies gathered data between 2019–2020 (n = 1), 2020 (n = 28), 2020–2021 (n = 11), 2021 (n = 7), and 2021–2022 (n = 1).

DESCRIPTIVE THEMES

Theme 1: Shifting Foundations

Subtheme 1.1: Systemic Changes Disrupted the Routines of Palliative Care

As COVID-19 rapidly spread across the globe, the routines of palliative care practices were challenged both at the system and institution level.^3,21–45 Some clinicians experienced disrupted supply chains resulting in compromised access to medications (e.g., morphine powder)²¹ and personal protective equipment³⁵ while many clinicians also scrambled to adjust to an increasingly “virtual” workplace.^{6,21,22,24,26,27,29,31,34,37,44} Many palliative clinicians experienced a dramatic decrease in workload,^{24,27,29,34,43,45,46} having “nothing to do”⁴⁵ with beds being “hard to fill,”³⁰ while others experienced a dramatic increase in workload,^{3,6,25,26,32,35–37,39,40,42} becoming engulfed within a “tsunami of death”⁴² and patients “swamping a bazillion beds.”⁴⁰ As new rules and guidelines appeared “every hour,”^6,23,35 palliative care clinicians felt that they became “disembodied professionals”⁴⁰ constantly “reacting to threats”²³ and “resigning”³⁴ to new, more “complicated and lengthy”²⁸ processes. Non-palliative care inpatient colleagues shared in the disruption of clinical routines, with virtual work becoming the new “norm,”^{12,30,32,43,47} and staff members working “overtime”^4,30,48 and being “redeployed”⁴⁸ to confront the threat of the pandemic.

Subtheme 1.2: Disruptions in Routines Created Confusion and Misunderstandings of Roles

Accompanying the clinical disruptions were changes in how palliative care was regarded.^{21,22,25,28–32,36–40,44,46,48–57} At the institutional level, some palliative care clinicians felt they were “integral to the mission” and the “overall strategy”⁴⁹ against COVID-19.^22,36,51,53 However, many feared that as a “non-front-line service,”^21,38 their program would be “chopped”⁴⁹ as they were an “expendable”⁴⁶ resource or an “easy target”⁴⁹ for institutional financial restructuring.^25,31,32,37 Between colleagues, some palliative care clinicians in the telehealth setting worried that they became an “annoyance”³⁷ or an “outsider”²⁵ while others felt “resented”³⁷ for their absence and were “reprimanded for not doing enough.”⁴⁶ The conflicting and competing expectations created internal existential distress^40,44,48 for palliative care clinicians and a yearning for clear directions on how to be most effective.⁴⁹ To non-palliative care clinicians and the general public, however, palliative care represented a pivotal and indispensable force in providing high-quality care.^4,23,50,58 Although accounts of stigma and misunderstandings existed,^9,30,54–56 many were overtaken by positive endorsements after interacting with palliative care clinicians.^{4,45,47,55–58}

Subtheme 1.3: Lack of Presence Spurred Feelings of Clinical Ineffectiveness

Transmission-based precautions limited physical presence and challenged palliative care clinicians’ sense of clinical efficacy.^{3,21,22,25–27,30,31,34,37,39–41,43,44,48,52,59–62} For inpatient palliative clinicians, the sense of “inadequacy”²⁵ arose from their “tools being taken away,”^26,40 a lack of familial presence,^{21,23–25,30,31,34,36,37,39–41,43,44,50–54,58,63–65} and feeling “disengaged from their emotions.”⁴⁸ Although some clinicians felt they were able to “successfully”^27,37,59 adapt to the virtual environment, most palliative clinicians felt that virtual care limited their ability to deliver optimal care,^{21,22,27,30,31,37,39,40,43,44,61,62} leaving a few patients feeling “abandoned,”³⁷ untouchable,⁴¹ and without a sense of “trust” in their clinicians.^24,44 On a practical level, clinicians described feeling that they were “not doctoring,”⁴⁴ that they lost their “psychosocial diagnostic skills,”³⁷ and that they questioned their ability to safely prescribe medications.⁴⁴ These sentiments of moral distress, loss of self-efficacy, and the feeling that “everything you do sets them up for failure”⁶⁶ resonated with the experience of non-palliative care clinicians during the initial period of added hospital precautions.^{23,30,33,47,61–63,67}

Theme 2: Reorienting to Relationships

Subtheme 2.1: Nimbleness and Thoughtful Risk-taking Were Essential for Bridging Relational Gaps

Inpatient palliative care clinicians recognized that policy changes “challenged”²² the relational aspects of high-quality serious illness care.^{21,23–25,30,31,34,36,37,39–41,43,44,50–54,58,63–65} Feeling responsible for ensuring that patients had access to healing relationships, many clinicians consciously chose to “transgress,”⁵³ make “exceptions,”²⁴ and shoulder any “blame”²⁵ from allowing increased family presence,^52,63 access to “home cooked food,”⁴¹ and more relaxed social distancing.^34,61 To bridge the gap in familial presence, clinicians also invested in new technology to allow virtual goodbyes^43,51 and to celebrate milestones.^25,34,42,51 Palliative care clinicians’ efforts to maintain connection and to “support patients early, where possible”^21,28,43 did not go unnoticed. Interdisciplinary team members consistently endorsed palliative care clinicians’ boldness to “negotiate”⁴⁸ and to make “exceptions”⁶¹ as these actions exemplified “humanity over policy”⁶¹ during a period of unprecedented suffering.^{30,42,47,48,55,58,60,66}

Subtheme 2.2: Palliative Care Clinicians Enhanced Interdisciplinary Efficacy Through Compassionate Presence

Beyond bridging relational care for patients and families, palliative care clinicians also adapted their skills to support their colleagues.^{4,9,23,24,29,32,34–37,39,42–45,47,49,50,55,57,58,60,66} This meant caring for their colleagues with the “same harmony”³⁹ as they did with patients by actively offering colleagues a shoulder to “lean on.”³⁷ Palliative care clinicians recognized that by bolstering interdisciplinary “resilience,”³⁴ “preventing burnout,”⁴⁹ and ameliorating “moral distress,”²³ palliative care clinicians could enhance interdisciplinary camaraderie and team effectiveness.^{23,24,29,32,34–37,39,43,44,49} While the majority of colleagues expressed gratitude^{4,9,32,42,45,47,50,55,57,58,60,66} for palliative care clinicians’ ability to “take away uncertainties”^45,57 and “bring calmness,”⁴⁵ build “resilience,”⁵⁸ “innovate,”⁴⁷ and boost “confidence,”⁵⁷ a few non-palliative clinicians also expressed feelings of being “imposed on”⁴⁵ and that palliative care was “not useful.”⁹ Overall, the profound positive impact from collaborating with palliative care clinicians was shared by both palliative and non-palliative clinicians.^{4,9,23,24,29,32,34–37,39,42–45,47,49,50,55,57,58,60,66}

Theme 3: Evolving Identities

Subtheme 3.1: Rapid Evolution of Roles Created Emotional Anguish for Palliative Care Clinicians

The sudden, volatile evolution of roles had profound physical and psychosocial impacts on inpatient palliative care clinicians.^{4,21,22,24–27,31–36,39,40,42–45,48,49,51,54,58,60,63,65,67} Beyond resolving conflicting expectations and building relational presence, palliative care clinicians embodied additional educational and novel leadership roles.^{4,21,24,26,32,36,42–45,49,51,54,58,60,65,67} This ranged from orchestrating “teaching sessions”²⁶ on establishing trust, to regional committee meetings with public health,³² to disseminating best telehealth practices.^24,44 A few palliative care clinicians also expressed how they took on more “active” roles in “advanced care” and “treatment escalation planning”^24,26,36,65 for patients, and some felt they were delegated the roles of “infection prevention specialists.”²¹ Though one palliative clinician found their new roles to be “very satisfying,”⁶³ for most clinicians, such abrupt role evolution was physically and emotionally “burdensome,”^{21,25,27,31,33,35,39,40,42,49} caused members to “resign,”⁴⁹ and led to a constant state of emotional distress.^{22,27,31,40,42,44,48} The deep emotional anguish was shared by non-palliative care clinicians,^42,61,63,68 consequently triggering both healthy and maladaptive coping mechanisms.^{22,27,34,35,39,51}

Subtheme 3.2: Decentralizing and Expanding the Tenets of Palliative Care

As the presence and exposure of palliative care became more pronounced throughout the pandemic, widespread acknowledgment of the value of palliative care grew.^{3,17,18,21,23,34,39,41,43} In the eyes of inpatient palliative care clinicians, “palliative principles” and “approaches” to serious illness are ubiquitous and “should not be consigned to those who practice palliative care as a medical specialty.”^{3,17,18,21,23,34,39,41,43} For institutions that provided a concrete “bedrock”²³ of primary palliative care skills to non-palliative clinicians, specialty services were less likely to be overburdened.^{23,29,40,47,53} Not only did non-palliative colleagues echo this protective need for palliative care,^{4,32,50,58,68} some also recognized that “all doctors are palliative care doctors”^4,50 and wished they were “more skilled”⁶⁰ in providing palliative care after challenging experiences with patients “already in the dying process.”^24,45,50,53 Appreciating the profound benefits of a robust system of primary palliative care practitioners, policy-makers emerged from the pandemic to advocate²⁷ for the expansion of palliative care capacity and an increase in palliative care training among “undergraduate and postgraduate trainees.”⁴ They saw these measures as a proactive step to help in case of future pandemics when palliative care skills would again be front and center.^4,40,49

ANALYTICAL THEMES

Palliative Care Propagates Compassion Through a Healing Presence

In response to the disconnection and chaos inflicted by COVID-19, palliative care clinicians broke through institutional boundaries to maintain a healing presence. The impact of palliative care’s presence extended from patients and caregivers to interdisciplinary colleagues, where palliative care clinicians propagated compassion to combat sinking moral distress from traumatic psychosocial experiences. While palliative care’s presence was celebrated by most, the perception of an “imposing presence” necessitates a careful reflection of the changing clinical landscape.

Palliative Care Enhances Systemic Response to Suffering Through Nimble Leadership

The pandemic created unmet systemic needs that served as opportunities for palliative care clinicians to transcend their conventional roles and skillset in navigating uncertainty associated with loss and suffering. From becoming leaders in interdisciplinary palliative education to embracing new clinical duties, this plasticity allowed palliative care clinicians to bridge gaps in clinical spaces that were unaccustomed to loss and suffering, thereby enhancing the overall systemic response against COVID-19. Although these opportunities provided palliative care clinicians a platform to demonstrate their impact, a lack of formal guidelines and leadership training may have prevented some clinicians from harnessing these opportunities.

DISCUSSION

The unprecedented suffering caused by COVID-19 required a collaborative, interdisciplinary, and systemic response. Our systematic review of the global literature triangulated the roles that specialist palliative care providers played in responding to the distress and devastation across institutionalized settings. We found that in response to shifting foundations in systemic care, inpatient palliative care clinicians adapted their identity and reoriented towards mending relational gaps between patients, caregivers, the healthcare system, and among interdisciplinary colleagues. Together, these findings signal that palliative care clinicians can adapt their clinical skills in service of their colleagues, while emphasizing the need for leadership skill development within the field.

At the onset of the pandemic, palliative care received varying degrees of attention. Although international organizations (e.g., World Health Organization) and experts advocated for early integration of palliative care services into systemic responses,⁶⁹ uptake of these recommendations was variable due to changing clinical needs and lack of primary data.^70,71 As the pandemic unfolded, data emerged to describe the role and experiences of palliative care in non-institutional settings. Reviews of the role of palliative care in long-term care, hospice, and home-based settings identified a consistent need for palliative clinicians to be flexible and to adapt to the multidimensional needs of the system and interdisciplinary colleagues.^70,72–77 The results of our systematic review are consistent with prior literature, but also expand it by triangulating the role(s), expectation(s), and experiences of inpatient palliative care clinicians through the perspectives of palliative care professionals, interdisciplinary colleagues, and caregivers.

The impact of inpatient palliative care specialists’ presence transcended direct clinical care to include interdisciplinary relationships as well. In our study, we triangulated the role of inpatient palliative clinicians in mitigating moral distress and propagating compassionate practices among colleagues, potentially alleviating burnout and compassion fatigue. Our findings resonate with prior research describing the benefits of collegial trust and collaboration in improving clinical outcomes.^78–81 Palliative clinicians may facilitate interdisciplinary collaborations by creating a “holding space,” which is a theoretical relational space created for the referring clinicians by accompaniment, recognizing challenges, establishing expectations, and providing a clinical second look.⁸² These findings raise concerns that conventional metrics (e.g., relative value units) may not adequately capture the interdisciplinary and collaborative role that inpatient palliative clinicians may play during and beyond pandemic care.⁸³ Innovations in patient-reported experience measures,^84–86 particularly in the realm of perceived system compassion,^87,88 represent an opportunity to demonstrate the interprofessional impact of palliative care prospectively. Future studies are also needed to elucidate the optimal process for building safe and effective interdisciplinary collaborations in response to systemic threats.

Building future pandemic preparedness requires attention to leadership development among palliative care clinicians. We found that inpatient palliative care clinicians demonstrated strong leadership qualities in effectively identifying and managing heightened uncertainty, loss, and suffering. This suggests that inpatient palliative care clinicians may play a central role in leading and directing systemic change to understand and address unprecedented suffering. Prior research recognizes that palliative leadership training and skill development represent a vital component to ensuring high-quality patient care.^89–94 Simultaneously, many barriers exist which inhibit the integration of leadership training, including a lack of contextually relevant content and inequities in accessing leader mentors.^80,90–103 Leadership education, possibly drawing from business literature and initiatives undertaken in other medical specialties, urgently needs to be developed and integrated throughout a palliative care clinician’s career.^{89,90,104–108}

LIMITATIONS

Our study is the first theoretically framed, globally relevant systematic review that triangulated the roles and expectations of inpatient palliative care clinicians during the COVID-19 pandemic, but like any study it has limitations. First, our data predominantly represents Westernized healthcare teams, systems, and philosophies of care in high-income countries, with limited perspectives from Asian, African, and Middle Eastern contexts. This limits the transferability of our findings for inpatient palliative care clinicians who practice in non-Western medical settings. Secondly, the credibility of our study findings to direct clinical care may be limited by the lack of perspectives of the general public, patients, and caregivers. Finally, given that the included prospective studies were limited in their time frame, a future, retrospective analysis is needed to prioritize lessons learned from the pandemic.

CONCLUSION

This systematic review illustrates how inpatient, palliative care specialists played a complex, multifaceted role in the systemic response to suffering during the COVID-19 pandemic. Evidence suggests that palliative care clinicians prioritized and maintained relational presence despite disruptions in routines and interpersonal misunderstandings. In turn, inpatient palliative clinicians alleviated suffering faced by patients, families, and their colleagues. Future research is needed to characterize how inpatient palliative care clinicians are regarded within institutionalized settings and to foster leadership development among palliative care clinicians.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

Conception and design: all authors. Collection and assembly of data: DWZ, SGR. Data analysis and interpretation: all authors. Article writing: all authors. Final approval of article: all authors.

Declarations

Conflict of Interest

The authors declared no potential conflicts of interests with respect to the research, authorship, or publication of this article.