Palliative Care Consults for Clinician Distress: Part of the Job?

Abstract

Clinician distress is common in serious illness care. Palliative specialists are often consulted for cases involving significant distress among primary teams. Consults involving clinician distress can be challenging to navigate when it feels like 1) palliative specialists do not have the right skills to be helpful or 2) palliative specialists are being asked to ‘fix’ difficult situations that would require changing other people’s attitudes, beliefs, or behaviors, or healthcare systems writ large. This article uses three composite cases to illustrate types of clinician distress and examine the benefits and risks of palliative specialist involvement. We conclude with a discussion of potential impacts of palliative care consults for clinician distress on the field of palliative care and consider next steps in critically important efforts to support and sustain the entire workforce—both palliative specialists and nonspecialists alike—when caring for patients with serious illness and their family caregivers.

Introduction

As clinicians on the palliative care service at large hospitals (YS and RA), we are accustomed to consults for cases involving significant patient and family distress. The role of palliative care specialists includes addressing debilitating physical and psychological symptoms, leading complex discussions about goals of care, and supporting patients and their families near the end of life. We are well-prepared for these tasks, which are described in clinical practice guidelines and taught as core competencies in hospice and palliative care medicine fellowships.^1,2 However, increasingly, we are seeing a different kind of palliative care consult, exemplified in the composite cases described above. These consults involve significant distress among our nonpalliative care colleagues. Consults involving clinician distress can be challenging to navigate when it feels like 1) we as palliative specialists do not have the right skills to be helpful or 2) we are being asked to ‘fix’ difficult situations that would require changing other people’s attitudes, beliefs, or behaviors, or healthcare systems writ large. We have begun to wonder if our colleagues’ distress is part of our job responsibility. In this article, we describe clinician distress, identify benefits and risks of palliative specialist involvement in such cases, and consider the potential impacts on our field. We conclude with a discussion of next steps in critically important efforts to support and sustain the entire workforce—both palliative specialists and nonspecialists alike—when caring for patients with serious illness and their family caregivers.

Clinician Distress in Serious Illness Care

Distress is common and may take many forms among clinicians caring for patients with serious illness. Moral dilemmas— as illustrated by case #1, in which there is a difficult decision for which more than one answer is morally defensible but none is ideal—are frequent and often distressing for clinicians. Case #2 represents an ethical tension that may be highly distressing: the ICU physician feels compelled to provide potentially harmful treatments with a low probability of success when the family and clinicians disagree about the right course of action. Family and clinician conflicts may worsen distress, particularly when clinicians have not received training in having difficult conversations and/or do not have adequate time for navigating complex interpersonal issues. A large body of literature has described these situations as moral distress,^3–5 the painful experience of “knowing the right thing to do while being in a situation in which it is nearly impossible to do it.”⁶ Finally, as illustrated by case #3, simply witnessing unrelieved patient and family suffering can be emotionally exhausting, particularly for frontline clinicians who spend the most time with patients and families (e.g., bedside nurses and physician trainees) and may not have successful coping strategies or perceive psychological safety in voicing their concerns.^7,8

Seminal events and societal changes in recent years have significantly increased clinician distress, which is associated with substantial turnover and attrition. Physicians and nurses have both shared and unique experiences: in one recent survey of US Magnet hospitals, a poor work environment and not enough nurses were the largest contributors to nurse burnout, while a lack of control over workload was the largest contributor to physician burnout.⁹ The COVID pandemic created acute staffing shortages, leaving overworked clinicians feeling physically and mentally drained; many also feared for their personal or family safety. Fewer collegial interactions, a consequence of social distancing and remote work, left many clinicians feeling lonelier and less engaged. Increasing financialization of health care services^10,11 has led many clinicians to feel no longer able to practice medicine in meaningful or patient-centered ways.⁷ Regulatory changes, budget cuts, unwieldy electronic health records, and overflowing inboxes mean clinicians spend more time in administrative roles which they did not seek out, for which they are not trained, and from which they derive little joy. Longstanding and persistent failures to promote diversity, equity and inclusion and to combat bias, stigma and racism within medicine contribute to clinician distress and lead some practitioners to leave their jobs.¹² Finally, political battles during COVID steadily eroded societal deference to scientific expertise, leading to more conflicts with patients who do not trust their clinicians.

The distress that clinicians experience leads to adverse outcomes. Burnout, characterized by exhaustion, cynicism, and decreased effectiveness at work, represents a growing public health crisis among physicians and nurses caring for seriously ill and dying patients in the hospital. By the end of 2021, nearly two thirds of US physicians exhibited at least one manifestation of burnout, which has been tragically associated with increased rates of depression and suicidal ideation, commission of medical errors, and delivery of worse quality care.^13–17 Burnout rates among nurses are also quite high, with 62% reporting burnout in one national survey¹⁸ and over half reporting that they intended to leave or were considering leaving their position.¹⁹ Thus clinician distress has profound and lasting negative impacts for clinicians, patients, families, and healthcare systems.

Opportunities for Palliative Specialists to Help With Clinician Distress

Palliative specialists have expertise navigating complex psychosocial, legal, ethical, and moral dilemmas and training in advanced communication skills, which may not only improve patient and family outcomes, but also have a potential secondary benefit of decreasing distress on the consulting team. All members of the specialty palliative care team (physicians, nurses, social workers, and chaplains) may be involved in providing clinician support. To the extent that clinicians who feel supported are better able to meet patient needs, some argue that addressing clinician distress could be a high yield use of palliative specialists’ time. It is also sometimes difficult to distinguish between patient-related and team-related questions.

For example, in Case #1 the neurosurgery resident may be distressed because he does not understand the patient’s thought process or the values that inform the patient’s decision-making. In talking with the patient, the palliative clinician may learn that he has survived many previous high-risk surgeries and fully understands the risks involved, viewing the outcome as “in God’s hands.” Explaining this to the neurosurgical team may help them to understand that offering surgery is the right decision for this patient, thereby decreasing the resident’s distress. Alternatively, the patient’s decision may have been made in a hasty or overly emotional state or driven by poor understanding of the most likely postoperative outcomes. In this scenario, a conversation with a palliative specialist may lead to a different decision. In either case, the palliative specialist’s expertise in leading goals of care discussions may be helpful for the patient and for the primary team, who can feel reassured that the decision about surgery is consistent with the patient’s goals, as elicited by a highly skilled clinician’s conversation.

In Case #2, the patient’s wife, daughter, thoracic surgery and critical care teams are in disagreement about the optimal approach to care. Systemic or programmatic factors (e.g., transplant center outcomes with implications for program viability) may conflict with patient-centered care and contribute to perceptions of conflict between clinical teams. Palliative specialists have experience with conflict and bring expertise in mediation. As a consulting service with relationships spanning multiple different hospital services, palliative specialists can be helpful in facilitating and leading discussions among clinicians to ensure open lines of communication and work towards ensuring that everyone is on the same page, while keeping the patient’s goals, values, and overall welfare at the fore. While staffing models vary, palliative specialists often have more time to spend with family members than surgical or ICU teams, for whom the demands of the operating room or caring for a large number of critically ill patients may preclude being fully present for family meetings. In this case, the palliative care specialist may be helpful in alleviating distress for the patient’s family members and clinicians.

Palliative specialists are also adept at recognizing and responding to patient and family emotion, and these same skills may be helpful in supporting colleagues experiencing emotional distress. For example, in Case #3, simply naming the sadness of seeing someone so young receive a devastating diagnosis may be helpful to the patient’s nurse. When the distress of such cases is overwhelming for the primary team—because of their prior connections with patients, their competing roles, or a lack of comfort and/or skillsets for addressing highly distressing situations—palliative specialists may help by using palliative communication skills to address patient and family emotions, which in turn may decrease team distress.

Are Palliative Specialists Responsible for Clinician Distress?

While bringing relevant expertise to meet the palliative care needs of a patient and/or family may sometimes alleviate clinician distress, there are also situations in which clinician distress persists or supercedes patient and family needs. In case #1, despite the palliative specialist explaining the patient’s values, the resident may be distressed because he feels the patient is making a bad decision. In case #2, despite the palliative specialist’s attempts at mediation, the clinicians are angry and the ICU attending feels disrespected by the transplant team. The patient in case #3 is sad and the nurse feels overwhelmed by sitting with the patient’s sadness. In these cases, the primary teams’ distress is on-going and the question becomes the degree to which the palliative care team should attend to these emotions. It is important to consider potential downsides of accepting this as part of our job.

First, it is not known the extent to which palliative specialists are actually helpful in alleviating clinician distress. Prior research has not found that increased access to palliative specialists significantly lowers nursing distress.^20,21 This is a particular concern when the distress occurs across hospital hierarchies (e.g., a palliative care fellow called on for a case involving a distressed neurosurgery attending) or clinical roles (e.g., a palliative physician called on for a case involving a distressed ICU nurse). While attending to patient emotions and a colleague’s distress entail similar skill sets, they are not the same. Palliative specialists do not receive targeted therapeutic training to effectively identify and address clinician emotions and may be ineffective in this role. Determining when and how clinician distress should be treated is best done by psychologists or other mental health experts, who are better equipped than palliative specialists to intervene accordingly. Using palliative specialists to manage clinician distress may also create unrealistic expectations and/or misunderstandings about the purpose and scope of palliative care teams. Although palliative specialists may be eager to be ‘value added’ in complex clinical circumstances based on their desire to do good for primary clinician collagues (beneficence), their inability to maintain such presence and serve in this capacity as a long-term solution may ultimately leave primary clinicians feeling unheard, misunderstood, and abandoned. These relationships are unsustainable at best and detrimental at worst.

Second, feeling responsible for other clinicians’ distress may send the wrong message. At times, clinician distress reflects uncertainty, conflict, or discomfort with patient and family emotions that are inevitable given the circumstances. The optimal approach for clinicians is to sit with these issues, bear witness to them, consider whether they are ethically justifiable, and explore their source, rather than simply trying to resolve them for the purpose of timely discharge or decision-making. Consistently seeking palliative specialist input for the purpose of minimizing clinician distress may weaken primary clinicians’ sense of confidence and efficacy in managing difficult scenarios, increasing their reliance on consultation that curbs their clinical agency and diminishes their full role and responsibilities.

Third, while attending to clinician distress may generate more palliative care consults, these cases can consume considerable time and energy, and they may not be the optimal use of a limited specialty resource. One of us (WR) once spent many hours in a single day alleviating the distress of a multidisciplinary primary team withdrawing life-prolonging treatments from a patient with end-stage lung cancer who was still conscious.²² This time, spent over and above the time required to meet patient and family needs, may overstretch palliative care teams—many of which are not adequately staffed to meet growing consult volumes—and could detract from other patient’s care or prevent a timely response to more urgent consults. Optimizing use of specialty palliative care to maximize impact is an important ongoing effort for our field.

Finally, attending to a colleague’s distress may be the wrong action. While palliative specialists typically attend to distress on an interpersonal level, in some cases a better approach may be to pursue systemic changes. For example, a clinician who is distressed about conflict with a particular service may be motivated to schedule interdisciplinary conferences or catalyze other formal opportunities for cross-disciplinary connections. A clinician who is distressed about the organization of emergency department care may be motivated to write an op ed or join an ED redesign workgroup. To the extent that clinicians consult palliative care to absorb distress instead of taking other value-driven actions, this may only increase the distance between clinicians and important sources of meaning and purpose in medicine, while also delaying the systems-level changes required to improve work environment factors (e.g., safe staffing levels, clinician involvement in institutional policies, or adequate time off).

Potential Impact on Palliative Specialists

It is also important to consider the potential impacts of feeling responsible for clinician distress on palliative specialists. Most palliative specialists do not have backgrounds in therapy or workplace wellness. Moral distress and peer support are not covered in hospice and palliative medicine fellowship curricula. Palliative care clinicians may be reluctant to fill a role for which they do not have adequate preparation or skills. Taking on clinician distress may leave palliative specialists feeling like they are supporting the entire healthcare system, a Sisyphean task that may worsen exhaustion, cynism and feelings of decreased effectiveness. That is, feeling responsible for our colleagues’ negative emotions as the ‘experts’ in alleviating suffering may have the unintended consequence of worsening distress and burnout among palliative specialists. Given the growing burden of serious illness nationally and globally, health systems cannot afford to overwhelm palliative care teams with additional responsibilities that will undoubtedly lead to increased attrition and turnover.

Normalizing palliative care consults for clinician distress can also place the specialist in a dilemma of obligations: to whom are they responsible? From an ethical perspective, the patient is the priority. However, in the context of everyday work environments, cross-service relationships, and institutional politics, it is not unthinkable that the palliative specialist would feel stuck between what the primary clinician views as ‘right’ and an alternative decision that aligns with the patient’s values. For example, in case #1, if the palliative specialist identifies that the patient’s goals align with surgery but feels like in doing so she is letting down the neurosurgery resident and causing distress, the relationship between palliative specialist and primary clinician may become strained. If such interactions are left unaddressed and become repetitive, there can be substantial breakdown in primary team—palliative care team relationships and miscommunication that will ultimately endanger patient care.

Future Directions

If our view of clinician distress as an important driver of palliative care consults is correct, we think our field needs to have a strategic and thoughtful discussion about how we are approaching this role. Given the complexity of palliative specialist activities,²³ many of which are not specified in National Consensus Project Guidelines domains, it is reasonable to consider the extent to which addressing primary team clinician distress falls within our scope. If it does, palliative care clinical practice guidelines should be updated to reflect these tasks, and palliative care trainees should be taught the appropriate skills. This work should be done in close collaboration with colleagues who are experts in psychology and mental health.

From a systems point of view, it is important to understand the predictors, outcomes, and extent of clinician distress, as well as how best to alleviate it, so that palliative care teams can adopt, scale, and prioritize targeted, evidence-based approaches. Working across disciplines to identify and implement brief, evidence-based interventions that can be used in-the-moment to alleviate clinician distress could be an important step toward acknowledging suffering, building community, and leaning into meaning making in serious illness care. Many hospitals have critical incident support programs for addressing symptoms of acute, work-related distress. Clinical ethics consultation services may also play a role in select cases.

However, we also worry that providing an extra layer of support for everyone is not a reasonable or sustainable palliative specialist role. We echo the sentiments of many who have argued that the suffering of healthcare workers is unlikely to be sufficiently addressed through interpersonal, psychotherapeutic interventions in the absence of system-level changes.²⁴ Strategies for addressing clinician distress are the focus of considerable attention and debate, given widespread recognition that the current system is in crisis and our nation’s health is at risk.²⁵ The enormity and complexity of this problem requires collective action. In this context, palliative specialists may play a part without taking primary responsibility—for example, by recognizing our colleagues’ distress and calling attention to the issues that must be addressed at a system level. By sounding a call for needed changes we can work to ensure the wellbeing of everyone who cares for the fast-growing population of patients and their families with serious illness.

Key message.

This article examines the role of palliative care specialists in addressing clinician distress. We highlight the potential benefits and risks of palliative specialist involvement and argue that recommended approaches must consider impacts on the entire workforce caring for patients with serious illness.

Case #1. A 79-year man with a history of multiple spinal surgeries presents to the hospital with infected spinal hardware. The neurosurgical team has offered surgery, while noting that it is extremely high risk and unlikely to improve the patient’s mobility. The patient has noted that mobility is a primary goal of his, but nonetheless elected to proceed with the operation. The neurosurgery resident is upset because he is not sure this is the right thing to do. He places a consult requesting that a palliative specialist talk with the patient and family to clarify goals of care.

Case #2: A 55-year-old man, post-op day 30 s/p double lung transplant, remains intubated and sedated in the ICU with multi-organ system failure. The patient’s wife is hoping for a miracle and requesting that all life-prolonging treatment be continued, while his daughter is insistent that her father never would have wanted to be kept alive in this way. The thoracic surgery team is advocating for continued intensive care. The ICU attending is distressed because she views continuing life-prolonging treatment as providing potentially inappropriate care. She requests a palliative care consult for assistance with resolving an ethical dilemma at end of life.

Case #3: A 28-year-old woman with a history of colon cancer presents to the hospital with intractable total body pain. CT scans reveal widely metastatic disease. This information is shared with her by the ED attending. After the attending leaves, the patient is in tears and verbalizes shock, confusion, and anger. The patient’s nurse is disturbed by how upset the patient is. She asks the resident to place a palliative care consult for patient support.