mental health in palliative care

Mental Health: How to deal with moral distress in palliative care

Christina Omlor

Palliative care workers are among some of the toughest jobs in the healthcare industry. Unlike those working in healthcare with patients with acute and easily solvable issues, palliative care workers deal with chronic, often terminal, health conditions. Although many palliative care workers report a high level of job satisfaction, a new survey finds burnout rates exceed those in cancer medicine.[1] Some of the biggest factors driving this burnout rate are moral distress and emotional exhaustion. This is why it is so important to know how to manage a career like this with your everyday life, so that your life outside of work isn’t affected. Learning how to take better care of your own mental health will help you remain engaged in your career.

Burnout and Moral Distress in Palliative Care

Whether you are a doctor, nurse, paraprofessional or chaplain, working in a palliative care setting can take a toll on your mental health. In bas cases this can cause moral distress, which occurs when you cannot act in line with your ethical beliefs due to institutional constraints.[2] For palliative care workers, this may occur when navigating decisions regarding those such as withholding life-sustaining treatments, honoring end-of-life wishes, or facing limitations on medical care that is covered by a patient’s insurance company. Repeatedly running into these hurdles can leave you feeling overwhelmed, burnt out, and distressed.

A recent survey of 1,357 palliative care workers found that 62% experienced burnout. Interestingly, non-physician clinicians were more likely to endorse burnout than physicians. Furthermore, researchers found that most people who felt burned out attributed it to emotional exhaustion. Working long hours and weekends were associated with greater burnout. [3]

Very stressful, very understaffed. High turnout rate. This is not a unique problem to this facility, though.” – Anonymous Employer Review on Prestige Healthcare Atlanta

How to Deal with Burnout and Moral Distress in Palliative Care

Be vigilant for signs of burnout and moral distress, including:

  • Constant fatigue
  • Dreading going to work
  • Inability to feel compassion for patients
  • Depersonalization, or emotional numbing
  • Emotional exhaustion
  • Irritability
  • Discomfort in being asked to do something that goes against your professional values or judgment

If you’re noticing signs of burnout or moral distress, use the following strategies to take action.

1. Set good boundaries:
By definition, palliative care involves working with patients with chronic illnesses as they face the end of life. It isn’t difficult to imagine why workers tend to form genuine, emotional connections with patients and their families. While this can be rewarding, it also has the potential to blur boundaries between your professional self and personal self. Set boundaries around things like accepting gifts from patients, giving out your personal contact information, or working longer than your shift requires. Though you may feel an emotional tug in the moment, these things will help you stay mentally healthy and engaged at work.

2. Create a group to process difficult cases with your colleagues:
When working in palliative care, certain patients elicit strong feelings of moral distress. For example: Perhaps a patient’s medical providers are not communicating clearly with the patient and family, creating false hope that a cure is on the way. This can be challenging for nursing staff or others working directly with the patient, as it gets in the way of providing high-quality care.

Setting aside time to process these ethical issues with your colleagues can improve quality of care as well as your own feelings of distress. The American Association of Critical Care Nurses recommends using the 4 As as a framework: ASK whether you’re feeling moral distress, AFFIRM your feelings, ASSESS the difference between the “right” action and what you are being asked to do, and ACT to put a plan in place.

Daily huddle meetings where employees can share their thoughts and concerns” – Anonymous Review on Allina Health

3. Bring up your concerns at the institutional level:
Working in healthcare is stressful enough as it is, with many employees over-exerting themselves. If you are working extra shifts, weekends, or care for too many patients at once, you’re at high risk for burnout. Gather your colleagues to bring these concerns to your institution. Highlight data showing the negative relationships between burnout and patient safety to illustrate the need for change. [4]

4. Practice self-care. Self-care is critically important for palliative care workers.
Just as parents on airplanes are reminded to put on their own oxygen mask before helping their children, palliative care workers should take care of themselves before caring for their patients. Self-care covers a range of activities which include regular exercise, eating a healthy diet, getting enough sleep, following religious or spiritual practices, and other self-nourishing activities. From taking a hot bath to lighting an aromatherapy candle, small everyday acts allow you to mentally rejuvenate to prepare to care for others at your job.

Above all, it is important to notice when you’ve reached your breaking point. If you’re consistently struggling, seek professional mental health treatment. Be aware, that there is no shame in taking care of yourself first, even if that means quitting your job.

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[1] Ascopost: Survey of Burnout in palliative care
[2] Journal of Pain and Symptom Management, 2018
[3] Journal of Pain and Symptom Management,2016
[4] Jama Internal Medicine, 2018