Care ethics and compassion satisfaction in the palliative care provider experience: narrative review of provider-centered outcomes in palliative care

Introduction

Attention to provider burnout and compassion fatigue has increased in recent years, particularly in the wake of the coronavirus disease (COVID) pandemic (1). Given their exposure to the suffering of others, palliative care providers may be uniquely at risk for emotional exhaustion, depersonalization, and secondary trauma (2). Though reported ranges vary, literature synthesis estimates that burnout affects approximately one-fifth of palliative care providers (3). Yet due to the patient-centered nature of their work, palliative care providers may also encounter opportunities to experience compassion satisfaction, defined as the pleasure one derives from being able to do their work well in the service of others (4). Compassion satisfaction may be key to clinician resiliency, as it appears to be protective against burnout and secondary trauma among palliative care providers (5,6).

Provider experience is critical to the acceptance and sustainability of palliative care delivery models. Compassion satisfaction and burnout make up key components of provider wellbeing and therefore serve as important targets for measurement. Exploring the impact of palliative care interventions on provider experience, therefore, offers significant potential for innovation.

This study utilizes a narrative review methodology to provide an overview of existing research on palliative care provider outcomes, synthesize connections between research subfields, and identify targets for future research. Our primary research questions guiding the review were as follows:

• What factors and interventions influence compassion satisfaction and burnout among palliative care providers?
• What provider wellbeing outcomes have been measured for patient-centered palliative care interventions?

This narrative review explores existing literature regarding provider-wellbeing outcomes in palliative care delivery, ultimately proposing an underlying conceptual model founded in care ethics to guide future research. We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-60/rc).

Methods

We queried PubMed from April to June 2025, with additional articles found through backward chaining. Our search prioritized randomized clinical trials, single-arm clinical trials, observational studies, cohort studies, systematic reviews, scoping reviews, narrative reviews, and meta-analyses. Case reports and editorials were excluded. No geographical constraints were placed upon our search and international articles were also considered, but non-English articles were excluded. No publication timeframe was imposed in order to capture a broad spectrum of research on this topic; article publication dates ranged from July 1996 to May 2025. Search terms were developed through an iterative process over our search period. Relevant article references were stored in EndNote v21. As is typical in narrative reviews, we did not formally assess these references for bias or quality. A summary of our search strategy can be found in Table 1. In our search results, clinicians were considered palliative care providers if they were caring for seriously ill patients and providing services considered to be part of the palliative care skillset, including serious illness communication, psychosocial support, and intensive symptom management. Palliative care providers in our search results held a wide range of roles, including physicians with and without formal palliative care fellowship training, advanced practice providers, nurses, hospice volunteers, social workers, chaplains, and psychologists.

Key content and findings

Measurement of compassion satisfaction and burnout

Existing studies present a variety of measurement tools to capture provider-centered outcomes in palliative care delivery (3,7). For example, the Professional Quality of Life Scale (ProQOL) (4,8,9) has been widely adapted in palliative care literature. It comprises three separate components: (I) compassion satisfaction, (II) burnout, and (III) secondary traumatic stress, or the negative impact of exposure to patient trauma. The Maslach Burnout Inventory is also a common tool in provider outcome research, assessing emotional exhaustion, depersonalization, and feelings of personal accomplishment (10). Other measurement tools found in our literature search include the Pines Burnout Measure (11), the Compassion Fatigue Scale, and the Compassion Fatigue Short-Scale (12).

Range of palliative care clinicians

While some studies in our review focused on specific provider groups such as palliative care physicians (13), oncologists (14), hospitalists (15), advanced practice providers (16), or nurses (6,17-20), the majority included a wide range of palliative care clinicians, including providers such as physicians, advanced practice providers, nurses, social workers, chaplains, psychologists, and hospice volunteers. These providers represent a wide range of roles, backgrounds, and training pathways. Palliative care is an interdisciplinary field, and many interventions may therefore include multiple types of providers by necessity. However, the breadth of clinicians represented by the current state of research may make it challenging to draw conclusions about any particular provider type, and future studies may consider focusing on particular provider types in order to nuance the field.

Factors associated with provider compassion satisfaction and burnout

Prior research and multiple reviews have examined various factors associated with compassion satisfaction and burnout among palliative care providers (3,7). Many of these factors are individual practices. For example, a study of 390 hospice staff and hospice volunteers found that those who reported use of personal rituals such as prayer, journaling, or calling patient caregivers after a patient death also reported lower rates of burnout and higher rates of compassion satisfaction (21). Similarly, regular use of multiple self-care practices among hospice workers has been associated with increased professional quality of life (22). Other factors are reflective of personal traits; a survey study of 385 palliative care professionals found that greater levels of self-awareness were correlated with increased ability to cope with death, which in turn were negatively correlated with compassion fatigue and burnout (23). A smaller survey study of 66 palliative care providers found that neuroticism was negatively correlated with compassion satisfaction, while agreeableness was strongly associated with it (24).

Other factors are organizational. Shared workplace values and effective team communication have been associated with palliative care providers’ satisfaction with work-related tasks (25). Similarly, perceived coworker and organizational support appear to be protective against burnout among palliative care nurses (18). Increased workload, longer hours, and weekend work have also been linked to burnout and decreased compassion satisfaction among hospice and palliative care providers (19,20,26).

A sense of personal efficacy and competency may also modulate clinician risk for burnout. For example, one study found that palliative care clinicians who doubted their ability to communicate bad news were more likely to report low levels of job satisfaction and a higher likelihood of leaving the field (27). Similarly, burnout rates have been found to be higher among palliative care physicians who report inadequate communication and management skills training (13).

Impact of provider-centered interventions

Previous work has explored various interventions that may improve the experiences of palliative care providers. Some interventions address structural targets; one study found that providing a monthly professional development day to palliative care advanced practice providers led to decreased burnout and increased compassion satisfaction (16). Another study found that employing a paired buddy system among palliative care providers during the COVID pandemic decreased compassion fatigue and personal distress (28). Other interventions focus on provider education. For example, palliative care providers who participated in three didactic sessions on the phenomenon of compassion fatigue noted an increase in compassion satisfaction and a small decrease in burnout (29). Mindfulness training has also shown promise; one six-week mindfulness program was shown to decrease compassion fatigue and emotional exhaustion among clinicians providing end-of-life care (30), whereas a 10-week workplace meditation training program decreased emotional exhaustion and increased a sense of personal accomplishment among palliative care staff (31).

Impact of palliative care interventions on palliative care providers

In contrast to investigations targeting clinician burnout and compassion fatigue, relatively little research has explored how patient- rather than provider-centered interventions may impact providers, even as a secondary outcome. Existing literature primarily explores the role of training programs for palliative care providers. For example, one randomized control trial examined an eight-session training program designed to improve nurses’ ability to care for patients experiencing meaninglessness at the end of life. The training program decreased levels of self-reported burnout and increased job satisfaction for participants as compared to the waitlist control group (17). Another intervention targeting a range of health care workers caring for dying patients (physicians, nurses, chaplains, physical therapists, etc.) explored the impact of a six-day training program designed to allow providers to both address any personal anxieties regarding death as well as better investigate the emotional and spiritual needs of their patients. Compared to the control group, providers showed both a decrease in levels of burnout and emotional exhaustion as well as an increase in professional satisfaction (32).

Notably, though these interventions sought to improve the care offered by palliative care providers, neither of these studies captures patient-reported outcomes. Instead, they illuminate how targeted skills training may improve the provider rather than the patient experience. Whether interventions that target palliative care providers also benefit patients is relatively unexplored. For example, another randomized control trial provided palliative care physicians and advanced practice providers with one-on-one communication coaching designed to improve their motivational interviewing skills. Similar to prior studies, clinicians in the intervention arm reported decreased burnout and depersonalization scores (33). Unlike the other studies, however, this trial collected patient outcomes, including patient-reported satisfaction and perceived empathy of the provider, ultimately finding no difference between the intervention and control group. Of note, however, patient-reported measures were only a secondary outcome for which the study was not powered.

Impact of palliative care interventions on non-palliative-care specialists

The benefits of palliative care interventions are not limited to palliative care specialists. Providers without formal palliative care training may also benefit from patient-centered interventions. For example, use of the Serious Illness Conversation Guide, a framework for early discussion of patient goals, values, and prognosis, has been shown to improve patient anxiety (34,35), depression (35), and documentation of patient goals and values (36). However, its use has also been found to increase professional role satisfaction among both oncologists (14) and hospitalists (15), suggesting that the tool may confer bidirectional benefits to both patient and provider.

Provider benefits can be found in the critical care setting as well. One study in a surgical intensive care unit (ICU) found that implementation of a comprehensive end-of-life care program, including end-of-life order sets, patient-centered information pamphlets, didactics, and a multidisciplinary goals of care team resulted in a statistically significant reduction in work stress among critical care staff (37). Another multi-pronged ICU-based intervention designed to improve team and caregiver communication at the end of life demonstrated decreased relative risk of both burnout and depressive symptoms by half among critical care physicians, nurses, and nursing aids (38). Though the study did not capture patient-specific outcomes, the wide-ranging interventions, which included expansion of family visiting hours, improved family meeting scheduling, and more robust documentation of patient wishes in light of limited prognosis, largely targeted the patient and family experience.

Such studies of non-palliative-care specialists point to the growing interest in “primary palliative care”, the provision of basic palliative care services—i.e., advanced care planning, goals of care conversations, pain and symptom management—by providers without formal palliative care training (39). The principle of primary palliative care presupposes that basic palliative care skillsets are within the realm of all clinicians, regardless of specialty. Moreover, reserving the involvement of specialists for particularly complex needs by offering general palliative care across care settings may improve patient access and encourage early incorporation of palliative care principles (39). Though limited, these studies demonstrate that patient-targeted palliative care interventions confer benefits even to providers without formal training in palliative care.

The above studies examine patient-centered interventions. However, similar to studies of palliative care specialists, most information we have on outcomes among non-palliative care providers focuses on provider- and not patient-targeted interventions. A substantial body of research examines educational interventions in primary palliative care delivery. One systematic review found 160 studies on end-of-life communication training for clinicians without formal palliative care training. Notably, although provider-reported measures such as confidence and attitudes towards palliative care were measured in 94% of studies, only 6% of studies examined patient- and family-centered outcomes of these training interventions (40).

Discussion

This narrative review provides an overview of how palliative care interventions impact provider compassion satisfaction and wellbeing. Most investigations in this space appear to explore factors associated with provider satisfaction and burnout, as well as provider-centered interventions that modulate these outcomes.

A smaller body of research indicates that improving palliative care for patients may also confer benefits to providers, including non-palliative-care specialists, suggesting that improving provider experience is not solely limited to implementation of provider-targeted interventions. This phenomenon provides a significant opportunity for future research. Optimizing provider experience is key to both the sustainability of current palliative care models as well as the expansion of palliative care services across care settings and among providers without formal palliative care training.

Moreover, the possibility that patient-centered palliative care interventions may also combat provider burnout and improve compassion satisfaction points to an underlying conceptual framing of the patient-clinician interaction. Provider and patient experiences are shaped by the entire environment of palliative care delivery. As a result, research focused solely on how provider-targeted interventions impact providers and how patient-targeted interventions affect patients may be blind to complex interactions between patient, provider, and caregiver wellbeing.

We therefore propose an alternate model of palliative care innovation, situated within a dynamic web of interactions (Figure 1). This model is an extension of ethics of care, a theory pioneered by Carol Gilligan and Nel Noddings that posits that caregivers and care-receivers exist in a network of social relationships, and that such mutual interdependence provides the foundation for moral responsibilities and ethical behavior. Wide-ranging applicability of care ethics to palliative care practice has previously been described (41). Grounded in a framework of care ethics, clinicians are not simply service providers; instead, they are relational agents. When all individuals are interconnected, the interests of each are integral to the health of the system. Care ethics acknowledges mutual vulnerability; in medicine, both patients and providers have something at stake in the clinical interactions that unfold between them. Care is neither unidirectional nor transactional. Attention to the mutually constitutive elements of the care relationship may support uniquely effective innovations across disciplines.

Figure 1 Model of palliative care innovation informed by care ethics.

When viewed through the lens of care ethics, the body of literature on the provider experience suggests a need to further explore how interventions targeting one stakeholder may affect the experience and outcomes of others. In this sense, the historical focus on patient-centered care may warrant further refinement toward a model that acknowledges and leverages the interdependence of patients, caregivers, and providers.

Conclusions

Although compassion fatigue and burnout are well-documented among palliative care providers, research into how patient-centered palliative care interventions affect providers is limited. Future research should leverage existing tools measuring compassion satisfaction and burnout to better understand how patient-centered interventions impact providers and vice versa. Such an approach may support sustainable adoption of palliative care interventions across multiple domains and draw attention to the far-reaching costs associated with their absence.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-60/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-60/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-60/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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