Stress in Palliative Care

Abstract

This paper briefly outlines the relevant literature in palliative care related to stress. This paper reviews stress in relation to dominant theories of stress and their relevance to our current environment and across different professional groupings. This paper makes clear that there is a need to look wider than the literature specific to palliative care which allows cross fertilisation of ideas and knowledge. The paper emphasises the importance of emotional factors in stress, which are essential to the success of the work itself. The paper is essentially focused on the professional carer, though some of the literature reviewed here and conclusions made may be applicable beyond these parameters. The paper reviews the importance of perceptions of stress and mediating factors in this. Ultimately, the pathway between stress and outcome will not be a direct one, but complex and multifactorial. The paper suggests that the nature of the work in palliative care (regardless of professional background and training) is intensely emotional and psychological, if a real connection with the patient and others is to be truly made. The benefits of working in palliative care settings, which include the time to form attachments with patients and others, also constitute unavoidable loss for the professional carer. The relevance here to the literature on attachment theory is examined, as are issues of transference and counter-transference. Models for management of such emotional factors, from clinical psychology and psychotherapy, are therefore reviewed alongside issues of end stage stress or ‘burnout’. The paper examines issues related to measurement of stress specific to palliative care and considers the importance of the system in which the work of palliative care is undertaken. Threats to the individual within the environment in which they work, which may be perceived as life threatening, impact on stress and burnout. In some environments these threats are real. The paper argues that with good supervision and consultation with individuals possessing psychological training and expertise (e.g. clinical psychologists, psychiatrists and psychotherapists) much of this stress can be mediated or better managed. In conclusion, this paper argues that the level of emotional and psychological intensity involved in working in palliative care, requires appropriate training, access to specialist consultation and emotional support generally. A discussion of some ways of managing such factors is suggested and, specifically, in relation to the recently published NICE guidance (Improving supportive and palliative care for adults with cancer). It is, however, acknowledged that the topic of stress management, though related to the focus of this paper, would require separate consideration.