Psychological ethical aspects of healthcare professionals in the care of terminally ill patientsAbstract
Palliative care aims to assess and monitor patients in order to provide safety and well-being, even in the presence of illness. Healthcare teams should address suffering across multiple dimensions: physical, psychological, social, and spiritual. This study investigated the psychological effects experienced by healthcare professionals during the process of patient death. It is a literature review that highlights the complexity of the emotional and professional challenges faced by nurses when caring for dying patients. The findings consistently indicate that specialized training in palliative care, empathetic communication, and adequate team support can mitigate negative emotional impacts, promoting more humane and effective care.
Keywords:
Bereavement; Occupational stress; Health personnel
Resumo
O cuidado paliativo visa avaliar e acompanhar o paciente de modo a proporcionar segurança e bem-estar, mesmo diante da doença. A equipe de saúde deve abordar os sofrimentos em várias dimensões: física, psicológica, social e espiritual. Este estudo investigou os efeitos psicológicos enfrentados pelos profissionais de saúde durante o processo de morte do paciente. Trata-se de uma revisão da literatura que revela a complexidade dos aspectos emocionais e profissionais vivenciados por enfermeiros diante da morte. Os dados indicam consistentemente que a formação específica em cuidados paliativos, uma comunicação empática e o suporte à equipe podem reduzir os efeitos emocionais negativos, promovendo um cuidado mais humano e eficaz.
Palavras-chave:
Luto; Estresse ocupacional; Pessoal de saúde
Resumen
Los cuidados paliativos tienen como objetivo evaluar y acompañar al paciente para proporcionarle seguridad y bienestar, incluso frente a la enfermedad. El equipo de salud debe abordar el sufrimiento en sus diferentes dimensiones: física, psicológica, social y espiritual. Este estudio investigó los efectos psicológicos que enfrentan los profesionales de la salud durante el proceso de muerte del paciente. Se trata de una revisión de la literatura que pone de manifiesto la complejidad de los aspectos emocionales y profesionales experimentados por los enfermeros ante la muerte. Los resultados indican de manera consistente que la formación específica en cuidados paliativos, una comunicación empática y el apoyo al equipo pueden reducir los efectos emocionales negativos, favoreciendo una atención más humana y eficaz.
Palabras clave:
Aflicción; Estrés laboral; Personal de salud
Patients’ dying process is one of the most challenging situations for healthcare providers, especially physicians and nurses, who are in direct and constant contact with terminally ill individuals. The care provided to patients in the final phase of their lives involves physical interventions and the management of emotions and psychological suffering imposed by the proximity of death1.
Palliative care aims to evaluate and monitor patients to provide them safety and well-being, even in the face of illness. Healthcare providers must address suffering in various manifestations-physical, psychological, social, and spiritual2.
Coping with patients’ death process can represent a great psychological challenge for healthcare providers, whose work involves clinical care and emotional support for patients and their families. The constant proximity to human finitude forces nurses, for example, to experience helplessness, sadness, and frustration, especially in cases of terminal patients or those with serious illnesses. The death process brings to light ethical and emotional dilemmas, requiring that healthcare providers balance professionalism and human sensitivity. This reality can sometimes generate significant emotional fatigue, leading to mental exhaustion and suffering3.
The need to provide humanized care up to the last moments of patients’ life imposes the task of dealing with their own emotions and beliefs about death upon healthcare providers. Many professionals report difficulties disconnecting emotionally from patients, especially after long periods of monitoring and building affective bonds4. Thus, it is essential that healthcare providers have spaces for discussion and emotional support to minimize the impacts of grief and psychological overload5.
Psychological preparation and palliative care training play crucial roles. By acquiring skills to more consciously and professionally deal with death, healthcare professionals can provide care that respects patients’ dignity and preserve their own mental health. Thus, academic training addressing the end of life, ethical decisions, and palliative care can enable professionals to offer adequate emotional support to patients and families and help them to better process their own emotions in the face of the end of life6.
It is also necessary to better understand the psychological impact on physicians and nurses, a central issue since emotional overload can generate stress, burnout syndrome, and even psychological disorders, affecting healthcare providers’ quality of service and health7.
Elisabeth Kübler-Ross offers one of the main references on coping with death8 by developing the five stages of grief model: denial, anger, bargaining, depression, and acceptance. Although originally created to describe the experience of terminally ill patients, this model can be applied to healthcare providers who daily deal with death. Kübler-Ross’ theory enables us to understand the emotions nurses, for example, may experience when caring for terminal patients, highlighting the importance of adequate psychological support to help them face the grieving process and the emotional adversities that arise in their occupation9.
Therefore, this study is justified by the importance of understanding the psychological impact of patients’ death on nurses since the latter play a central role in the direct care of terminally ill individuals. In hospitals, nursers are exposed the most to death and suffering. Moreover, continuous contact with human finitude can have significant consequences for nurses’ mental health10. Psychological exhaustion due to frequent contact with death can also compromise the quality of the provided care and, therefore, the integrity of nursing professionals11. Thus, investigating these impacts is essential for developing psychological and emotional support strategies to minimize these professionals’ suffering.
The creation of more humanized work environments that emotionally and psychologically support nurses can result in more empathetic and safe care, promoting the well-being of professionals and good-quality care. Thus, understanding the emotional challenges healthcare providers face in this context and proposing interventions to improve their management are essential for the well-being of professionals and for maintaining excellent care for terminal patients.
This research aims to investigate the psychological impacts healthcare providers endure in the process of patient death. More specifically, it aims to find the main factors contributing to the emotional exhaustion of nurses dealing with terminal patients, analyze the coping strategies these professionals most commonly use, and to identify the institutional and psychological support offered to healthcare providers during their practice.
The grieving and dying process in hospitals affects patients, their families, and healthcare providers, especially nurses, who remain on the front line of care. In this context, nursing requires the integration of technical competencies and relational skills, such as empathy and welcoming, which are fundamental in the care of terminally ill patients12.
The daily practice near the death process brings to light a series of often neglected emotional issues, which can lead to professionals’ psychic exhaustion and dehumanization. Understanding the impact of this context on healthcare providers is essential to ensure that they have adequate support and can continue to provide humanized and effective care13.
Overall, health courses scarcely address emotional training to deal with death. According to Moreira and collaborators14, most professionals report receiving inadequate training to deal with death in hospitals, which increases their vulnerability to psychological suffering. Faced with the death of a patient, these professionals face ethical, professional, and personal dilemmas that can generate feelings of helplessness, sadness, and frustration.
The lack of appropriate coping strategies and a space to discuss and understand these feelings contribute to stress accumulation, which often leads to mental illness and absenteeism. In this context, palliative care emerges as a positive approach for both terminally ill patients and the professionals who monitor them15.
Dadalto16 highlights that palliative care has human dignity and the suffering alleviation as its basic principles. Moreover, this approach should include the involved healthcare providers. By providing a more welcoming and humanized environment, palliative care helps professionals feel more prepared to deal with the process of death. However, to meet such end health institutions must implement support programs that encompass the technical and emotional dimensions of care.
Death, although natural and inevitable, remains a sensitive topic often avoided in health practice. In hospitals, physicians and nurses stand on the front line of care for terminal patients, putting them before emotionally intense situations that can profoundly impact their psychological well-being16.
The proximity to human finitude requires from professionals a balance between technical rationality and emotional sensitivity. This dichotomy often generates internal conflicts because, at the same time that effective professional performance is required, the pain of loss and the affective bond with patients become inevitable. Death exposes professionals to their own vulnerability, activating feelings such as fear, impotence, and sadness, which, if improperly addressed, can trigger psychological suffering9.
Academic training still lacks strategies that prepare physicians and nurses to cope with death. As Corradi points out17, many professionals report feeling unprepared to deal with death because they have received little or no training in palliative care and emotional support for patients and families.
According to the World Health Organization18, palliative care should also include care for professionals due to the psychological distress from continuous exposure to pain and death. Well-implemented processes provide a more humanized and welcoming environment for patients and healthcare professionals.
Moreover, the concept of “anticipatory grief” is relevant in this context. Such experience of grief prior to death often occurs in professionals who monitor patients in their terminal phase. According to Paczek19, anticipatory grief can generate chronic emotional distress, especially in professionals who lack listening and support spaces.
The absence of institutional support and spaces for collective reflection contributes to nurses’ mental illness. Emotional coping strategies, such as support groups, psychological supervision, and continuing education programs, have been shown to be effective in preventing emotional exhaustion. According to Maslach and Jackson20, burnout syndrome-characterized by emotional exhaustion, depersonalization, and low professional fulfillment-is frequent in healthcare providers, especially those recurrently exposed to death.
Method
This is a literature review developed in five stages: 1) definition of the research problem, data sources, search strategies, and eligibility criteria; 2) search and selection on databases; 3) identification, extraction, and organization of the selected sample; 4) categorization, integration, and critical evaluation of the findings; and 5) analysis and discussion of the results21. This methodological approach enables evaluate the object of this research from the perspective of several specialists on the subject. It may also bring relevant reflections on care practices to light. LILACS, Medline/PubMed, and SciELO were searched as they are reliable and extensive sources of the best journals in Latin America (Lilacs) and the world (Medline); as were Virtual Health Library and Google Scholar. The descriptors “impacto psicológico,” “luto,” “estresse ocupacional,” and “profissional de saúde,” were used according to the search criteria on each database.
After study selection, a critical review of the included articles was carried out. The studies were organized by year of publication and methodological characteristics. Then, information was collected from each article to assess the quality of the research and synthesize its main results, enabling a detailed analysis of the scientific production on the subject.
The review included all studies that met previously defined inclusion criteria: articles that explored the psychological dimension of healthcare providers in the face of patients’ death process with quantitative, qualitative, descriptive, experimental, quasi-experimental, or literature reviews designs that were published in Portuguese, English, or Spanish and were fully available online. Publications from 2019 to 2024 were considered given the scope of the topic.
Study selection took place in two stages. Firstly, titles and abstracts in the databases were screened to verify their relevance regarding the proposed theme and the inclusion criteria. Then, eligible articles were read in full to confirm their adequacy. Duplicates, articles the abstracts of which were their only available section, those with no full text access, and publications prior to 2019 were excluded. After applying the eligibility criteria, the selected articles composed the final sample of this review, being then analyzed for their methodological characteristics and main outcomes.
The selected articles were thoroughly read. Data were extracted based on the suggestions by the JBI Manual22. The following data were extracted: title; authorship; year of publication; study objectives; method; participant population; main outcomes of each article, and publication limitations.
Results and discussion
All articles consist of original research the main information of which is shown in Chart 1.
The chosen studies prove the complexity of the emotional and professional aspects nurses experience in the face of patients’ death. Gois, Abrão, and França23 found the need for a humanized approach based on health reflection and education, in line with what Garcia proposes24, which highlights that training in empathetic communication and palliative care is essential to promote more effective and respectful care at this time.
The lack of institutional training, as described by Dias, Pereira, and Finelli25, is a reality that was also identified in Hott and Reinaldo29, reinforcing the urgency of including disciplines focused on grief, terminality, and emotional support for professionals’ undergraduate nursing curricula. Training gaps are one of the factors that most negatively impact nurses’ performance, as in Silva30, who observed a significant increase in psychological distress in professionals who received neither support nor guidance.
Regarding terminality, Paczek and collaborators19 highlight the importance of multiprofessional and empathetic care, in line with Paiva’s findings31, who defend the valuing of active listening and patients’ autonomy in the final phase of their life. The integral approach was found to effectively minimize suffering and ensure dignity in the dying process.
Klaus and Baggio26 emphasize the prevalence of defense mechanisms such as denial and rationalization, which were also observed by Casellato32, as temporary strategies to cope with the impact of death that can develop into stress syndromes if not followed by adequate support. Communicating death was reported as one of the most distressing moments for nurses, corroborating previous studies on the emotional impact of conveying difficult news18.
In the neonatal sphere, Roco and collaborators27 observed a feeling of impotence and anguish in the face of the death of newborns, a result similar to that of Kolachi, Becker, and Crepaldi33, who pointed to the high emotional vulnerability of neonatal intensive care unit professionals. This requires specialized training and continuous institutional support, as Silva and Perez argue6, proposing systematic psychological monitoring as part of occupational well-being policies.
Almeida and collaborators28 add an essential clinical perspective by recognizing the diagnosis of terminal syndrome as a tool to guide palliative care. This finding is consistent with the approach in Silva34, which considers nurses’ clinical judgment essential for therapeutic planning and the guarantee of quality of care at the end of life.
Final considerations
The findings show that the care provided by healthcare providers (physicians and nurses) in the face of patient death demands more than technical skills, involving psychological aspects. These professionals require emotional training, institutional support, and appreciation of the human dimension of care. The emotions they experience, such as sadness, impotence, fear, and anguish, are crossed by contexts that involve poor training, absence of psychological support, and difficulties communicating death to patients and family members.
The literature consistently shows that specific training in palliative care, empathetic communication, and support for health teams can mitigate negative emotional impacts, contributing to more humane and assertive care. Moreover, institutional psychological support programs, case discussions, and collective listening are valuable strategies to preserve teams’ well-being and mental health.
Thus, it is essential to reassess the training model and care practices related to the death process. Valuing care humanization, promoting self-knowledge, and offering adequate support are fundamental for nurses to act with greater security, empathy, and competence in the face of the finiteness of life.
Data availability:
All data used or generated in this study are described and presented in full in the body of the article.
References
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