Caring for People We Know: An Unrecognized Risk for Burnout?

Abstract

Background:

As the field of palliative care continues to grow, many clinicians will care for patients with whom they have personal connections. Breaching the boundary between a clinician's personal and professional life is potentially an unrecognized risk for burnout.

Objective:

We explored the challenges of caring for patients personally known to clinicians and the types of support needed, with a view to developing preliminary practice guidelines.

Design:

Focus groups.

Setting/Subjects:

Thirteen psychosocial oncology and palliative care clinicians who care for adult patients participated in one of two focus groups. Six participants were physicians, four were nurse practitioner/registered nurse/physician assistant (NP/RN/PAs), and three were psychosocial clinicians.

Measurement:

Using NVivo 12, we analyzed focus group transcripts from clinicians about their experiences caring for patients they know personally, the impact of such experiences, and the type of support and guidelines that could benefit clinicians in these unique situations.

Results:

Navigating boundaries and managing the psychological impact on the clinician, including fear of negative evaluation, increased anxiety and emotional exhaustion were the most challenging aspects of providing such care. Suggested guidelines include an early team meeting, a buddy system, a conversation guide to address the dual relationship, and embedded psychological support and mentorship.

Conclusions:

Feedback from clinicians identified preliminary guidelines that incorporate tools palliative care teams can use to improve support for clinicians caring for patients with whom they have a personal connection. These tools address the psychosocial aspects of care and have the potential to help clinicians feel a greater sense of control in these often, challenging and emotionally taxing situations.

Introduction

Clinicians working in psychosocial oncology and palliative care face a number of unique challenges, including navigating personal and professional boundaries with patients and their families during times of great distress.^1–4 As the field of palliative care continues to grow, many clinicians will be required to care for patients with whom they have personal connections as colleagues, friends, neighbors, and family members. Breaching the boundary between a clinician's personal and professional life in these situations might be an unrecognized risk for burnout.⁵ Unlike mental health clinicians who typically learn how to navigate boundaries during their training, medical providers receive less training about managing boundaries with their patients and the dilemmas that can arise when boundaries are crossed.^4,6 Ideally, clinicians would avoid caring for people they know but for those who work in specialized fields, such as psychosocial oncology and palliative care, this may not always be possible.⁵

The medical literature is limited in addressing the complexities of clinicians caring for those with whom they have personal connections, and there are few explicit guidelines about best practices in providing care for patients under these circumstances. Commentaries about the challenges of physicians “doctoring family members” or giving medical advice to relatives, offer some insight.^5,7,8 In addition, others have addressed the inherent difficulties of caring for patients who are physicians, suggesting guidelines, such as clarifying the patient–physician relationship, and discussing confidentiality and privacy, as early as possible.⁹ Lastly, there is the related topic of “VIP syndrome,” where clinicians caring for “very important people” who hold celebrity status, power, or perceived connections,^7,10 feel pressure to bend the rules by which they usually practice medicine, sometimes leading to moral distress and safety concerns.^11,12 Despite the various ways that boundaries can be crossed and potentially impact the delivery of care, very little research has engaged clinicians about this experience.

At Dana-Farber Cancer Institute (DFCI), the Divisions of Adult Psychosocial Oncology and Palliative Care are collaborating to address this issue, recognizing that the likelihood of caring for people with whom we have other relationships will increase over time. Psychosocial oncology and palliative care clinicians were invited to participate in one of two focus groups to explore their experiences of caring for patients with whom they have a personal connection. We sought their input about their experiences to develop preliminary practice guidelines that teams can implement when caring for a patient known to them or following the death of their own relative. We believe this is the first study of this kind.

Methods

Study design and participants

We conducted an exploratory qualitative study using focus groups with psychosocial and palliative care clinicians. Focus groups were selected as the data collection method to explore key concepts and dimensions of this understudied phenomenon, as they are ideal for facilitating idea generation and needs identification in a dynamic environment.^13–15 Two focus groups were conducted at DFCI in late February 2020 and early March 2020, just before the beginning of the COVID-19 pandemic. Eligible participants included clinicians from the Department of Psychosocial Oncology and Adult Palliative Care service. This study was part of a larger survey study on clinician wellbeing and burnout within our department. Participants taking part in this larger study were recruited by e-mail inviting them to complete a survey about wellbeing.

The invitation also included an option to participate in a focus group about their experiences of caring for patients with whom they have a personal connection, with the eventual goal of contributing to practice guidelines for use by teams. Considering the exploratory nature of the study and the time and resource requirements of the funding source, sampling was based on a convenience sample of clinicians working at our institute. Interested participants signed up for either focus group based on their availability. A handout outlining the elements of consent for participating in the focus groups was distributed at the beginning of each group and written consent was waivered. The Institutional Research Board (IRB) at DFCI approved this study.

Data collection

The research team iteratively developed a semistructured moderator's guide (Supplementary Appendix SA1) that prioritized open-ended questions exploring clinician experiences caring for individuals with whom they have a personal connection, the impact of such experiences, as well as resources and supports that could benefit clinicians as they navigate these unique care circumstances. The two focus groups were moderated by an experienced qualitative researcher (A.C.R.), and lasted 85 and 91 minutes, respectively. They were audiorecorded and professionally transcribed.

Data analysis

To balance the exploratory design with the more applied nature of the study, we used a multistaged analysis process that incorporated aspects of grounded theory as well as framework analysis.^15–19 The coding structure was iteratively developed and the final comprehensive coding structure included both prefigured and emergent codes. Axial coding, and mapping and interpretation (A.C.R.) focused on the identification of key dynamics, patterns, and relationships across and between coding categories.^15,20,21 NVivo 12 (QSR International) was used to support the coding and analysis, and each stage of the process was reviewed and discussed by two members of the research team (A.C.R. and S.E.M.).

Results

Thirteen clinicians participated in two focus groups, including six physicians, four nurse practitioner/registered nurse/physician assistant (NP/RN/PAs), and three psychosocial clinicians from psychology or social work. Participants across both groups identified a wide range of direct and indirect relationships that they had navigated in patient care, with two main types of existing relationships and connections to patients: (1) those patients with whom they had a personal relationship, and (2) those patients with whom they were connected through a colleague's relationship. Most of these relationships were known beforehand, but there were a few examples of participants being surprised by an unexpected relationship when they walked into the patient room. Below we discuss two primary dimensions of caring for a patient with whom the clinician has another relationship: the challenging aspects of these care dynamics, and the types of support that would help clinicians navigate these patient care situations, with recommendations for team guidelines. Table 1 outlines representative quotes.

Table 1.

Themes and Representative Quotes from Focus Groups

Theme	Representative quote
Challenging aspects of care
Boundaries, dual roles, with friends and family members	She got hospitalized and she was in the ED. I was with her and I ended up doing the code status discussion because the hospitalist came in, didn't introduce himself by name, was talking all jargon. Like this was not going to go well, and I was like well, I have the skills to do this, and in the moment stupidly decided to do it. And it was like in Star Wars where the Jedi used all of their energy to do—so they could move a mountain or a plane, a ship or something, and then they just disappear, and that was like me. I just used all my energy. And for three days afterwards, I was just toast because there's like—every single boundary was breached and I have absolutely nothing left.
Boundaries/dual roles/hierarchy	I was on service and ended up taking care of my minister's husband's mother. And there was something about having like the minister of my church in there while I'm trying to lead a family meeting and do counseling and like support. It was like—it was so wild, right? It's like upside down. I consider it different to take care of a colleague or a colleague's family member than to take care of somebody I know personally. I think there are different challenges to each of those things. I think one of the things about taking care of a colleague's family member or a colleague is they have access to you in a way that patients don't usually, and I find that challenging to navigate. So I've taken care of people who have my cell phone number, who text me. And that's—I don't give my cell phone number out to my patients. I had a situation in my first year or two here where I ended up taking care of one of my professors from graduate school. And so, all of my other professors were coming in and spending time at the bedside, and I was doing psychosocial work with someone who had been a mentor to me and there—I feel like each of these categories comes with its own challenges. I've worked with nurses in this hospital who then have had family members that have been hospitalized. And some of them I've known before I kind of went into the room that they were related to somebody that I had a work connection with, and some of them I haven't known. So I think it's … just always kind of a factor in your mind. Like it's hard. It makes it harder to kind of remove yourself and think like what would I do for any other person or any other encounter that didn't have this extra layer of kind of I guess pressure…. My own experience is that I go into patient rooms … with a persona, which is Dr. XX, and then I'll ask them to call me (my first name). But there's my professional persona, which is not the full totality of who I am in the world. And when there is a personal connection, more of that other stuff comes in, and my ability to kind of manage what it is I'm showing to that person or not, like it's harder to manage that.
Need to debrief/inability to debrief	We took care of the mother of a physician who we all work with quite closely—and it turns out we learn in the process of caring for this mother that the family has like deep dysfunction. There was like substance abuse, that there's like estrangement, that there's personality issues, like really—and we—I needed to talk about that. I couldn't just carry this kind of on my own. I had a similar thought to xxxx's point (above) in that typically I would go back to my team and talk a lot with my team about that, but especially when we're taking care of colleagues, it feels like a much finer line. Because as a social worker, I get a ton of very private social information from people, a lot of emotional and complicated family dynamics, things that even if people know I'm taking care of someone would still feel very precious and raw to share with their colleagues. And that kind of stuff I would normally take back to my team if it were just a (regular) patient. And so, I find myself holding some of the deeper kind of emotional psychosocial issues on my own in a way that I would be sharing otherwise with people. And so, I think that's another component that's different. We shouldn't know who she's talking about, right (colleague's relative)? But it's actually relevant to the experience, right? So she's trying to give the right level of detail so that we can understand what the experience was without like breaking HIPAA, right? So that's a really hard thing to actually do. And it's hard because we rely on each other so much to get ourselves through the day, right? Like we have to be able—I have to go—be able to go cry to (name), … or just say like today is a really hard day. I have no idea what to do. And be able to do that without breaking those boundaries.
Increased stress, anxiety, and checking behavior	I've had a couple of experiences on the inpatient side where it's not necessarily a close colleague, but it's another physician…. (one) who's more senior to me—and to me, I get this extra voice in my head being like is that the right opioid conversion? Are you doing the right thing? Is this the right communication skill to use now? And it's just this like added pressure that I don't think is actually there, and I think my opioid conversions are fine. But it's almost like “oh, am I messing this up?” “Am I doing this right?” And I try to do what a lot of is just kind of like “let that go,” but it's tough.
Impact on clinician
Balance, lack of control	And so, there was a way that I went from being a clinician who was very worried about a patient I hadn't met, and already had this kind of fear for this nameless, faceless person, and then it was my neighbor who knew my dog that was really unsettling. Like I really lost my balance and was so distracted by that that it actually was hard for me to kind of—I was already having to work to keep my balance just in the clinical scenario, and then this added kind of personal connection really threw me off my game for like the first—I don't know—five minutes or more of the encounter, just trying to navigate that.
Self-doubt and criticism	I am kind of like harder on myself when it comes to like if I'm calculating a medication or if I'm making a recommendation, I am thinking about it more than I normally would. And then trying to say “okay, don't think about this more than you normally would, because that's treating it differently”—so, it's like that tension internally of trying to do my best job, but not go anymore into it.
Vicarious trauma	I think especially with people (we know), that there's a more—like the boundary is harder, that you keep yourself, and that to—it's like you're not keeping yourself and the person as distant. There's not that professional armor that you can put on in the same way…. I think we get so used to it, but we are like in a warzone every day. It's like I do think there's something about trauma that happens in this work that we underestimate, that we under-address.
Increased tiredness, exhaustion, stress, and emotional intensity	… how much more tired you feel, even if you're doing the same amount of work, the hours. It is just a different fatigue that comes with it that I didn't expect necessarily. Right now, I'm caring for a physician's wife who's incredibly ill, and it just—it's this emotional intensity that you carry home with you because from a hierarchy standpoint, you're at a different level, and you're trying to provide superior care because of who they are, and it just—I think I noticed that it impacts both my other patient care and that I'm spent by the time I get to my other patients, but then also creates almost a lack of empathy in other aspects of my life so that I get home and my 3-year-old is like I don't want peanut butter—nuts in my peanut butter on my toast, and I'm like are you kidding me? Like I'm taking care of somebody who's dying and you don't want chunky peanut butter?
Impostor syndrome	(When there is a personal connection)…sometimes it triggers a sense of am I good enough? So whatever impostor syndrome we all have I think can really flare in these times.
Fear of negative evaluation	I ended up seeing a relative … of a very high up clinician here. And I just remember that encounter and how I felt afterwards. I just felt really stretched throughout that entire encounter. I just felt like I was trying to perform at 110 percent. And especially as a young attending, you want to make the best impression because you know it's going to get back to that individual, like how you encounter that person. And so, I just felt like I was throwing everything into that sort of encounter and by the end of it, I just felt pretty spent.
Having “secret” knowledge	The night before she was going to start her bone marrow transplant workup, we all went out to dinner. And I found out that afternoon that she had relapsed and would not have the transplant. So at dinner, I was the only one who knew that … and it was—that was hard. That was the hardest of it, sitting there having knowledge that nobody else had.
Supports
Space to reflect	So, I would say the idea of having some observing distance or some ability to watch what's happening and monitor what's going on in yourself … I think that's why I get so tired afterward is because I'm both in the moment, trying to be very present and connected, and I'm doing a lot of managing my own reactions and sort of watching them and making sure that I'm achieving that balancing between all of those different factors that I was describing before. So, the practice that I've gained over years—I've been doing this for almost 15 years—is this idea of being less immediately reactive to whatever is happening in the moment, whether it's like pressure being exerted or the feeling of impostor syndrome or whatever it is, not kind of rushing to it and having to react to it right away, but to have a little bit of space in between that and my own stuff. I have always felt like after a certain amount of time doing this work, whether it's five years, whether it's ten years, that we should have the option of a sabbatical.
“Office hours”—opportunity to speak to a colleague who is a mental health professional	I wonder if something like office hours for certain people who wanted to do that role and be there as support or something like that where it could just be you knew that—if I knew that (psychologist) was available from 12:00 to 5:00 on Mondays, I might drop in and say hey, can I chat with you? I like the idea of having access to someone like a mental health professional, so like a social worker or psychologist or psychiatrist, probably one of the first two, who—so for example, our department chair has office hours where anybody can just stop by. We also have a chaplain that works with our team that has a lot of wisdom and—but he's split between our group—he's 50 per cent with our group and 50 percent with xxx group. And we need him full-time….He was a priest for many years. He is accustomed to being in the role of like—of ministering, and that—and he sees his role as not just being for patients and families, but also for being for clinicians and teams…
Promote a culture that normalizes the vulnerability of what we do	I would also say normalizing. We work in a culture where vulnerability is not the thing people lead with. And I think a lot of these situations are vulnerable to talk about the impact of something on you, and it's very hard to figure out what's—where the safety is in that, in this culture, and it's—I find that really challenging. The work we do, what we do is so vulnerable.
Team-based support	We had that one session that was helpful where everybody was .… There were probably 20 people in the group, and it went for an hour and people were talking about different ideas. But that was the first time I had ever been exposed to the—and you could tell that everybody in the room was like nodding and like “oh, yeah, this happened to me.” And so, it's just like raising awareness in that way, like everybody left the room being—feeling relieved and thankful and emotional that they'd been there. We have weekly rounds with a psychiatrist talking about difficult cases, and one of those a month is how we as clinicians are affected by the work. So—and both formats can be helpful. We have a Remembrance weekly, which is half an hour when we think about the patients who have died and if there's an issue like this in that—in those patient situations, we have a forum to talk about it and receive support from our colleagues.
Guidelines and principles	I like the idea of guidelines … the idea that we have principles in place that help us, that kind of reinforce the idea that these cases need particular thought and perhaps a particular approach, that seems like a great idea to me, especially because I think where we get in trouble is where we—when we don't have a set of principles and we're just kind of in the middle of it guessing …. I think it's the feeling of like having the lighthouse or something that helps us kind of figure out again, “okay, this is a safe direction to go in. That sounds good to me.” There's guidelines and there's culture, and you need both in order for somebody (mental health professional) like this to be successful, but it's just a matter of thinking about what kind of comes first. Like do the guidelines come first, and that changes the culture, or do you try to have somebody available and have a buddy system and does that change the culture, which then facilitates guidelines? I don't know. Probably both at the same time. I think one thing that our team has done when we've taken care of people we know through work is to talk as a team about the boundary setting piece, and that has been helpful I think for all of us, because whatever people's individual impulses might be, there is a sense about how we will approach things together, and that that has been useful in certain cases where that's been needed. My initial reaction is no, because guidelines put everybody in the same way. We're not all the same way. We all have different styles. We're all bringing a different self to the bedside. And nobody follows them anyway. I think there are guidelines that are constraining and ultimately ineffective, and then there are also ways of putting in place guidelines that can feel supportive and can be there to allow us to sort of systematize a way of having some flexibility around the tough cases. So whether it's to be able to say you know what? This is too much for me. Or I've been on service three weeks in a row. I've cared for this family. I can't do it anymore. And like there's institutional support, departmental support to say I am going to hand this off to someone else, or like this is my backup. A way of saying so that we don't feel—I mean, it's putting ourselves out there to say like I feel vulnerable in this case and I need help. But I think if there are supports in place and it's just made clear, like when we deal with one of these cases, we're all going to get a backup or we're all going to debrief it in a way that is like process improvement so we're HIPAA protecting—whatever it is as a way of sort of building in that support, I think it could be helpful.

ED, emergency department; HIPAA, Health Insurance and Portability Accountability Act.

Challenging aspects of care

In recounting their experiences caring for individuals with whom they had an established relationship or connection, participants identified and discussed various difficult and complex aspects of these care situations and the impact on them (Table 1). Overall, caring for these patients was recognized as challenging because it took more emotional work to simultaneously navigate the complexities of the medical issues and personal issues. Having a relationship or connection with a patient was described as amplifying the already difficult and complex aspects of their jobs, making it a “loaded” situation and a “heavier lift.”

Dual relationships and blurred boundaries

Personal relationships were the most frequently discussed type of connection to patients, and included a broad range of connections with family friends, friends, professors, relatives, neighbors/community members, and coworkers. These relationships varied in terms of depth and strength of the connections, ranging from a relative's child to a friend's spouse, to an acquaintance from the neighborhood. Across these relationships, there were varying levels of involvement. Some participants cared for these patients directly, while others described less formal or indirect involvement in their care. For example, a few participants described becoming the de facto medical person within their family, and another noted that when a family member was sick and being taking care of by colleagues, this also can create a complicated dynamic regarding navigating boundaries.

Colleagues' relationships were most often family members, including spouses and in-laws. A unique aspect of caring for a colleague's relative, however, was when participants had to consider the workplace hierarchy with the colleague whose family member needed care. There was recognition by some that caring for the relative or loved one of a “higher-up” introduced additional complexities, often exacerbating the challenges associated with fear of negative evaluation, impostor syndrome, or providing appropriate care.

Clinicians found themselves having to constantly create, navigate, and monitor these shifting relationships and boundaries. While all patient relationships can introduce challenges, most clinicians acknowledged that caring for a person with whom there was a relationship or connection presented its own challenges. While some participants said that they usually feel relatively confident and comfortable presenting their “professional self” in a regular patient care setting, when a patient is known to them in some way, their ability to control and manage who or what they present to the patient becomes more difficult. The patient would often know about their personal life or have access to them in ways that “regular” patients did not. The clinicians did not have the ability to easily remove themselves from the relationship, and even felt added pressure to provide excellent care, all of which required increased energy and work. It was also recognized that the ongoing relationships with these patients added a layer of complexity.

Clinicians described having to navigate the reality that the relationship would not simply end once the medical relationship was over or the patient was discharged. Clinicians had to traverse multiple roles and dynamics, providing medical care and personal care simultaneously. Additionally, becoming intimately involved with a colleague's family, exposed vulnerabilities, and made it difficult to discuss the cases with colleagues, “I get a ton of very private social information…And that kind of stuff I would normally take back to my team if it were just a (regular) patient.”

There could be, however, positive aspects of caring for patients with whom clinicians had a prior connection. A few participants across both groups asserted that taking care of these patients was especially rewarding and meaningful, and appreciated by the family or colleague, “The toll is very high… it can be kind of high reward” and “it was just a lot of extra work, but it was really rewarding.”

Impact on clinicians

The impact of providing care for individuals known to clinicians included a range of psychological constructs and patterns of behavior, such as: fear of negative evaluation; impostor syndrome; increased stress; heightened anxiety; increased checking behavior of routine medical procedures; uncertainty; vicarious trauma; emotional exhaustion; lack of ability to debrief with colleagues due to privacy concerns; lack of control; and having “secret” knowledge about the diagnosis or illness trajectory.

Participants described being harder on themselves and often questioned their competency in providing the right type and right amount of care. A few participants noted that the high emotional burden of caring for patients with whom they have an existing connection could result in reduced capacity to give emotional energy to other patients later in the day, “you sometimes feel like you've given so much to that patient or to that situation, you just have nothing left to give to other people.” There was also an acknowledgment that relationships change after providing care to someone known to you, “I was asked to see somebody… that had a power dynamic, … it was a totally different role. And I was able to do my job and be able to bring all the skills in order to help, while also understanding that the relationship was forever altered.” Finally, there was acknowledgment of the existential toll of doing this work, “Somehow when the boundaries are a little blurrier with your own family or with patients that you know, there's like this loneliness … the existential loneliness of the fact that people die and you can't fix it.”

Types of support needed

The participants were also asked about the existing support they currently use in their work and their ideas of the types of support they believed necessary when caring for patients with whom there is a personal connection.

Existing support

Team-based support and having the opportunity to speak with another person about their experience were the most frequently identified beneficial types of support that participants currently utilized. Some participants also spoke of the value of structured group sessions or reflection rounds, such as Remembrance,²² where deceased patients are discussed each week. Several participants highlighted the unique benefit of having a close and supportive team, especially because they realized that this was not necessarily the norm for medical teams. Their team offered a sense of belonging and provided a place to turn for help and guidance, and to debrief, normalizing the need to discuss issues and seek help. “Our palliative care group tends to be fairly self-reflective and we do a lot of thinking about … the psychological dynamics at play in a way that I think a lot of medical teams don't.”

A few noted that having a psychologist or a chaplain available was especially helpful, with some also recalling how helpful it was to have structured support in their training programs. It was also acknowledged that having someone familiar with their experience, such as a mentor, could be beneficial, as it was difficult to bring the experiences home to your family, where people just did not or could not understand.

Additional support needed

Participants identified several types of support they believed were necessary but often lacking when caring for patients known to them. These included: team support; debriefing; intentional switching of patients or transferring care; structured check-ins; guidelines to discuss rules of engagement with the patient, including how to acknowledge the prior connection; a buddy system for clinicians providing care similar to the double-check done when administering chemotherapy; an embedded psychosocial clinician to offer guidance, support, and a confidential place to debrief; role modeling of self-care, boundary setting and asking for help from senior clinicians; and real-time mentorship by clinicians who have previously been in this situation. “I wonder if something like office hours for certain people who wanted to do that role and be there as support … if I knew that (psychologist) was available from 12:00 to 5:00 on Mondays, I might drop in and say hey, can I chat with you?” There was also discussion around needing to have protected time and space to be able to debrief with colleagues without feeling guilty for doing so and incorporating a sabbatical to allow clinicians to get away to come back and continue to love their work.

Guidelines

In relation to developing guidelines, the participants emphasized the need for guidelines to be flexible given the range of potential scenarios and varying personalities and experience of providers. There were somewhat mixed views on the creation of guidelines for circumstances in which the provider had an established connection to a patient. A few participants at first, had a very strong initial “no” reaction, but overall, guidelines were seen as potentially beneficial, as long as they were not too prescriptive or rigid. Guidelines that were flexible, helped provide options or reinforced a particular approach, were recognized as having the potential to be helpful. “It's not that it's dictated how people respond to these things, but it's dictated that these (things) should be like flagged—so if we're taking care of a colleague, there should be a conversation at the beginning of the week saying okay, let's watch for this, let's think about this…Let's make sure it continues to be a conversation.”

Discussion

The findings from this exploratory study highlight the challenges clinicians face when caring for seriously ill patients with whom they have a prior connection of some kind. Whether the patient is a relative of a friend, an acquaintance, or the relative of a colleague, such dual relationships create blurred boundaries that tend to amplify the already difficult aspects of caring for seriously ill and dying people. It seems likely that as the population ages, more and more clinicians, especially those in smaller communities, will care for patients with whom they have a prior relationship or connection.⁵ Given that emotional exhaustion is a factor believed to contribute to burnout,²³ caring for patients with a personal connection is potentially an unrecognized risk for burnout.⁵ Adopting a preventive stance, we as a field should start to address this issue now, both in clinical practice and medical training.

Unlike the delivery of mental health care where there are clear guidelines and regulations stating that a clinician should refrain from treating a person known to them (e.g., The American Psychological Association, www.apa.org/ethics/code), the delivery of medical care is less clear. In serious illness and end-of-life care, where teams are often small and specialized, creating a confidential space to discuss these challenges and provide instruction and guidance for care can help clinicians and teams feel a greater sense of control. Just as with any complex medical case, navigating challenging dynamics, having difficult conversations, and developing a plan, are tools within the palliative care clinician's toolbox. The aim is to apply some of these same tools that are used in our everyday care of patients, to situations involving the care of patients known to us. These tools, which predominantly address the psychosocial aspects of care, include “naming the dilemma” in reference to the dual relationship, and ensuring a safe space to talk or debrief about these challenging issues either as a team or with a psychosocial clinician, while adopting the motto that “no-one should have to worry alone.”

In situations where boundaries are blurred, guidelines provide a structure and have the potential not only to improve the care of the patient and family, but also the care of the providers. Our previous work referencing lower rates of burnout in psychosocial oncology clinicians, highlights the benefit of individual and team debriefing, supervision, and self-reflection,²⁴ which can be incorporated into any set of guidelines.

Based on the findings of this study, we propose the following preliminary guidelines for teams to consider in their practice. Ideally these guidelines offer a starting point for teams to adapt to their own specific organization, allowing for flexibility as needed.

Team meeting on initial outpatient visit or by hospital admission day 3, accounting for weekend admissions, to discuss boundaries, team approach and any other concerns about the treatment of the patient and care of the family.

Create a buddy system for primary providers, in which each clinician has an identified colleague to rely on in patient encounters that involve challenges with professional boundaries.

Develop and pilot test a conversation guide for clinicians to use to address the dual relationship with the patient.

Embed a psychosocial clinician to offer confidential support and debriefing for the team and individual providers.

Provide real-time mentorship by clinicians who have significant experience navigating these complex relationships.

Limitations

The main limitations of this study relate to the small sample size of psychosocial oncology and palliative care clinicians who care for adult patients, and it being a convenience sample from a large academic institution. As such, transferability of the findings to smaller teams or providers of pediatric patients may be limited. In addition, because participants agreed to take part in both the larger research study, as well as the focus groups described herein, there may be some self-selection bias, in which participants had a vested interest, or in-depth experience navigating these challenging relationships. Recruiting broader and additional diverse perspectives in future studies will broaden our understanding of how other clinical teams or hospital systems approach boundary issues.

Conclusions

This study explores the challenges that psychosocial oncology and palliative care clinicians face when caring for seriously ill patients with whom they have a personal connection. Feedback from clinicians identified several challenging aspects of delivering such care, including navigating blurred boundaries with patients and families, and the psychological impact on the clinician themselves, such as fear of negative evaluation, emotional exhaustion, and increased stress and anxiety. Given that clinicians outside of mental health receive little training in managing boundaries with their patients, we propose preliminary practice guidelines for teams to consider when caring for patients personally known to them to not only improve patient care but also the wellbeing of clinicians.

Footnotes

Authors' Contributions

All authors contributed to the conception and design of the work.

Dr. Revette facilitated the focus groups and was responsible for the acquisition, analysis, and interpretation of data. Dr. Morris contributed to the interpretation of the results.

Drs. Morris and Revette were primarily responsible for the preparation of the article for submission. All authors reviewed the final draft of the article.

Acknowledgment

The authors thank the clinicians who participated in the focus groups and freely shared their ideas.

Funding Information

Brigham and Women's Physicians Organization's (BWPO's) B-Well Grant Program FY 2020; Subaward from the Department of Medicine.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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