Burnout has been described as “the progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work” [2]. As many as one-half of clinicians report experiencing at least one of the three defining symptoms of burnout during their careers [3], which include exhaustion, a sense of professional ineffectiveness, and cynicism or depersonalization. The first symptom, exhaustion, is characterized not only by physical and mental fatigue but also emotional weariness. The second symptom, a loss of professional efficacy, refers to the perceived inability to meet one’s professional obligations, and may be linked to a chronic lack of resources or inadequate training. The third symptom, cynicism, refers to the emotional detachment or disengagement from patient care, often characterized by the loss of empathic connection with patients. These symptoms can manifest as behavioral changes that can significantly impact one’s work environment, listed in Table 19.1.

Conceptually, burnout is thought to arise from conflict between a clinician and his or her work environment [4]. Six key work-related factors have been identified that most significantly increase risk of burnout. These include an excessively large or intense workload, lack of control or autonomy, lack of recognition or reward, dissonance within one’s workplace culture or community, lack of a sense of fairness, and discordance with the values represented within one’s work environment that may lead to moral distress [4]. An individual clinician may prioritize these factors differently, and the extent to which they are discordant with one’s own priorities, needs, or capabilities informs the overall risk of burnout [2, 4].

While any combination of factors producing clinician–work environment mismatch can lead to burnout, the unique demands of caring for the seriously ill and dying in the hospital setting can potentially challenge many of these factors. For instance, providing care to seriously ill or dying patients can further impact already high volume workloads. In the care of the seriously ill or dying, the intense suffering that patients and families tend to experience during hospitalization for an acute crisis often demands increased resources from clinicians providing their care, including time and energy needed for careful communication, potential conflict resolution, the coordination of complex care, and often difficult decision-making [5]. Repeated encounters or a high volume of patients in crisis can tax a clinician’s endurance and ability to maintain high workloads and remain empathically engaged with his or her patients.

Clinicians may experience moral distress or discordant values with their institution or practice culture when trying to balance clinical care, costs, and the demands of efficiency. While this can arise in many different contexts, the provision of end-of-life care frequently stirs strong and disparate opinions even within the same health-care setting, and the burden of negotiating these differing views can result in a sense of compromising one’s own values. In one study of five hospitals, nearly one-half of all clinicians and 70% of house staff reported acting against their conscience in providing care to terminally ill patients [6].

The extent to which a work community provides support for clinicians facing these challenges may also impact burnout risk. For instance, some clinicians report that their practice setting or work culture may not permit the expression of strong emotions related to patient care or grief after the death of a patient [7]. For clinicians who value the support of their colleagues as a strategy for well-being, these community characteristics may generate feelings of isolation.

A fourth factor, sense of control, is also particularly relevant to challenges in providing end-of-life care. The care of seriously ill patients and their families frequently requires advanced skills in communication and symptom management that may not be available within a medical community’s or individual clinician’s resources. In many hospitals, palliative care is a new field with a set of specialized skills that may be of limited availability. Hospital-based clinicians without sufficient training in palliative medicine may feel a sense of helplessness, ineffectiveness, or loss of control in providing care to a suffering patient, especially without institutional support to seek opportunities for further training or access to other palliative care resources (including an interdisciplinary palliative care team).

Risk Factors for Burnout. While any clinician may be at risk for developing burnout, several individual characteristics have been associated with increased risk. Clinicians seem to be at higher risk earlier in their careers, with higher rates of burnout even among medical students and residents. Females seem to be at higher risk of developing burnout than males, although this finding is inconsistent across studies. Being single is an independent risk factor, with less burnout observed among married clinicians and those with children [5]. Certain personality traits may also predispose to burnout, including high levels of motivation and professional investment, an exaggerated sense of responsibility for others, and a tendency toward self-doubt or guilt [8]. In one qualitative study of 18 academic oncologists, it was observed that the cognitive framework with which a clinician approached his or her patients may also be linked to risk for burnout [9]. For example, those who viewed the medical care they provided in a biopsychosocial context experienced greater satisfaction in providing end-of-life care than colleagues who viewed their role in a purely biomedical context. The latter group tended to experience greater emotional distance from patients, as well as a sense of failure when a terminal course of illness could not be altered with medical interventions. Of note, data suggests that clinicians providing palliative care are not at increased risk and may even have lower rates of burnout than non-palliative care clinicians [10]. This may suggest that increased training and experience in managing end-of-life care may mitigate the risks of developing burnout.

Compassion Fatigue. Compassion fatigue, while related to burnout, is a distinct potential complication of providing care for the seriously ill or dying and was once termed the “cost of caring.” It has also been referred to as secondary trauma or vicarious traumatization. Whereas burnout is thought to arise specifically from one’s interaction with challenges or difficult-to-meet expectations within one’s work environment, compassion fatigue is conceptualized as the product of repeat exposure to the traumatic experiences or suffering of patients. The process of empathic engagement with others’ suffering leads to accumulated vicarious distress, and individuals with a greater empathic sensitivity may be at increased risk of developing compassion fatigue [11]. The symptom profile is similar to posttraumatic stress disorder: hypervigilance, involuntary reexperiencing of others’ reported or witnessed traumas, avoidance of situations or individuals that might invoke intense feelings or memories, and mood disturbance, such as depression or anxiety. Other reported symptoms include feelings of discouragement, emptiness, or having exhausted one’s emotional reserves. Najjar and colleagues [11], in their review of compassion fatigue among oncologists, suggested that given the high emotional engagement characteristic of caring for seriously ill patients, compassion fatigue may be an expected, rather than exceptional, occurrence that warrants acknowledgement, open discussion, and the institution of preventive measures where possible.

Clinician Grief. Most clinicians can recount experiences in which the death of a patient left a lasting impact. The role of clinician grief is a relatively new focus of investigation, and as yet, the prevalence and full impact of grief reactions among clinicians remain incompletely characterized [12]. Qualitative studies describing interviews with oncologists suggest high emotional intensity around the experience of patient death, particularly for close or more long-standing patient–clinician relationships, patients with children, challenging patients, long-term patients, and unexpected patient loss [7]. For many clinicians, the medical culture seems to place constraints on the expression of grief, influenced by social stigma of death, avoidance, concern that emotional expression may be perceived as weakness, and a prevailing focus on the goal of curing patients that precludes acknowledgement of death and dying. In studies characterizing the reactions of a dying patient among physicians, particularly for those earlier in their careers, the added burden of feelings of guilt, clinical uncertainty, and isolation were prominent themes that could further compound the experience of a patient’s death [13]. Insofar as grief can deplete emotional reserve, the accumulated loss of patients understandably can contribute to the development of clinician distress. Similarly, prevailing attitudes within a medical community or greater medical culture may conflict with an individual clinician’s need to express or process grief over the death of a patient, potentially increasing the risk of burnout.

Grief, of course, is not limited to the experience of a dying patient. Rather, the sorrow experienced by a clinician who suffers the loss of a loved one may be reignited upon encountering a dying patient or a similarly grieving family [1].

Consequences of Burnout, Compassion Fatigue, and Clinician Grief. The effects of burnout can be significant and far-reaching [3, 14]. Not only do clinicians with burnout experience increased emotional distress, when unmanaged they may also be at higher risk of developing more pervasive psychological disorders like depression, which increases the risk of suicidal ideation or suicide attempt [15]. Burnout may lead to poorer health behaviors, such as increased alcohol consumption, and may have an adverse interpersonal effect [3], leaving clinicians feeling too depleted to maintain investment in relationships with their friends or families. Those with compassion fatigue may be more likely to consume alcohol, engage in overeating, or experience exacerbations of physical ailments such as headache or other pain [11]. In terms of professional effects, burnout is linked to poor job satisfaction and increased employee turnover. Job performance may suffer, with evidence that burnout may lead to an increase in medical errors, poorer patient outcomes, and decreased patient satisfaction [14]. Research characterizing medical trainees with burnout also links the syndrome to compromised professional standards and a diminished sense of altruism [16]. These individual effects of burnout and compassion fatigue can negatively impact a health-care system as well, as reviewed by Wallace and colleagues [14], with associations of decreased productivity among clinicians with burnout, increased absenteeism or job turnover, or compromised morale of a medical community. Given the potential impact of burnout and compassion fatigue, prevention becomes an issue of not only personal well-being and job sustainability, but also one of professionalism and quality patient care.