Table 7 Thematic Coding of Open Text Comments (N = 25)

Unique context of palliative care –

Meaningful, sustaining and impactful work with patients while also needing to advocate and fight for administrative, organizational, and political support to be able to provide optimal treatments, services and supports

“I find working in Palliative Care a double-edged sword. Positive: the most fulfilling, impactful work that I have ever done. Negative and Irony: The personal costs of this work is massive. Contributors: Having no control over treatment/admissions decisions, Timeline and Acuity of Patients, Current system and supports for patients (lacking), Stress/Burnout of Self/Colleagues, Empathic suffering. My connection, empathy, and caring with patients and families is what makes me great at my job, but unable to sustain it. These patients can be very sick, and the timelines are short, so reversal/treatment is urgent. I feel tremendous emotional distress when I am unable to get what I perceive to be to be the most appropriate or timely procedure/intervention/action for my patient. The impact for the patient can be huge, and I feel powerless, emotionally distressed” (P-8)

“I have read that the majority of burnout in Palliative Care Physicians comes not from the emotional toll our jobs take dealing with death and dying all the time but from the actual amount of work we have (increased number of complex patients, increased consult numbers, etc.) I find that is certainly true in my case and the cases of many of the physicians around me. Palliative Care definitely gives more immediate rewards and job satisfaction than (my other speciality), so I do not find the job itself increases burnout but the amount of work thrust upon me and the huge lack of resources and lack of Palliative Care Physicians in my province does contribute daily towards a feeling of burnout.” (P-14)

“what provides me with the biggest “stress” is the constant fight for palliative care and its value and the constant push towards medical assistance in dying at the expense of palliative care. There is a need for some of us to advocate for the survival of palliative care but the climate at this point in time is hard to handle. There also is a lack of “recognition” within the medical profession for the work that palliative care physicians do.” (P-10)

“The patients are uplifting, the administration not” (P-1)

“The most difficult part of the job isn’t the patients – it’s the politics and administration” (P-21)

Conflicts between caregivers and care providers

Conflicts as a result of other caregivers and care providers’ about the value and importance of palliative care

“personnellement, ce qui est. le plus difficile pour moi en soins palliatifs, et ce qui m’apporte le plus d’épuisement, est. la présence de conflits entre soignants face aux mythes et réticences encore présents envers les soins palliatifs” ^a (P-25)

“I am often exhausted due to the poor opinion other areas have of Palliative Care especially “rich” areas such as Oncology and Cardiology where we get to deal with their patients at the most difficult time … It is rarely the work or patients that wear me out. It is the bureaucratic fights such as double rooms, non-functioning air conditioners, no view for the patients, terrible mattresses etc. that I find very hard to deal with.” (P-2)

“Advocacy is one of my main roles, and it is a constant dance - trying to convince other physician subspecialty groups (with the power to make these decisions) to engage, act, treat …. during the day I will have threatened my physician-physician relationships by strongly advocating for my patients.” (P-8)

Experiences of stress, fatigue, burnout

Present & Past Experiences

of burnout

“I feel that PallCare is so protected compared to my previous speciality. It is hard to ever feel stress or burnout, as I know what that feels like in my Medicine world, rarely sleeping with 10–15 admissions a day.” (P-6)

“I feel extremely burned out from my Palliative Care work. I am very close to quitting Palliative Care entirely.” (P-8)

“Thanks for doing this. I am currently off work on stress leave due to professional burnout. Hoping I will be able to return but some things will need to change in the work environment.” (P-20)

“Very glad to participate in this survey as this has been a very real concern for me in my personal practice lately. I look forward to hearing the results of the survey.” (P-19)

“I want to comment that as a young physician working less than < 5 years total, my answers would have been drastically different one year ago when I burned out a couple of times in the first few years of practice. We do not learn how to practice resiliency and avoid burnout in medicine, let alone palliative care. We need to make this a focus for our new trainees as well as the current practicing physicians, who need to guide the trainees. I do not feel that I received any training on resiliency or burnout nor did I receive my institutional support when I burned out. I hope your study shows that even though burnout/resilience may be at the same rate as other physicians, as pall care physicians, we need to be able to support our colleagues.” (P-7)

“You didn’t ask if I had experienced burnout in the PAST-to my surprise, I did and learned a number of my palliative colleagues had as well.” (P-17)

“I did experience burnout in medical school, therefore learned to be resilient as I’ve progressed in my medical training and practice.” (P-3)

Resilience-building – supporting self, having very firm personal and professional boundaries

“This is very beautiful but also very brutal work. If we do not take the time to look after ourselves, in a real and meaningful way, this work will consume us … take the time to enjoy the happiness, love and sorrows in life is integral to living with purpose.” (P-5)

“I have found it necessary to have very firm personal and professional boundaries in order to protect my physical and mental health. I still feel stressed a few times per month by having to defend those boundaries against judgments and pressures from colleagues. It would be very helpful if there were enough staff to do the amount of work to which our palliative program has committed. As it is, the demands are often unreasonable, and the choice facing the physician is to say no and feel that they are judged as uncooperative or lazy; or to say yes and feel the health effects of working excessively. That atmosphere is very jading.” (P-11)

“Ma perception de stress et de fatigue évolue au fil d’une semaine de travail en soins palliatifs. Ça fait du bien d’avoir des congés, des pauses, afin de pouvoir être efficace, aidante et concentrée sur la tâche … Ma vie a totalement changé et je me sens nettement mieux; je n’aurais pas du tout répondu de la même façon à ce questionnaire il y a un an, étant sur le point d’un burn-out à ce moment.” ^b (P-24)

“… I perceive that my past failures (rather than my past successes) have provided me with more resilience, specifically, overcoming past failures.” (P-3)

Comments on survey in use of concepts, language and use of assessment tools

“There are ways in which these inventories may fail to (fully) capture the experience of palliative care physicians … Frequent exposure to dying patients in an education in how little control we have in our lives, but I don’t feel particularly distressed by this.” (P-4)

“The terms and concepts used fail to accept other belief systems, and use concepts that are foreign to my understanding of eastern spirituality and religion, potentially biasing your outcomes.” (P-9)