Exploration of the psychological factors impacting confidence in, and comfort with, the delivery of end-of-life care

Part 1: Systematic Review Abstract Objective To explore the emotional experience of physicians in acute settings when encountering end-of-life conversations and decision making. Method Thematic Synthesis of qualitative studies. Medline, PsycINFO, PubMed, BNI, and CIAHL were searched from 1985 to 2021 for studies published in English. Data extraction was informed by a framework created for assessing methodological quality by Polanin, Pigott, Espelage, & Grotpeter (2019) and adapted by Draper et al. (2019). Results Of 8429 papers identified, 17 were selected for review. Two themes containing 10 sub-themes described the emotional and psychological factors impacting the experience of end-of-life care, namely: a tension between desire and ability to communicate end-of-life news, and a conflict of hiding versus revealing self across several practical and emotional contexts. Conclusion Medical training is only a minor factor influencing how well a person copes with end-of-life care and may sometimes feed negative appraisals. Lack of support from senior colleagues, fear of criticism and a sense of perceived failure were linked to lower self-efficacy in end-of-life care. Beyond learning practical skills, physicians benefit from understanding the psychological factors impacting their experience and in building self-efficacy and observing senior colleagues processing strong and difficult emotions effectively. Clinical Implications Promoting personal reflection and sharing of the experiences encountered in end-of-life care, especially modelled from senior colleagues, may contribute to improvements in competence and reduce the impact of heroism, feelings of failure, and avoidance in practice. Part 2: Empirical Study Abstract Objective To investigate whether fear of failure (FOF) influences a clinician's perception of their confidence and comfortableness with the delivery of end of life (EOL) care, controlling for gender, role, years of experience, and number of EOL conversations. Methods Cross-sectional questionnaire study, using the Performance Failure Appraisal Inventory, the Self-Efficacy in Palliative Care scale, the Thanatophobia Scale, and analysed using a two-step multiple regression. Recruitment was across two large NHS hospital trusts in the UK, and national UK professional networks. Results Participants included 104 doctors and 101 specialist nurses across 20 hospital specialties. The study validated the use of the PFAI and its subscales within a novel population. No. of EOL conversations, gender, and role impacted confidence and comfortableness with EOL care. Fearing loss of interest negatively impacted a clinician's confidence in communicating with patients. Fear of devaluing one's self-estimate negatively impacted confidence in decision-making, working with others, and self-efficacy. Conclusion Three aspects of FOF negatively impacted both doctors' and nurses' delivery of EOL care. Clinical Implications Further study should explore how FOF develops, sustaining factors, and other areas of clinical practice that FOF impacts, drawing also from FOF research outside the field of medicine. Techniques developed to manage FOF in other populations can now be investigated with a medical population.