Terminal versus non-terminal care in physician burnout: the role of decision-making processes and attitudes to death

Abstract

Introduction Physicians are often overloaded with high demands of patient care in an environment where organizational resources are frequently scarce, leading to occupational stress and physician burnout. When physicians suffer from these disorders, the potential negative influence on patient care is likely to be much greater and they are more prone to make errors of judgment in decision–making processes. Some authors have proposed that physicians perceive decision–making as the main stressor, especially in chronic and terminal care. Caring for the dying is a remarkably stressful work. Many physicians feel helpless in the face of a patient's struggle with terminal illness. In this context, some questions arise: What is the interplay role of attitudes to death in decision–making processes in physicians' suffering from burnout? Are there any differences according to attitudes to death, target patients (i.e., terminal patients), or the classic sociodemographic variables? To what extent? This study has attempted to examine these differences in the burnout process in physicians attending adult patients versus children, and terminal versus non–terminal cases, considering also the decision–making process and physicians' attitudes to death; to determine the core personal variables implied in this process, and to identify educational opportunities to improve physicians' well–being. Method A total of 130 physicians working in six general hospitals and two health centers in downtown Madrid completed and returned the questionnaire (response rate 72.2%). The sample resembles the overall area population in age distribution as well as in health status and sociodemographic characteristics. Participation was voluntary and anonymous; no incentives were offered to participants. Results Results suggested that the effects of burnout have more to do with chronic and terminal care than with the classic sociodemographic variables. Among the univariate tests for the first criterion variable doctors attending child versus adult patients, only avoidance of death was significantly higher in pediatricians. Univariate tests for scores of physicians working with terminal versus non–terminal patients (the second criterion variable) revealed significant effects for two of the ten variables. Physicians who attended terminal patients had higher exhaustion scores and lower scores in acceptance of death. Taking together both criterion variables, pediatricians' self–reports revealed significantly lower acceptance of death scores in the terminal care condition, whereas physicians working with adult patients had a significantly higher fear of choice scores in the terminal care condition. Additionally, through hierarchical regression analyses, anxiety about the decision–making process was the main precursor of burnout, controlling for age, gender and terminal versus non–terminal care of child versus adult patients. Attitudes to death, that is, acceptance or avoidance of death, were revealed as moderators of the relationship between decision–making processes and burnout. Conclusions Findings are discussed concerning the burnout process and the need for educational interventions in death and communication. The results were in keeping with the contention that, during explorations of career choice and even in the admission process, understanding of what the helping role implies should be increased, and the personal variables that are necessary to increase physicians' performance and well–being should be explicitly identified.