Healthcare professionals working in palliative care repeatedly encounter suffering, dying, and death; nurses, physicians, social workers, physiotherapists, dietitians, and allied health professionals must remain clinically engaged while continuously confronting treatment limits and human mortality (Lifshits et al. Reference Lifshits, Agbaria and Sawaed2025; Freeman Reference Freeman2017; Emanuel and Emanuel Reference Emanuel and Emanuel1998). Sustained exposure to these experiences contributes to burnout, compassion fatigue, moral distress, and reduced well-being (Wong et al. Reference Wong, Broom and Kirby2020; Gustafsson and Hemberg Reference Gustafsson and Hemberg2021; Campos i Arnal et al. Reference Campos I Arnal, Galiana and Sánchez-ruiz2024). However, conventional models of occupational stress do not fully capture how clinicians psychologically adapt to repeated mortality encounters – nor why those experiencing the highest burden are often the least likely to seek support.
Existing approaches to clinician well-being primarily emphasize workload, emotional exhaustion, organizational stress, and individual resilience. While essential, these factors overlook a critical dimension: the existential meaning of mortality itself. Recognizing personal vulnerability can be uniquely difficult for professionals whose daily work requires standing at the boundary between life and death.
Terror management theory (TMT) provides a compelling framework for understanding this dynamic. TMT posits that awareness of mortality generates existential anxiety, which individuals manage through psychological defenses that protect self-esteem, meaning, identity, and security (El-Ashry et al. Reference El-ashry, Abdallah and Elsayed2025; Greenberg et al. Reference Greenberg, Pyszczynski, Solomon and Baumeister1986; Solomon et al. Reference Solomon, Greenberg, Pyszczynski, Greenberg, Koole and Pyszczynski2004). In palliative settings, constant encounters with dying patients create persistent mortality salience (Kraitenberger et al. Reference Kraitenberger, Goldzweig and Aviv2021; Zdziarski et al. Reference Zdziarski, Zabielska and Karakiewicz-krawczyk2025). Clinicians must therefore regulate not only the complex clinical demands of end-of-life care but also their own underlying responses to human mortality.
This dynamic gives rise to the avoidance paradox term: the very psychological defenses that enable clinicians to function in the presence of death can, under sustained conditions, suppress their willingness to acknowledge personal distress or seek psychological support.
Mortality, defense, and the avoidance paradox
TMT distinguishes between proximal defenses (which directly eliminate death-related thoughts from conscious awareness) and distal defenses (which indirectly buffer mortality anxiety by bolstering self-esteem, cultural worldviews, and professional identity) (Greenberg et al. Reference Greenberg, Pyszczynski, Solomon and Baumeister1986; Solomon et al. Reference Solomon, Greenberg, Pyszczynski, Greenberg, Koole and Pyszczynski2004). In clinical practice, repeated exposure to death encourages reliance on proximal and distal strategies alike – such as emotional withdrawal, intellectualization, suppression, and professional distancing (Black Reference Black2007; Wong et al. Reference Wong, Broom and Kirby2020; Omoya et al. Reference Omoya, De Bellis and Breaden2022; Harnischfeger et al. Reference Harnischfeger, Rath and Alt-epping2023).
Crucially, emotional distance is not inherently maladaptive. Clinicians cannot remain fully emotionally immersed in every patient death and continue to function effectively. Establishing a temporary emotional boundary can be an essential coping mechanism, allowing professionals to remain focused and clinically effective during emotionally demanding situations. The paradox emerges when this initially adaptive strategy becomes persistent and rigid, transforming a protective boundary into a barrier that prevents clinicians from recognizing their own distress, processing difficult experiences, or seeking support when needed.
This creates a tension between functioning effectively and remaining emotionally accessible to oneself. A clinician may continue to provide high-quality care while becoming increasingly disconnected from their own emotional experiences. Although suppressing emotions may provide immediate relief, it can limit opportunities for meaningful emotional processing and recovery. As a result, the clinician may appear resilient on the outside while becoming increasingly isolated on the inside. Healthcare staff’s professional identity may further reinforce this barrier.
Admitting distress or seeking help can be unconsciously processed as a threat to professional competence or self-esteem – the very distal defense buffering mortality anxiety. Research confirms that clinicians’ personal attitudes toward death and death anxiety directly shape their communication and coping behaviors at the end of life (Ablett and Jones Reference Ablett and Jones2007; Harnischfeger et al. Reference Harnischfeger, Rath and Alt-epping2023).
The avoidance paradox suggests that clinicians experiencing significant mortality-related distress may be less likely to recognize their own need for support or to seek it voluntarily (Davis et al. Reference Davis, Serfaty and Low2023). Rather than becoming more visible to support systems, they may become increasingly reliant on defensive strategies that limit emotional disclosure and help-seeking. Avoidance of support should therefore not be interpreted as an absence of need; it may instead represent a protective mechanism that has become counterproductive.
Recognizing this distinction reshapes how clinician resilience is conceptualized. Resilience cannot be reduced to the ability to continue working without visible impairment. Rather, it should encompass psychological flexibility: the capacity to maintain appropriate clinical boundaries while remaining aware of personal vulnerability, process difficult experiences, and access support without experiencing help-seeking as a threat to professional identity.
This dynamic spans the entire interdisciplinary team. Dietitians navigating artificial nutrition, physiotherapists managing declining mobility, social workers supporting grieving families, and physicians and nurses directing end-of-life transitions each encounter mortality through different responsibilities (Wu et al. Reference Wu, Chen and Ho2021; Farrer and Tieman Reference Farrer and Tieman2024). Treating clinicians as a uniform workforce masks distinct nuances in how different disciplines process mortality and vulnerability.
Healthcare organizations as external distal defenses
Clinicians do not experience death in a vacuum; they encounter it within clinical teams, professional hierarchies, and organizational systems. Extending TMT beyond individual psychology suggests that healthcare organizations may function as an external distal defense system. While organizations do not possess psychological defenses in the human sense, their structures and cultures can provide external conditions that reinforce meaning, belonging, predictability, professional competence, and shared responsibility.
A cohesive interdisciplinary team can distribute the psychological burden (Cottrell and Duggleby Reference Cottrell and Duggleby2016) of a patient’s death across multiple professionals rather than leaving an individual clinician to confront it alone. Clear clinical pathways, open interprofessional communication, and collaborative decision-making can reinforce professional identity and collective responsibility, potentially buffering clinicians against some of the psychological consequences of repeated mortality exposure.
Conversely, organizational dysfunction may weaken this protective buffer. Integrated palliative care systems characterized by clear communication and coordinated responsibilities may provide clinicians with greater opportunities for shared meaning and collective coping (Bentur et al. Reference Bentur, Emanuel and Cherney2012; Tripodoro et al. Reference Tripodoro, López Fidalgo and Pons2025). In under-resourced or fragmented settings, clinicians may face both heightened mortality salience and moral distress, particularly when they recognize the care they believe should be provided but encounter institutional barriers to delivering it (Tsao et al. Reference Tsao, Slater and Doyle2019; Awny et al. Reference Awny, Al-touny and Gaafar2022). When organizational structures fail to provide adequate support, meaning, or shared responsibility, clinicians may become increasingly dependent on individual defensive strategies to manage mortality-related distress.
Resilience, therefore, may be understood not merely as an individual trait but as a relational and organizational process. A clinician’s psychological adaptation to mortality is shaped not only by individual coping mechanisms but also by the organizational environment in which end-of-life care is delivered.
From voluntary help-seeking to embedded support
The avoidance paradox exposes a potential limitation of traditional occupational well-being programs: their reliance on voluntary engagement. If mortality-related defenses suppress help-seeking and emotional disclosure, support systems that require distressed clinicians to recognize their own need and initiate contact may fail to reach those who need support most.
Palliative care organizations should therefore move beyond reactive, voluntary support and embed opportunities for psychological reflection within routine clinical practice. For example, they could integrate multidisciplinary debriefing. Organizations can incorporate interprofessional reflection and debriefing into regular clinical workflows (Freeman Reference Freeman2017; Farrer and Tieman Reference Farrer and Tieman2024). Making reflective space a routine component of practice can reduce the stigma associated with identifying oneself as unable to cope and frame reflection as a normal element of professional practice.
Additionally, they may develop TMT-informed death education. Training should extend beyond clinical competencies and communication with dying patients to address clinicians’ own psychological and existential responses to mortality. Normalizing mortality-related anxiety and emotional reactions may help clinicians acknowledge vulnerability without interpreting it as a threat to professional competence (Hao et al. Reference Hao, Zhan and Huang2021; von Blanckenburg et al. Reference von Blanckenburg, Leppin and Nagelschmidt2021).
Finally, health systems should consider team psychological well-being alongside clinical performance, workload, staffing, and other indicators of service sustainability (Campos i Arnal et al. Reference Campos I Arnal, Galiana and Sánchez-ruiz2024; Wang et al. Reference Wang, Yuan and He2024). These proposals do not seek to eliminate clinicians’ emotional defenses. Protective distance remains necessary for effective clinical practice. The goal is instead to prevent an initially adaptive form of emotional protection from becoming rigid avoidance that limits self-awareness, emotional processing, and access to support.
Conclusion
Caring for dying patients requires remaining psychologically present in the face of death. While emotional distance enables day-to-day clinical functioning, the avoidance paradox highlights how defensive mechanisms against mortality can simultaneously erect barriers to self-care and support. Overcoming this paradox requires shifting responsibility away from the isolated clinician and onto the organizational structures of palliative care. Interdisciplinary collaboration, open communication, and embedded reflective spaces function as external buffers, allowing clinicians to confront human mortality without bearing its existential burden alone.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.
Acknowledgments
The authors would like to thank the medical records department at Ziv Medical Center for their assistance in data extraction and the nursing staff of the Orthopedic Department for their dedication to geriatric patient care.
Author contributions
Study conception and design: I.L., drafting of the article: I.L., and critical revision of the article: I.L.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests
The authors declare no conflict of interest.
Ethical approval
The study was approved by the institutional ethics board (No. xxxxx) and conducted in accordance with the Declaration of Helsinki.
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