The Emotional Cost of Clarity

Navigating honesty, hope, and emotional risk in palliative care

In palliative care, doing the right thing doesn’t always earn applause. Sometimes it gets you removed from the team.

A recent JAMA article—"Why Good Palliative Care Clinicians Get Fired”—underscores the vulnerability of clinicians who communicate honestly about serious illness in a system that often treats dying as a failure. Even when delivered with skill and compassion, such honesty can provoke discomfort or resistance, revealing the emotional terrain clinicians are expected to navigate discreetly.

Walking the Line

Rosenberg and colleagues describe this dynamic as walking the line between security and vulnerability. Palliative care clinicians help people face difficult realities, articulate what matters most, and prepare for change—often in situations where patients and families are still hoping for stability. That work, while essential, can be emotionally fraught. This balance—between telling the truth and protecting trust—is the tightrope we walk.

Research shows that patients with advanced illness often hold hopeful beliefs, even when those beliefs conflict with medical evidence. The Tanco study, for example, found that patients rated physicians who gave more optimistic messages as more compassionate and trustworthy, even if the information was inaccurate. Similarly, another study reveals that satisfaction with communication tends to decrease as prognostic understanding increases. In other words, truth may cost trust—at least in the short term.

These findings align with what many of us experience: patients may not reject the clinician, but rather the feeling of loss that honesty evokes.

Hope and Cognitive Bias

Finkelstein and colleagues offer deeper insight into this phenomenon. In their study of patients with advanced cancer and a prognosis of less than one year, 40% believed their treatment would cure them. The average expected survival was nearly 10 years. Only 8.5% anticipated living less than a year.

These perceptions weren’t random—they were shaped by hope, which amplified optimism bias, self-deception, and misattribution. Each one-point increase in a validated hope scale correlated with:

• 6% higher odds of believing the illness was curable
• 4 additional months of expected survival
• 6% higher likelihood of believing outcomes would exceed average
• 12% higher odds of believing they were well-informed

Hope, in this context, is not delusion. It’s protection.

The Role of Death Anxiety

A 2024 study in the Journal of Pain and Symptom Management offers important context. It found that 37% of advanced cancer patients and 75% of family caregivers reported clinically significant death anxiety. Among patients, the most common concern was the impact of their death on loved ones. Among caregivers, it was the fear of “running out of time.”

Notably, younger age, female gender, and a more recent diagnosis predicted higher distress. These findings suggest that clinicians aren’t just navigating preferences or misunderstandings—they’re engaging with deeply rooted existential fears.

As Ernest Becker, Irvin Yalom, and others have argued, death anxiety is a central organizing force in human psychology. In palliative care, we don’t just manage symptoms. We manage the terror of mortality, often masked as hope, avoidance, or silence.

The Language of Palliative Care

Tony Back’s research (he delivered a great talk at the last AAHPM’s meeting in Denver in February) shows that patients rarely describe palliative care in technical terms. Instead, they use language like “validation,” “agency,” “guidance,” and “regeneration.” One patient put it simply: “Illness takes. Palliative care gives.”

That giving isn’t just about medications or prognostic estimates. It’s about helping people name what matters most—and holding space for the fear that naming it brings.

Personal Reflections

In my practice, I’ve watched this tension unfold. I’ve sat with families navigating contradictory messages. I’ve named uncertainty where others promised stability. And yes, at times, I’ve been the one patients no longer wanted to see.

What I’ve learned is this: our job is not to confront death anxiety, but to work alongside it. Denial is not the enemy. It is a psychological shield. The goal is not to tear it down but to gently explore what it protects—and what lies behind it.

Strategies for Communication

Back’s research and recent empirical studies suggest we may navigate this terrain more skillfully by:

• Leading with what patients gain from palliative care
• Framing conversations around choice and agency
• Using stories instead of statistics
• Letting dialogue unfold rather than delivering conclusions
• Centering patients and families as part of the team

When Doing the Right Thing Comes at a Cost

As Rosenberg and colleagues write, our job is not necessarily to be liked. It is to advance conversations and care, even when those conversations are painful. The short-term cost may be rejection. But the long-term gain is trust, clarity, and dignity.

“If palliative care clinicians walk the line between security and vulnerability, then they must expect to misstep sometimes...  Being fired too often may mean we lean too heavily toward challenging our patients. Never being fired may suggest an opportunity to challenge our patients, our colleagues, and ourselves a bit more.”

So I’ll ask:  Have you ever been “fired” for doing what you believed was right?  How do you navigate the line between honesty, hope, and fear in your work?  And how might we better frame palliative care—not as surrender, but as a kind of strength?