The Ethical Challenge of Negative Compassion: How Excessive Empathy in End-of-Life Care Affects Decision-Making and Patient Autonomy

Negative compassion-excessive empathy that leads to emotional overload-presents a significant ethical challenge in end-of-life care. This qualitative phenomenological study explored how negative compassion affects adherence to advance directives and ethical decision-making among health care professionals in 6 long-term care facilities in Spain and Italy. Through 8 focus groups and 9 in-depth interviews with nurses, auxiliary caregivers, and support staff (n = 105), 3 key themes emerged: decision paralysis and emotional overload, conflicts between personal beliefs and professional responsibilities, and institutional barriers to ethical practice. Findings reveal that excessive emotional involvement can hinder the implementation of patients' documented wishes, potentially compromising patient autonomy and increasing caregiver distress. The study highlights the need for institutional policies that support emotional resilience, structured debriefing, and ethics training. Mindfulness-based interventions may help caregivers regulate emotional responses while maintaining professional integrity. These insights are highly relevant for palliative nursing practice, offering guidance for supporting staff and upholding patient-centered care in end-of-life settings.