“Caring in Both Directions”: Supporting the Sandwich Generation in Palliative Care

In palliative care, we have a front-row seat to love in action. We watch adult children pour themselves into caregiving for aging parents—managing appointments, medications, decisions, grief. But increasingly, those same caregivers are also raising children or supporting young adults at the very same time.

They are “the sandwich generation.”
Pressed from both sides. Pulled in every direction. Often invisible in their struggle.

And yet—they are the quiet backbone of our healthcare system.

As palliative providers, we have an opportunity—and an obligation—to understand, validate, and support this unique caregiver experience.

What Is the Sandwich Generation?

The term “sandwich generation” refers to people (often ages 35–65) who are caring for aging parents while also raising children or supporting dependent young adults or grandchildren.

Some even refer to the “club sandwich” generation—those caring for parents, adult children, and grandchildren all at once.

This isn’t a niche group anymore. It’s one of the fastest growing caregiving trends in the U.S. As people live longer and parents have children later in life, these overlapping responsibilities are becoming the norm, not the exception.

Why It Matters in Palliative Care

When serious illness enters the equation, sandwich caregiving gets exponentially harder. These caregivers are navigating:

• Medical decisions and end-of-life planning for a parent
• School schedules, emotional development, and daily care for children
• Work and financial responsibilities
• Household management
• Their own grief, guilt, and exhaustion

They are living two full-time caregiver roles—while still expected to function as employees, spouses, siblings, and human beings.

And many of them feel like they’re failing at all of it.

“I’m Failing Everyone”: The Emotional Weight

One caregiver once told me:

“When I’m with my mom at chemo, I feel guilty for missing my daughter’s dance recital.
When I’m at the recital, I feel guilty for not being with my mom.
There is no version of this where I don’t feel like I’m letting someone down.”

This is the emotional math of the sandwich caregiver.
Even when they’re doing everything right—they still feel like it’s never enough.

Common emotional experiences:

• Anticipatory grief for a parent
• Anxiety about children absorbing the stress
• Isolation (“No one else understands this life.”)
• Role reversal (“I’m parenting my parent.”)
• Guilt—constant, crushing guilt
• Burnout and compassion fatigue
• Loss of identity or personal time
• Difficulty asking for help

The Healthcare System Isn’t Built for Them

Sandwich caregivers fall through the cracks because our systems are siloed.

• Pediatric care on one side.
• Geriatric or palliative care on the other.
• Workplaces expecting “100% focus.”
• Limited respite options.
• Few policies that recognize caregiving as labor.

And yet, they are the glue holding everything together.

What Palliative Providers Can Do (Even in Small Ways)

You don’t have to fix everything. But the smallest changes in approach can have the biggest impact.

1. Ask early and explicitly.

“Do you also provide care for children or others at home?”
This single question can open the door to deeper understanding.

2. Name the experience.

“You are caring in both directions. That’s an enormous weight.”
A caregiver who feels seen is a caregiver who can breathe.

3. Normalize the guilt.

Let them know guilt is a symptom of love—not failure.

4. Help them prioritize.

Not every task is urgent. Help them choose what matters most without shame.

5. Offer flexible scheduling and virtual options.

Telehealth visits, end-of-day appointments, combining visits when possible.

6. Bring in your interdisciplinary team.

Social work, chaplaincy, child life specialists, counseling, respite programs.

7. Watch for caregiver burnout red flags.

• Sleep changes
• Withdrawal
• Hopelessness
• Decline in personal health
• Statements like “I can’t keep doing this.”

8. Collaborate beyond silos.

Bridge pediatric and palliative teams where appropriate. The caregiver is the constant—support them across systems.

9. Remind them they matter too.

Caregivers often put their own health last. A gentle nudge to schedule their own appointments or accept help can be life-changing.

A Real-Life Vignette: “Marissa”

Marissa is 52.
She works part-time.
She has a 9-year-old daughter with asthma.
Her mom has metastatic cancer on home hospice.

Her day looks like this:

• Pack school lunches
• Morning inhalers
• Work meetings
• Doctor appointment with her mom
• School pickup
• Medication administration
• Homework supervision
• Hospice nurse visit
• Laundry
• Bills
• Collapse

She told the team, “I feel like I’m raising a child and losing a parent at the same time.”

What helped?

• Hospice coordinated visits after school hours.
• The team helped her apply for respite support.
• A social worker connected her with a sandwich generation support group.
• The nurse told her, “You’re doing enough.”

Marissa started to breathe again—not because the load disappeared, but because she no longer carried it alone.

The Heart of the Matter

Sandwich caregivers are not just logistics managers.
They are cycle breakers. Bridge builders. Legacy carriers.
They are raising the next generation while honoring the last.

And they need us—palliative care providers—to see them.

To say:
You’re not invisible.
You’re not failing.
This is hard because it is hard.
We can help you carry it.

RESOURCES & SUPPORT

Caregiver Action Network (CAN)
Free resources, caregiver help desk, peer support.
https://www.caregiveraction.org

Family Caregiver Alliance (FCA)
Education, legal/financial guidance, support groups.
https://www.caregiver.org

National Alliance for Caregiving
Research, advocacy, workplace policy tools, caregiving reports.
https://www.caregiving.org

Eldercare Locator (U.S.)
Find local aging and caregiver support services.
https://eldercare.acl.gov

GetPalliativeCare.org – Tips for Family Caregivers
Resources tailored to serious illness and palliative settings.
https://getpalliativecare.org/tips-family-caregivers/

“Sandwich Generation” Facebook Groups
Large communities that offer peer connection and practical advice.
Search: “Sandwich Generation Support”

Hospital or Hospice-Based Caregiver Support Groups
Many local programs now offer groups specific to multigenerational caregivers—ask your local palliative or hospice provider.

MeetCaregivers.com
Articles and resources on navigating both child and elder care.
https://meetcaregivers.com

REFERENCES

Caregiver Action Network. “Supporting the Sandwich Generation.”
National Alliance for Caregiving. “Caregiving in the U.S.”
Family Caregiver Alliance. “Caregiver Statistics: Demographics.”
GetPalliativeCare.org. “Tips for Family Caregivers.”
Michigan Medicine. “Study on Sandwich Generation Challenges.”
JPSM Journal. “End-of-Life Caregiving Burden Studies.”
Psychology Today. “Sandwich Generation Support Groups.”
Eldercare Locator (ACL.gov).

If we want to rewrite the last chapter, we must also protect those writing it behind the scenes—the caregivers caring in both directions.

A Special Dedication to Caregivers and Palliative Care – November

November is both National Family Caregivers Month and National Hospice and Palliative Care Month—two observances that belong together, because our missions are inseparable.

To the caregivers:
You are the heartbeat of compassion.
You sit bedside in the quiet hours, advocate in the loud ones, and love in the in-between.
You hold hands through fear, laughter, exhaustion, and grace.
You carry stories, preserve dignity, and give more of yourself than most people will ever see.
You do sacred work—often unseen, but never insignificant.

To the palliative care teams:
You stand in the sacred spaces where medicine meets meaning.
You manage symptoms, yes—but more importantly, you protect hopes, honor values, and help people live fully until the very end.
You support families as fiercely as you care for patients.
You make room for tears, truth, and peace.
You are the steady presence in the storm.

This month, we honor the beautiful partnership between caregivers and palliative care.
One cannot thrive without the other.
Together, you rewrite the last chapter with dignity, humanity, and love.

To all who care:
Thank you.
We see you.
We honor you.
We are better—because of you.