Exploring palliative care access among older adults in Saudi Arabia: implications for nursing practice

Abstract

Background

Access to palliative care among elderly populations remains a global challenge, especially in regions where cultural beliefs, financial barriers, and healthcare infrastructure intersect. In Saudi Arabia, these challenges may be amplified due to social norms and service limitations.

Objectives

To explore the experiences and perspectives of older adults in the Riyadh region regarding their access to palliative care, with a focus on identifying key barriers, facilitators, and sociocultural influences.

Methods

A qualitative study using semi-structured face-to-face interviews was conducted with 18 elderly participants (aged 65–89) who had experience with or were recommended for palliative care. Thematic analysis followed Braun and Clarke’s six-step approach.

Results

Four key themes emerged: (1) limited awareness and misconceptions about palliative care; (2) financial and logistical access barriers; (3) sociocultural influences, including family roles and cultural taboos; and (4) variability in provider communication and continuity of care.

Conclusion

Palliative care access for older adults in Saudi Arabia is shaped by a complex interplay of personal, systemic, and cultural factors. Culturally sensitive education, improved provider communication, and home-based service models may improve access and equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03658-w.

Introduction

Access to palliative care services among elderly patients is a critical component of healthcare systems worldwide, particularly as populations age and the prevalence of chronic and terminal illnesses increases [1]. Palliative care focuses on improving the quality of life for patients with serious illnesses by addressing physical, emotional, social, and spiritual needs, rather than solely aiming to cure the disease [2]. As the global population of elderly individuals continues to grow, understanding and enhancing access to palliative care becomes increasingly vital to ensure that this demographic receives appropriate and compassionate end-of-life care [3, 4].

The aging population presents unique challenges and opportunities for palliative care services. Elderly patients often suffer from multiple comorbidities, which complicates their medical management and necessitates a comprehensive approach to care [5]. Palliative care is particularly beneficial for this group, as it can alleviate symptoms, reduce hospitalizations, and support both patients and their families in navigating complex healthcare decisions [6]. Despite these benefits, access to palliative care among elderly patients remains uneven, influenced by a myriad of factors including healthcare infrastructure, socioeconomic status, cultural beliefs, and policy frameworks [7].

One significant barrier to accessing palliative care for the elderly is the limited availability of specialized services. In many regions, palliative care resources are concentrated in urban areas, leaving those in rural or underserved locations with inadequate access [8]. This geographical disparity is exacerbated by a shortage of trained palliative care professionals, including physicians, nurses, and social workers, which limits the capacity to meet the growing demand [9]. Additionally, the integration of palliative care into mainstream healthcare systems is often fragmented, leading to delays in referrals and inconsistent service delivery [10].

Financial constraints also play a pivotal role in access disparities. Elderly patients frequently face economic hardships due to limited income, high out-of-pocket healthcare costs, and inadequate insurance coverage for palliative services^9^. These financial barriers can prevent timely access to necessary care, forcing patients to forego essential services or rely on less effective alternatives [11]. Moreover, the lack of standardized funding mechanisms for palliative care can result in inequitable distribution of resources, further hindering access for vulnerable populations [12].

Cultural and societal attitudes towards aging and death significantly influence the utilization of palliative care services. In many cultures, discussing death and end-of-life care is considered taboo, leading to reluctance among patients and families to seek palliative support [13]. Additionally, misconceptions about palliative care—that it is synonymous with giving up hope or hastening death—can deter individuals from accessing these services [14]. Healthcare providers may also harbor biases or lack cultural competence, impeding their ability to effectively communicate the benefits of palliative care to elderly patients from diverse backgrounds [15].

Health literacy is another critical factor affecting access to palliative care. Elderly patients may have limited understanding of palliative care options, available services, and how to navigate the healthcare system to obtain the care they need [16]. Cognitive impairments, which are more prevalent in older populations, can further hinder comprehension and decision-making regarding palliative care [17]. Enhancing health literacy through targeted education and clear communication strategies is essential to empower elderly patients to make informed choices about their care [18].

The role of primary care providers is instrumental in facilitating access to palliative care. However, many primary care physicians may lack sufficient training in palliative care principles and practices, limiting their ability to recognize when to refer patients to specialized services [19]. Effective collaboration between primary care and palliative care teams is crucial for ensuring seamless care transitions and comprehensive support for elderly patients [20]. Strengthening these professional relationships and providing ongoing education can enhance the referral process and improve overall access to palliative care [21].

Policy and regulatory frameworks also influence the accessibility of palliative care services. National and regional policies that prioritize palliative care integration into healthcare systems can drive improvements in service availability and quality [22]. Conversely, the absence of supportive policies or the presence of restrictive regulations can impede the expansion and standardization of palliative care services [23]. Advocacy efforts aimed at policy reform are necessary to create an enabling environment that facilitates equitable access to palliative care for all elderly patients [24].

Interdisciplinary approaches are essential in addressing the multifaceted barriers to palliative care access for elderly patients. Collaborative efforts involving healthcare providers, social workers, policymakers, and community organizations can develop comprehensive strategies to improve service delivery and address social determinants of health [25]. Community-based palliative care programs, for instance, can offer personalized support and integrate services within familiar environments, thereby enhancing accessibility and acceptability [26]. Such collaborative models emphasize the importance of tailored interventions that consider the diverse needs and preferences of the elderly population [27].

The primary aim of this study is to explore the experiences and perspectives of elderly patients regarding their access to palliative care services in the Riyadh region of Saudi Arabia. By gaining insight into the barriers, facilitators, and overall experiences encountered by older adults, this research seeks to contribute to a more comprehensive understanding of how palliative care can be made more accessible and responsive to this population’s needs.

The specific objectives of the study are:

• To identify the key factors influencing elderly patients’ access to palliative care services.

• To understand how socio-cultural, economic, and healthcare system factors shape the experiences of elderly patients when seeking palliative care.

Materials and methods

Design

This study employed a qualitative research design to capture the rich, in-depth experiences of elderly patients regarding their access to palliative care services. A qualitative approach was selected due to its capacity to reveal nuanced perspectives and lived realities that might be overlooked in quantitative studies. Semi-structured interviews were used as the primary method of data collection, allowing participants to discuss their experiences openly while the researcher explored key themes related to access and quality of palliative care.

Theoretical framework

This study was conceptually guided by Levesque et al.’s Framework of Access to Healthcare, which defines access as the opportunity to identify healthcare needs, seek services, reach resources, obtain or use services, and have the need for services fulfilled. This framework emphasizes five dimensions of accessibility (approachability, acceptability, availability and accommodation, affordability, and appropriateness) alongside corresponding patient abilities (to perceive, to seek, to reach, to pay, and to engage).

Applying this framework allowed the study to explore how elderly individuals in Saudi Arabia navigate access to palliative care across both structural and individual levels. Specifically, the framework helped illuminate how financial burdens (affordability), cultural norms (acceptability), geographic distance (availability), and communication barriers (approachability) influence participants’ access.

By integrating this model, the study captures the complex interplay between personal capacity and systemic design, offering a comprehensive lens through which to interpret the lived experiences of older adults seeking palliative care.

Study setting and recruitment

The study was conducted in the Riyadh region of Saudi Arabia, which is known for its diverse healthcare infrastructure, comprising both public and private facilities. Ethical approval for the study was obtained from the Institutional Review Board (IRB) of King Saud University (Approval No. KSU-HE-24-960) on 5 November 2024. Data collection took place on 15 December 2024.

A purposive sampling strategy was employed to recruit participants who were 60 years of age or older and had direct experience with palliative care services or expressed the need for such services. Emphasis was placed on including individuals from varied socioeconomic backgrounds and different healthcare institutions (e.g., hospitals, specialized palliative care centers, community clinics) to ensure a wide range of perspectives.

An initial pool of potential participants was identified through healthcare providers and community organizations involved in geriatric and end-of-life care. These contacts introduced the study to eligible individuals and invited them to participate. Of the individuals approached, 18 elderly patients were enrolled using purposive sampling, with variation sought across age, gender, living arrangement (urban/rural), education level, and primary diagnosis to ensure diverse representation. Data saturation was determined through an iterative process, in which transcripts were reviewed after each round of interviews. Saturation was considered achieved when no new codes or sub-themes emerged across three consecutive interviews, confirmed through ongoing discussions among the research team and use of a saturation tracking matrix.

Inclusion and exclusion criteria

• Inclusion criteria

1. Elderly individuals aged 60 years or older.

2. Previous or current experience with palliative care services, or recognition by healthcare professionals that palliative care would be beneficial.

3. Ability to communicate in Arabic (or English if comfortable) to ensure clear understanding of the interview questions.

• Exclusion criteria

1. Elderly individuals with severe cognitive impairments that would limit their ability to participate meaningfully in an in-depth interview.

2. Individuals without any direct or indirect experience or need for palliative care services, as determined by healthcare professionals or self-report.

These criteria ensured that the study focused on participants most likely to offer detailed insights into the realities of accessing palliative care.

Data collection

Data were collected through semi-structured (See Supplementary File S1 for the full interview guide used in this study), face-to-face interviews conducted at a time and place convenient for each participant, typically in a private room within a healthcare facility or in the participant’s residence if mobility was an issue. Each interview lasted between 45 and 60 min. The interview guide consisted of open-ended questions designed to probe the participants’ awareness of palliative care services, their perceptions of its benefits, and any barriers or facilitators they encountered.

Examples of guiding questions included:

1. “Can you describe your experience with palliative care services so far?”

2. “What challenges did you face when trying to access these services?”

3. “Could you tell me about any support systems (family, community, healthcare providers) that helped you in this process?”

4. “How do you feel cultural and social factors have influenced your choices or experiences?”

5. “What suggestions would you give to improve palliative care access for older adults?”

All interviews were audio-recorded with the participants’ consent and later transcribed verbatim. For participants who preferred Arabic, interviews were conducted in Arabic by native-speaking researchers with clinical and qualitative expertise. Audio recordings were transcribed verbatim in Arabic, then translated into English using a collaborative process. Forward translation was performed by the original interviewer, followed by independent back-translation by a certified bilingual translator to ensure semantic equivalence and cultural accuracy. Discrepancies were resolved through discussion and consensus between translators. This approach ensured that participants’ narratives were preserved with minimal distortion and contextual fidelity.

The interview guide was developed based on a review of existing literature on palliative care access and qualitative studies involving older adults. Questions were designed to be open-ended and culturally appropriate, with input from two palliative care nursing experts and a qualitative research specialist. A pilot interview was conducted with one elderly participant (not included in the final analysis) to refine question clarity, sequencing, and flow. Minor adjustments were made to enhance comprehension, particularly for participants with limited education.

Data analysis

A thematic analysis approach (Braun & Clarke, 2006) was used to interpret the interview data. The six-step process included:

1. Familiarization with the data: The research team repeatedly read the transcripts to gain a deep understanding of the content.

2. Generating initial codes: Relevant phrases, sentences, or paragraphs were assigned initial codes reflecting the essence of participants’ statements (e.g., “financial barrier,” “family support,” “cultural stigma,” “lack of information”).

3. Searching for themes: Codes were grouped into potential themes based on their interrelationships and recurring patterns (e.g., “Health System Constraints,” “Cultural and Familial Influences,” “Financial and Logistical Barriers”).

4. Reviewing themes: Thematic groups were refined by the research team to ensure internal coherence and distinctiveness from other themes.

5. Defining and naming themes: Each theme was clearly defined, and a concise name was assigned that captured its primary concept.

6. Producing the report: A comprehensive write-up was developed, incorporating participant quotations to illustrate each theme and provide authenticity to the findings.

Ethical considerations

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of King Saud University (Approval No. KSU-HE-24-960) on 5 November 2024.

All participants provided written informed consent after being fully informed about the study’s purpose, procedures, voluntary nature, and their right to withdraw at any point without any impact on their care. For participants with limited literacy, the consent process was conducted verbally and documented with a witness signature.

To ensure confidentiality and anonymity, each participant was assigned a pseudonymized identification number. All personal identifiers were removed from transcripts, and audio recordings were stored securely on encrypted devices accessible only to the research team.

The interviews were conducted in private settings of the participants’ choosing (e.g., homes or private hospital rooms) to ensure privacy and psychological comfort. Researchers were trained to use empathetic and non-judgmental language, especially when discussing sensitive topics such as illness, family decision-making, and end-of-life concerns.

Rigor and reflexivity

To enhance the trustworthiness of the study, several strategies were implemented:

1. Member Checking: Preliminary findings were shared with a few participants who agreed to review and confirm the emerging themes. This step helped validate the accuracy of the interpretations.

2. Peer Debriefing: The research team held regular meetings to discuss emerging codes, themes, and potential biases, promoting a rigorous interpretative process.

3. Reflexive Journals: The primary researchers maintained journals to record personal reflections, emotional responses, and potential biases after each interview and analysis session. These notes were revisited regularly to ensure that personal assumptions did not overshadow the participants’ voices.

4. Triangulation: Although interviews were the main data source, informal observations during hospital visits and clinic consultations provided additional contextual information. Cross-referencing these observations with the interview data bolstered the study’s credibility.

Researcher positionality

Both primary researchers are Saudi-licensed nurses with extensive backgrounds in geriatric and palliative care, as well as formal training in qualitative research. Their professional roles may have influenced the interpretation of data due to pre-existing knowledge and values regarding end-of-life care. To minimize bias, researchers maintained reflexive journals to critically examine their assumptions, acknowledged the power dynamics inherent in interviewing older adults, and engaged in peer debriefing throughout the coding and analysis phases. These practices enhanced transparency and supported a more grounded interpretation of participants’ perspectives.

Results

Characteristics of participants

The study included 18 elderly individuals (10 females and 8 males) residing in the Riyadh region of Saudi Arabia, aged between 65 and 89 years (mean age: 73.4 years). Participants presented with diverse chronic conditions including advanced cardiac disease, metastatic cancers, COPD, and end-stage renal disease, often with multiple comorbidities. Educational attainment varied: 6 participants had no formal education, 6 completed primary school, 6 completed secondary education or higher. Living arrangements reflected a mix of social contexts—some lived independently or with domestic caregivers, while others resided with spouses or extended families. Socioeconomic indicators such as education, housing situation, and reliance on family caregiving served as proxies for economic status, given the cultural sensitivity of directly reporting income in Saudi Arabia.

As shown in Table 1, The study included 18 elderly individuals (10 females and 8 males) residing in the Riyadh region of Saudi Arabia. Their ages ranged from 65 to 89 years, with an average age of 73. All participants either had direct experience with palliative care services or were recommended to receive such services by healthcare professionals due to chronic or life-limiting conditions. Seven participants lived in urban settings, while the remaining 11 resided in suburban or semi-rural areas surrounding Riyadh.

Table 1.

Participant characteristics

Participant ID	Age	Gender	Primary Condition	Education Level	Living Arrangement	Prior Palliative Care Use	SES Proxy
1	67	Female	Advanced Heart Failure	Secondary School	Lives with daughter	Yes	Moderate
2	72	Male	Metastatic Lung Cancer	Primary School	Lives with spouse	Yes	Low
3	65	Female	End-Stage Renal Disease	No Formal Education	Independent Apartment	No	Low
4	80	Male	Chronic Obstructive Pulmonary Disease (COPD)	Secondary School	Lives with extended family	No	Moderate
5	76	Female	Metastatic Breast Cancer	Diploma	Lives with spouse	Yes	Moderate
6	82	Male	Advanced Heart Failure	Secondary School	Independent Apartment	Yes	Moderate
7	70	Female	COPD	Bachelor’s	Lives with adult children	No	High
8	68	Male	End-Stage Renal Disease	Primary School	Lives alone	Yes	Low
9	74	Female	Metastatic Colon Cancer	Secondary School	Lives with spouse	Yes	Moderate
10	78	Female	Advanced Heart Failure	No Formal Education	Lives with adult children	No	Low
11	83	Male	COPD	Primary School	Lives with extended family	Yes	Low
12	69	Female	End-Stage Renal Disease	Bachelor’s	Independent Apartment	No	High
13	71	Male	Metastatic Prostate Cancer	Secondary School	Lives with spouse	No	Moderate
14	66	Female	Advanced Heart Failure	Secondary School	Lives with spouse	Yes	Moderate
15	88	Male	COPD	No Formal Education	Independent Apartment	No	Low
16	89	Female	Metastatic Ovarian Cancer	Primary School	Lives with extended family	Yes	Low
17	79	Male	End-Stage Renal Disease	Secondary School	Lives with son	Yes	Moderate
18	77	Female	Metastatic Colon Cancer	Bachelor’s	Lives with daughter	No	High

The participants presented a variety of underlying health conditions, including advanced cardiac disease (5 participants), metastatic cancers (4 participants), chronic obstructive pulmonary disease (3 participants), and other degenerative illnesses such as end-stage renal disease (6 participants). Several participants also reported multiple comorbidities, consistent with the complex health profiles often seen in elderly populations.

In terms of educational background, most participants had completed primary or secondary school (12 out of 18), while the remaining six held higher education qualifications. Family compositions ranged from those living independently to those residing in extended families. Some participants received help from domestic caregivers, while others relied on family members or community volunteers for daily assistance.

All participants had at least some awareness of palliative care, although the extent of their knowledge varied. Nine participants reported having accessed formal palliative care services (home-based or in-hospital) within the past year, while the others had only received cursory information or relied primarily on standard outpatient care and family support.

Thematic analysis

Four main themes emerged from the data, each encompassing subthemes that illuminated the nuanced experiences of elderly patients regarding palliative care access. Table 2 summarizes these themes, followed by a detailed discussion.

Table 2.

Thematic analysis table

Theme	Sub-theme	Description	Example of Participant Quote
Awareness and Understanding of Palliative Care	Limited Knowledge of Services	Uncertainty or misconceptions about what palliative care entails	“I assumed it was only for the final stage of life, so I didn’t think it was for me.” (P10)
	Role of Healthcare Professionals	The influence of physicians and nurses on educating and guiding patients	“My doctor explained that it’s not just for pain relief but overall support.” (P2)
Practical and Logistical Barriers	Financial and Insurance Constraints	Out-of-pocket expenses and coverage limitations affecting access	“I couldn’t afford extra nursing care at home, so I stopped the service.” (P11)
	Transportation and Mobility Challenges	Physical and geographic barriers to attending appointments or receiving care	“If my son can’t drive me, I often miss my follow-up visits.” (P4)
Sociocultural Influences on Care Decisions	Family Involvement and Decision-Making	The role of family members in endorsing or delaying palliative care use	“My children worried that palliative care meant giving up on treatment.” (P9)
	Cultural Perceptions of End-of-Life Care	Taboos around discussing death and seeking external help	“We believe we should care for elders at home, which can delay professional support.” (P14)
Quality of Interactions with Healthcare Providers	Consistency of Care and Follow-Up	How ongoing, coordinated care fosters trust and adherence to palliative services	“Seeing the same nurse or doctor each time gives me peace of mind.” (P12)
	Communication and Empathy	The extent to which providers offer emotional support and respect patient dignity	“I feel more inclined to continue treatment when they truly listen to me.” (P6)

Awareness and understanding of palliative care

Limited knowledge of services

Many participants acknowledged only a vague understanding of what palliative care entailed. Participant 3 recalled, “I had heard the term from a neighbor, but I didn’t really know it meant more than just pain management.” This gap in knowledge sometimes delayed engagement with specialized services. For instance, Participant 10 mentioned, “I assumed it was for people in the last stages of life, so I never thought it applied to me.” Observational data corroborated this finding, indicating confusion around terminology like “end-of-life care” versus “supportive care,” often leading elderly patients to believe that palliative services were synonymous with giving up on treatment.

Role of healthcare professionals

Despite limited personal awareness, participants who had positive palliative care experiences credited healthcare providers for clarifying the scope of services. Participant 2 said, “My doctor explained that palliative care can help with my breathing issues, not just pain. That made me consider it.” However, inconsistencies were evident. Participant 8 explained, “My physician never mentioned palliative care until I was admitted to the hospital. I think it would have helped if I’d known earlier.” Such discrepancies point to a need for consistent, proactive education about palliative care, rather than relegating these conversations to crisis moments.

Practical and logistical barriers

Financial and insurance constraints

A recurring subtheme involved the financial strain associated with specialized care. Participant 16 stated, “When I found out that some medications and home visits weren’t covered by my insurance, I hesitated to keep using those services.” Similarly, Participant 11 noted, “We can’t afford extra nursing care at home, so I had to rely on my grandson when I was discharged.” These examples highlight how insurance coverage, or lack thereof, can either facilitate or hinder ongoing engagement with palliative care.

Transportation and mobility challenges

For those living outside urban centers, limited mobility compounded access issues. Participant 4, who resided in a semi-rural area, remarked, “My son has to drive me to appointments in the city. If he’s busy, I miss my sessions.” Observational data indicated that even participants closer to healthcare facilities faced mobility challenges due to age-related physical limitations. Participant 15, an 88-year-old male with multiple comorbidities, shared, “Just getting into a car is a big ordeal for me. Sometimes, I’d rather skip my appointments than go through the struggle of traveling.” These logistical realities underscore the importance of community-based or home health options in facilitating better continuity of care for the elderly.

Sociocultural influences on care decisions

Family involvement and decision-making

Family members played a central role in discussions about care options. Several participants described deferring to relatives’ advice rather than making autonomous decisions. Participant 9 observed, “My children thought I should continue chemotherapy, even if I felt it was too much. When they heard about palliative care, they worried it meant I was giving up.” This dynamic sometimes delayed palliative care engagement. On the other hand, Participant 1 reported a more collaborative approach: “My family researched palliative services and supported me in trying them. Now they see how much it’s helped.” Such stories point to the pivotal role families hold in endorsing or discouraging specialized supportive services.

Cultural perceptions of end-of-life care

The cultural taboo around discussing mortality and end-of-life preparations also emerged. Participant 7 explained, “In our culture, we don’t like to talk about death. It makes people uncomfortable.” This hesitancy often led to avoidance of palliative discussions until health complications reached a critical point. Another participant (14) added, “We believe in taking care of our elders at home. Seeking external help sometimes feels like neglecting our responsibility.” Document analysis suggested that educational materials addressing cultural sensitivities and emphasizing the supportive nature of palliative care could help break down these barriers.

Quality of interactions with healthcare providers

Consistency of care and follow-up

Participants frequently highlighted the importance of consistent medical follow-up to maintain a sense of security. Participant 12 noted, “When I know my nurse or doctor will check on me regularly, I feel more at ease, and I keep up with treatment.” However, others cited lapses in coordination. Participant 5 remarked, “I saw different doctors each time. No one seemed to have my full history, so explaining everything repeatedly became frustrating.” This inconsistent provider–patient relationship sometimes discouraged participants from actively continuing palliative interventions.

Communication and empathy

Quality communication emerged as a crucial subtheme, affecting both satisfaction with care and willingness to remain engaged. Participant 6 said, “My palliative care nurse sits down and listens to me. It feels like they genuinely care, which makes a big difference in my comfort level.” In contrast, Participant 18 described a less empathetic experience: “They were very clinical, just listing out procedures. I felt like a number, not a person.” Such disparities highlight how empathetic engagement can bolster trust, adherence to care, and ultimately, the effectiveness of palliative interventions.

Summary of key findings

The analysis revealed a multifaceted picture of palliative care access among elderly participants. The most salient findings included:

• Limited awareness and misconceptions delayed initial engagement with palliative care services.

• Financial burden, insurance limitations, and transportation difficulties acted as major logistical barriers.

• Family influence and cultural taboos around death played a dual role, sometimes encouraging and sometimes delaying care.

• Consistency in follow-up and empathetic communication by providers strongly affected patient trust and ongoing engagement.

Discussion

This qualitative study provides valuable insights into the experiences of elderly patients accessing palliative care services in Saudi Arabia, revealing complex interplays between individual awareness, systemic barriers, and sociocultural factors that influence care utilization. The findings highlight several key areas that warrant detailed examination in the context of existing literature and healthcare practices.

The study revealed a significant knowledge gap regarding palliative care services among elderly patients, which aligns with previous research indicating limited awareness of palliative care in many populations [28]. Many participants initially associated palliative care exclusively with end-of-life support, demonstrating a common misconception that may delay early intervention. This finding echoes broader research showing that misconceptions about palliative care can create barriers to access [14]. The role of healthcare providers in bridging this knowledge gap emerged as crucial, yet the study found inconsistencies in how and when providers introduced palliative care options to their patients [29]. However, in contrast to some Western studies where media and public campaigns have increased awareness, participants in this study cited a lack of culturally relevant information sources, reflecting a gap in public health outreach in Saudi Arabia.

Financial and logistical barriers emerged as significant impediments to accessing palliative care services, particularly for those residing outside urban centers. The findings align with previous studies highlighting how geographic disparities and transportation challenges can limit access to specialized healthcare services [30]. The financial burden of palliative care, especially when services are not fully covered by insurance, creates additional barriers that may force elderly patients to choose between necessary care and financial stability. This situation reflects broader systemic issues in healthcare accessibility, as documented in existing literature [31].

A notable finding was the profound influence of family dynamics and cultural beliefs on palliative care decisions. The study revealed that family members often played a decisive role in care choices, sometimes superseding patient preferences. This finding is consistent with research highlighting the importance of family-centered decision-making in many cultural contexts [32]. However, the study also found that family involvement could either facilitate or hinder access to palliative care, depending on their understanding and acceptance of such services. The cultural stigma surrounding end-of-life discussions emerged as a particular challenge, potentially delaying necessary interventions until crisis points were reached [16].

The quality of healthcare provider interactions emerged as a critical factor in patients’ engagement with palliative care services. Participants who experienced consistent, empathetic care were more likely to maintain their involvement with palliative services, supporting previous research on the importance of continuity of care in chronic illness management [33]. The study found that fragmented care and poor communication could significantly impact patient satisfaction and adherence to treatment plans, highlighting the need for more integrated approaches to palliative care delivery [34].

The findings also revealed interesting patterns regarding the intersection of traditional values and modern healthcare needs. While many participants expressed a cultural preference for family-based care, they simultaneously acknowledged the benefits of professional palliative services when properly understood [35]. This dynamic suggests an evolving perspective on end-of-life care in Saudi society, where traditional values are being reconciled with contemporary healthcare approaches [36].

The role of health literacy emerged as a significant factor influencing access to palliative care. Participants with better understanding of their health conditions and available services were more likely to actively engage in their care planning. This finding aligns with research emphasizing the importance of health literacy in healthcare utilization [37]. However, the study also revealed that even educated participants sometimes struggled to navigate the complexities of the healthcare system, suggesting that systemic barriers exist independently of individual health literacy levels [38]. Transportation and mobility challenges highlighted the need for more flexible service delivery models. The difficulties faced by elderly patients in traveling to healthcare facilities, particularly those with multiple comorbidities, underscore the potential benefits of home-based palliative care services. This finding supports previous research advocating for community-based palliative care programs to enhance accessibility [39].

The study identified a critical need for better coordination between primary care providers and palliative care specialists. Participants often reported delays in referrals and inconsistent communication between different healthcare providers, reflecting broader challenges in healthcare system integration [40]. These findings suggest that strengthening primary care providers’ capacity to recognize and facilitate palliative care needs could improve access for elderly patients [41].

Cultural perceptions of aging and death significantly influenced how participants approached palliative care services. The study found that cultural taboos around discussing end-of-life care could prevent open dialogue about palliative options, supporting previous research on cultural barriers to palliative care access [42]. However, participants who received culturally sensitive care reported more positive experiences, highlighting the importance of cultural competency in healthcare delivery [43].

Understanding these complex interactions between individual, systemic, and cultural factors is crucial for developing effective strategies to improve palliative care access. The findings suggest that successful interventions must address not only practical barriers but also cultural and social factors that influence care decisions [44–46]. The study’s results indicate that while structural improvements in healthcare delivery are important, equal attention must be paid to building cultural competency and addressing familial dynamics in palliative care provision [3, 47–51].

Limitations

This study has several limitations that should be acknowledged when interpreting the findings. First, the research was conducted exclusively in the Riyadh region, which, while socio-demographically diverse, may not reflect the experiences of elderly patients in more remote or underserved areas of Saudi Arabia. Second, the sample consisted only of individuals who were able and willing to participate in face-to-face interviews, introducing potential selection bias. Those with more positive or articulate perspectives, or with easier access to services, may have been overrepresented.

Additionally, individuals with moderate to severe cognitive impairments—a group often highly relevant to palliative care planning—were excluded, which may have limited the range of experiences captured, particularly regarding decision-making support needs. The voices of healthcare providers and family caregivers, who play critical roles in palliative care navigation and advocacy, were also absent from this analysis, limiting triangulation of perspectives.

While informal observational data were used to contextualize findings, formal ethnographic techniques were not employed, and the reliance on self-reporting may have introduced recall bias. Furthermore, the cross-sectional design did not allow for tracking changes in participants’ experiences over time, limiting insights into how perceptions and barriers may evolve along the illness trajectory.

Implications

Findings underscore the need for nurses to take a proactive role in improving early engagement with palliative care among elderly patients. First, integrating structured, culturally sensitive palliative care education into routine nursing assessments can address widespread misconceptions. Nurses should be trained to initiate conversations about supportive care early in the disease trajectory, using terms that align with patient understanding (e.g., “comfort care” or “symptom relief”).

Second, nurses can advocate for the use of home-based services for patients with limited mobility and act as care coordinators in fragmented systems. Community health nurses, in particular, are well-positioned to assess access barriers and work with families to reduce stigma through culturally appropriate dialogue. Incorporating family meetings into nursing practice—similar to models used in family-centered care—can also help navigate conflicting preferences around treatment continuation and end-of-life decisions.

Conclusions

This study provides valuable insights into the complex landscape of palliative care access for elderly patients in Saudi Arabia. The findings reveal that access is influenced by a multifaceted interaction of individual awareness, practical barriers, cultural factors, and healthcare system characteristics. While some barriers, such as transportation and financial constraints, align with global healthcare access challenges, others, particularly those related to cultural beliefs and family dynamics, reflect unique aspects of the Saudi Arabian context.

The study highlights the critical need for a more integrated approach to palliative care delivery that considers both practical and cultural dimensions of access. Successful improvement of palliative care access will require addressing not only structural barriers but also cultural and social factors that influence care decisions. The findings suggest that enhancing provider communication, developing culturally sensitive education programs, and implementing flexible service delivery models could significantly improve palliative care access for elderly patients.

These insights contribute to the growing body of knowledge about palliative care access and provide a foundation for developing more effective, culturally appropriate interventions to support elderly patients in accessing the care they need. Future research and policy development should focus on implementing and evaluating strategies that address the identified barriers while building upon existing facilitators of care access.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Abdulaziz M. Alodhialah: Conceptualization, methodology, data collection, formal analysis, writing – original draft, supervision. Mohammed Almutairi: Review and editing, visualization, project administration. All authors read and approved the final manuscript.

Funding

This research was funded by the Ongoing Research Funding program, (ORF-2025-928), King Saud University, Riyadh, Saudi Arabia.

Data availability

The datasets generated and/or analyzed during the current study are included within the published article. Further details are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of King Saud University (Approval No. KSU-HE-24-960) on 5 November 2024. Written informed consent was obtained from all participants prior to their inclusion in the study.

Consent for publication

Written informed consent for publication of anonymized responses and quotations was obtained from all participants.

Competing interests

The authors declare no competing interests.