Cultural, religious, and demographic factors shaping Arab healthcare providers’ decisions on referring Arab patients to palliative care in Israel: a qualitative study

Abstract

Background

Palliative care (PC) aims to enhance the quality of life for critically or terminally ill patients by addressing medical, psychological, social, and spiritual needs. Despite its recognized importance, PC services remain underutilized, particularly within Israel’s Arab community.

Aim

To examine how cultural and religious factors, including religiosity and death-related anxieties, shape Arab healthcare providers’ decisions on PC referral at EOL, and to inform healthcare systems on reducing cultural barriers and improving the accessibility and quality of EOL care for Arab minorities in Israel.

Design

A descriptive qualitative study based on an interpretive-phenomenological approach was pursued. Data were collected between December 2022 and May 2023 through 26 semi-structured in-depth interviews with 10 physicians and 16 nurses, working in surgical, internal medicine, intensive care, and oncology departments in six major medical centers in Israel. Participants were recruited through purposive and snowball sampling from six hospitals. Data were analyzed thematically using Atlas.Ti software.

Result

The analysis explored three central themes:

1. Factors shaping the decision of whether to refer patients to PC:

Participants described a range of factors affecting their decision to refer patients to PC, including cultural and religious influences that intersect with medical considerations. These factors were seen as shaping, and at times complicating, the clinical judgment involved in making such referrals.

2. Factors shaping patient' and their family’s decision of whether to pursue PC within Arab society:

Participants identified patterns among patients who tend to either seek or avoid PC, emphasizing the role of personal, familial, and cultural dynamics in shaping patients’ decisions regarding the acceptance of such care.

3. The role of religious and cultural values in decision-making pertaining to PC:

Participants noted that religious beliefs and cultural values play a central role in shaping attitudes toward PC. In some cases, these beliefs were perceived as conflicting with the principle of the "sanctity of life," thus influencing both patients’ and families’ acceptance of PC.

Conclusions

Addressing cultural and religious barriers is essential for improving PC accessibility. Tailored strategies that respect and engage with these beliefs can enhance the delivery of culturally appropriate care within the Arab community.

Background

Palliative-care PC is a supportive care approach that strives to improve quality-of-life among critically or terminally-ill patients [1, 2]. This comprehensive care addresses medical, psychological, social, and spiritual needs, focusing on alleviating suffering and enhancing the overall well-being of patients and their families. The primary goal of PC is to provide relief from pain and other distressing symptoms, affirming life and regarding death as a natural process without hastening or prolonging the dying process [1, 3, 4].

Culture plays a significant role in PC practices, especially concerning EOL decisions [5, 6]. In Western medicine, individual patient autonomy is paramount; however, in cultural minorities such as Arab cultures, the extended family often serves as the primary decision makers. Additionally, PC is frequently perceived as an on-site treatment, such as a hospice, where patients spend their last moments. Yet, cultural preferences may otherwise shape patient’s decisions to spend these moments at home, surrounded by their beloved ones, rather than in a hospice or institution setting [5–9].

In recent years, there has been increasing recognition of the importance of cultural sensitivity in palliative care, especially when dealing with religiously and culturally diverse populations [5, 10]. Al-Harrasi and colleagues (2025) highlight how historical, religious, and cultural factors interact to influence the perceptions of Arab communities on EOL and their decision making. Specifically, the study demonstrates how Islamic values, the emphasis on family responsibility, and collective social norms play a central role in medical decision-making, at times also requiring to make a balance between spiritual preparedness for death and other medical needs [5]. Another qualitative study, focusing on the experiences of medical shift supervisors from different countries in intensive care units in Saudi Arabia regarding EOL under the Islamic tradition revealed that nursing teams had to deal with varied cultural complexities including the importance of family presence at the patient’s side, the need to maintain the spiritual dimension of care even when relatives are not present, and the commitment to providing a respectful and peaceful end to life [10]. These insights highlight the urgent need for training medical staff in culturally sensitive communication, especially when providing care to culturally and religiously diverse populations.

In Israel, a recent study examined the preferences of the Arab population regarding EOL and found that there is a clear preference to die at home, near family members. The study findings suggested that cultural taboos and intergenerational differences make it difficult to maintain open communication within the family, which sometimes leads to decisions being made based on preconceived ideas rather than the patient’s explicit wishes [6].Understanding these cultural nuances is essential for healthcare professionals to provide sensitive and appropriate care [11, 12].

Even among cultural minorities, such as the Arab communities, there exist differences between sub-groups consisting of these communities, mostly associated with their religious affiliation. Religion serves as an important institution in many countries and among many societies. Religious beliefs and practices usually influence people’s views regarding essential parts of life, whether consciously or unconsciously. Although the major practiced religions in the world share similar basic views on a person’s life, each of the religious communities internalizes, interprets, and applies its religious beliefs differently at EOL. Furthermore, misconceptions can arise between PC and legally prohibited actions at EOL by religion, such as euthanasia [13, 14].

In addition, death and dying anxiety are significant psychological phenomena frequently experienced by terminally ill patients, which are influenced by various socio-demographic, cultural, and religious factors. Previous studies have shown that terminal illness diagnoses intensify anxieties related to death, affecting patients’ mental health, quality of life, and decision-making regarding EOL [15, 16]. It is also reported that levels of death anxiety may differ according to culture, education, religious affiliation, and family context, as demonstrated in studies conducted among cancer patients and elderly populations [16, 17].

Despite substantial evidence supporting the impact of cultural and religious beliefs on PC, as well as on death and dying anxieties, and consequently on healthcare decision-making, to date, no comprehensive research has provided a rich exploration of these specific cultural and religious factors within the context of Arab healthcare providers and Arab patients in Israel.

In Israel, the Dying Patient Act was passed in 2005. The law was formulated based on the recommendations of a public committee appointed by the Ministry of Health in 2000. It consisted of 59 members from a variety of fields as well as representatives from the main religions in Israel, i.e. Judaism, Islam and Christianity, with the aim of reflecting the religious and culturally diverse perceptions and understandings of EOL [18]. The law integrates several ethical values and religious concepts in regulating care and making choice at EOL. These include the principle of sanctity of life, promoting patient autonomy, enhancing patients’ quality of life, preventing pain and suffering, and providing due acknowledgment to nutrition and hydrations at EOL [13, 14, 18] .

Following the law’s establishment of the right to receive PC services, since 2010, pain management and PC have been officially recognized as medical specialties [19] and by 2013, all medical institutions were expected to offer high-quality PC services included in the publicly funded health basket [19, 20]. In Israel, PC services are provided at three levels of care: hospital-based care, community services, and at hospice. These services are provided to various patients, especially oncology patients based on their preferences and care needs [21]. In recent years, PC services have also expanded to include patients suffering from chronic and incurable diseases other than cancer, such as heart failure, chronic lung disease, advanced neurological diseases, dementia, and end-stage renal disease [21–23].

Despite its recognized importance, the provision of PC remains limited both globally and within Israel. Many patients do not receive adequate care [12, 15, 16], with reports from the Ministry of Health highlighting a significant gap between the need for PC and its availability to relevant patients [19, 22, 23]. Based on OECD data, in 2018, only about 21.6% of those in need of PC services received them. Compared to the services gap in other Western countries, such as the United States (83.5%) and Canada (81.9%) the services gap in Israel was perceived extremely worrying [24], calling for the expansion of PC provision in Israel, including in the community and remote areas to provide an appropriate response to the population suffering from serious and incurable illnesses. Studies also suggest that terminally ill patients and healthcare providers lack acceptance of PC and appreciation for it [25–27]. Some of the main obstacles for the development and provision of palliative services include misconceptions and lack of awareness of their benefits, goals, and ways of provision, both among medical professionals and among the general public, specifically among cultural minorities, such as the Arab community in Israel [6, 16].

The Arab society in Israel constitutes 21.1% of Israel’s total population [28, 29], divided into three main religious groups: Muslims (82.9%), Druze (9.2%), and Christians (7.9%) [30]. These religious communities are geographically and socially isolated from one another, and they rarely intermarry. In general, the Israeli Arab society is characterized by lower socioeconomic status, higher poverty rates, and lower levels of higher education compared to the Jewish society [31]. Additionally, Israeli Arab citizens utilize healthcare services less frequently than their Jewish counterparts, partly due to cultural barriers [32, 33].

The Arab society in Israel is structured around three primary family units: the nuclear family, the extended family, and the clan. These units are characterized by strong emotional, social, and economic ties, with men, particularly fathers, traditionally holding primary authority over familial and intergenerational decision-making, including medical decision-making [34]. However, in recent decades, significant modernization processes have gradually altered family structures, gender roles, and family decision-making patterns within Arab society. These changes include a shift from extended to nuclear family models, increased independence of nuclear units, declining rates of early marriage and birthrates, and greater gender equality in family decision-making and household responsibilities [35–37].

The social changes in the Israeli Arab Society have led to a reduction in traditional familial obligations to care for elderly relatives, fostering a gradual recognition of the legitimacy of seeking external assistance, particularly in cases involving illness, disability, or EOL care [35, 36]. Yet the lack of culturally sensitive healthcare services remains a significant barrier [32]. A recent study found that cultural taboos and generational differences hinder open communication within families, leading to decisions based on assumptions rather than explicit patient wishes, thereby restricting access to and utilization of such services among the Arab population in Israel [6].

Cultural and religious barriers, combined with insufficient PC education and training among healthcare professionals focusing on the unique characteristics and preferences of Israeli Arabs impede the development of PC services among such populations According to a report by Israel’s Ministry of Health, healthcare professionals—particularly nurses lack adequate training in PC, underscoring the need for a national PC education program [19]. Moreover, while a specialty in PC Nursing training has been recently developed in some of the Israeli Academia at the Master’s level, only a few medical faculties in Israel provide mandatory PC courses at the undergraduate level in nursing, and most of physician training in this area occurs at the postgraduate level [20]. Despite recognition of the importance of such training, educational frameworks vary significantly in content and structure, highlighting the need for more standardized, culturally sensitive training to effectively address the needs of diverse populations, including the Arab community [19, 22, 38]In recent decades, research interest in the barriers, attitudes, and characteristics of referral to palliative care among Arab caregivers in various countries has increased. Studies conducted in Jordan, Palestine, Saudi Arabia, and Syria indicate low levels of professional knowledge in the field, a lack of formal training, and complex and sometimes ambivalent attitudes toward the principles of palliative care. For example, a recent study in the West Bank among intensive care nurses found that despite positive attitudes toward supportive care, actual knowledge was limited, leading to low self-confidence in providing this type of care [39]. Additionally, a qualitative study in Saudi Arabia revealed that cultural barriers, lack of infrastructure, and communication challenges with patients’ families hinder the availability of services [40].

Despite the significance of these findings, no empirical studies to date have focused specifically on Israeli Arab healthcare providers to explore and understand how their professional characteristics, attitudes toward PC, and cultural and religious beliefs may shape their decisions to refer (or not refer) Arab patients to PC services. While previous research on PC among Arab communities has largely examined patient and family perspectives, these studies typically included only a small number of Arab participants within much larger, predominantly non-Arab samples. Consequently, the unique cultural, religious, and professional contexts of Arab healthcare providers in Israel have remained underexplored. The current study directly addresses this gap by focusing exclusively on Arab healthcare professionals, offering an in-depth examination of how their cultural identity, religious beliefs, and clinical experience shape referral decisions for PC. This context marked by minority-majority dynamics and intergroup trust issues adds a crucial layer of complexity to our understanding of PC accessibility and delivery.

This literature gap underscores the need for focused research discovering on how cultural identity, religious affiliation, and professional background and training shape the clinical decision making of Arab healthcare providers in Israel when it comes to PC.

Methods

Aim

This study aims to examine how cultural and religious factors, including religiosity levels and death and dying anxieties, influence Arab healthcare providers’ decisions regarding referral of Arab patients to PC at the EOL. By exploring and understanding Arab caregivers’ perceptions and experiences, the study also seeks to inform healthcare systems to better address cultural barriers and enhance the quality and accessibility of EOL care for the cultural minorities, such as the Arab populations in Israel.

Design

This study employed a descriptive qualitative research design, following the Interpretive Phenomenological Analysis (IPA) approach [41]. Semi-structured, in-depth interviews were conducted to explore the perceptions, attitudes, and experiences of Israeli Arab healthcare professionals regarding PC and referrals of Arab patients to PC services at the EOL. IPA is a qualitative research approach that aims to understand how individuals make sense of their lived experiences and the meanings they attach to them. Rather than focusing on measuring behaviors or outcomes, it seeks to explore participants’ inner thoughts, emotions, and interpretations in their own words. This method is particularly valuable in studying culturally sensitive and emotionally charged topics, such as death, suffering, and EOL care, where personal meaning and context play a central role. This approach is well-suited to examining how healthcare professionals interpret their professional roles, ethical considerations, and sociocultural dynamics that influence their decisions and actions in the provision of PC.

Participants and sampling

Our research population include Israeli Arab professionals working with patients at EOL in the hospital setting. We chose this population for its engagement in medical decision-making concerning referral and utilization of PC services. The sample included 26 participants from six hospitals. The six hospitals were purposefully selected from different geographic and administrative regions of Israel, including Northern, Haifa, Central (Hasharon), Jerusalem, and Southern districts. The selection of these hospitals was aimed to correlate with the regional distribution of the Arab population in Israel to ensure broad cultural and religious participation of sub-groups within the Arab population, including Muslim, Christian, Druze, and Bedouin communities. In addition, these hospitals vary in size and in serving Israeli Arab populations with diverse religious backgrounds. Regional variation was reflected in the predominant religious affiliations of patients as follows: One hospital from the Haifa region, serving Israeli Arabs of all religions, primarily Muslims and Druze; One hospital from the Galilee region, treating a mixed Arab population, predominantly Muslim; One hospital from the Nazareth region, serving a primarily Christian Arab community; One hospital from the Hasharon region, with a patient population consisting mostly of Muslim Arabs; One hospital in southern Israel, providing care predominantly for Bedouin Arab patients; and one hospital from the Jerusalem area, serving a diverse Arab population from East Jerusalem and its surrounding neighborhoods. After obtaining institutional permission, researchers attended staff meetings in relevant departments (surgical, internal medicine, intensive care, and oncology) to present study details and invite participation. From those who agreed, participants were purposively selected based on their ability to contribute the most to the research study.

Participants were eligible for inclusion if they were Arab residents of Israel, and licensed medical doctors or registered nurses working in hospital settings that provide care to terminally ill patients at EOL. Additionally, participants were required to have at least two years of clinical experience in caring for patients approaching the EOL. This design aimed to include participants who could meaningfully articulate their thoughts, emotions, and behaviors regarding PC decision-making, based on their direct clinical encounters with EOL patients.

Data collection

Data collection began from December 2022 to May 2023 after receiving ethics approval from the University’s Ethics Committee (Approval No. 254/22, dated July 17, 2022) and the participating medical centers: EMMS Nazareth Hospital (Approval No. 55-22-EMMS), Hadassah Medical Center (HMO-0105-23), Galilee Medical Center (0152-22-NHR), Carmel Medical Center (CMC-0160-22), Hillel Yaffe Medical Center (0119-22-HYMC), and Soroka Medical Center (0103-23-SOR).

A total of 26 in-depth interviews were conducted with healthcare professionals, in Hebrew, based on participants’ language preferences and to facilitate joint analysis with the second author. Twenty-four interviews were conducted between March 2023 to April 2024, via Zoom, while two were held in person in hospital departments or alternative locations selected by the participants. Interview duration ranged from 51 to 147 min, with an average of 88 min, allowing for comprehensive exploration of the research questions. All interviews were audio-recorded and transcribed by the researcher. Data collection continued until thematic saturation was achieved when no new themes emerged from subsequent interviews [42].

Interview guide

An interview guide was developed specifically for this study based on the literature review, including 63 questions organized under seven major sections: [1] participants’ biographical information such as age, education, religion, religiosity practices and clinical experience; [2] participants’ perceptions regarding EOL and PC (e.g., “What is ‘EOL’ for you?“, “What do you think characterizes this stage?“, “In your viewpoint, what is PC?“; [3] participants’ referral practices and actors shaping their decision making in the area of PC (e.g., " In your view, what are the factors that influence (facilitate or hinder) referral to palliative care?“, “What factors influence your decision to refer patients to PC?“); [4] participants’ education and training in PC (e.g., “Do you have formal education or training qualifying you to deal with EOL issues?“, “To what extent do you believe your training in EOL care is sufficient?“) [5], external influences and interpersonal relationships related to ethical decision-making at EOL (e.g., “With whom do you discuss ethical dilemmas arising in your work?“) [6], perceptions regarding the patient’s family involvement in decision-making processes at EOL (e.g., “What role do family members play in the decision-making process for seeking PC ?“), and [7] a concluding section, including open-ended questions that allow participants to discuss additional relevant issues or clarify previous responses. An English version of the interview guide is available as a supplementary file (Supplementary File 1).

Data analysis

Data were analyzed following IPA Analysis [43], and consisted of several stages. In the initial phase, the researchers thoroughly reviewed the transcripts, reading them multiple times to grasp the broader context, identify emerging patterns, and recognizing key themes within the data. Next, transcripts were systematically coded, and key themes and sub-themes were collaboratively identified by the research team. Thematic analysis was employed to explore and understand participants’ overall views and attitudes on palliative care as well as factors influencing or deterring patient referral to PC. Relevant excerpts were coded in alignment with the research objectives and research questions through an initial coding process. Subsequently, a joint meeting of the research team was held to reassess the identified categories and core themes. This phase facilitated a more precise and in-depth interpretation of the data while enhancing the trustworthiness of the findings through the re-examination of codes and the identification of overlaps across different categories. To ensure credibility, findings were supported by representative quotations that authentically illustrate participants’ perspectives. We used ATLAS.ti (version 9) software to help with the data analysis.

Results

A total of 26 healthcare professionals participated in the study, including10 physicians and 16 nurses (15 Males, 11 females). They have been working in various departments including internal medicine, surgery, oncology, and intensive care across 6 hospitals. Participants’ ages ranged from 26 to 53 years old, with diverse religious affiliations including Muslims, Druze, and Christians. Participants’ reported levels of religiosity varied from secular to highly religious. Most participants were married, with varying numbers of children, ranging from zero to four. Participants’ biographical information using pseudonyms is described in Table 1.

Table 1.

Participants’ biographical information

Name	Role	Clinical Experience (Years)	Gender	Age	Department	Religion	Level of Religiosity	Marital Status	No. of Children	Region of Medical Center
Aziz	Nurse	4	Male	28	Intensive Care	Muslim	Traditional	Single	0	Jerusalem
Thaeer	Nurse	8	Male	31	Internal Medicine	Muslim	Religious	Married	1	Jerusalem
Salah	Physician	6	Male	43	Intensive Care	Muslim	Traditional	Married	1	Hasharon
Mayson	Nurse	6	Female	43	Internal Medicine	Muslim	Religious	Married	2	Hasharon
Ali	Nurse	5	Male	39	Internal Medicine	Muslim	Secular	Single	0	Galileel
Fatma	Physician	18	Female	47	Internal Medicine	Muslim	Secular	Married	1	South
Tony	Physician	4	Male	35	Internal Medicine	Christian	Secular	Married	0	Nazareth
Riham	Nurse	4	Female	26	Internal Medicine	Muslim	Very Religious	Single	0	South
Khaleed	Physician	6	Male	31	Internal Medicine	Muslim	Secular	Married	0	South
Mohamed	Physician	5	Male	34	Internal Medicine	Muslim	Religious	Married	2	Nazareth
Nasser	Physician	3	Male	30	Internal Medicine	Muslim	Secular	Married	0	South
Khaleel	Nurse	4	Male	32	Surgical	Muslim	Secular	Single	0	Haifa
Ruba	Physician	2	Female	29	Oncology	Muslim	Secular	Single	0	Galileel
Ahmad	Physician	2	Male	31	Internal Medicine	Muslim	Traditional	Married	2	Jerusalem
Sameh	Physician	4	Male		Internal Medicine	Christian	Secular	Married	2	Hasharon
Hani	Physician	6	Male		Hemato-oncology	Muslim	Secular			Haifa
Wafaa	Nurse	2	Female	41	Internal Medicine	Muslim	Religious	Widow	2	Nazareth
Sondos	Nurse	33	Female		Intensive Care	Christian	Traditional	Married	4	Nazareth
Haya	Nurse	20	Female	39	Internal Medicine	Christian	Secular	Married	1	Jerusalem
Lor	Nurse	16	Female	40	Intensive Care	Muslim	Religious	Married	2	Hasharon
Noor	Nurse	28	Female	53	Surgical	Christian	Traditional	Married	2	Galileel
Mervat	Nurse	10	Female	33	Internal Medicine	Muslim	Traditional	Single	0	South
Fady	Nurse	5	Male	33	Intensive Care	Druze	Traditional	Married	0	Nazareth
Nidal	Nurse	7	Male	34	Intensive Care	Muslim	Traditional	Married	0	Jerusalem
Sameer	Nurse	12	Male	36	Internal Medicine	Christian	Traditional	Married	1	Galileel
Siwar	Nurse	13	Female	35	Internal Medicine	Druze	Traditional	Married	2	Haifa

Three major themes emerged from the analysis: 1) factors shaping the decision of whether to refer patients to PC; 2) factors shaping patient’ and their family’s decision of whether to pursue PC within Arab society; 3) The role of religious and cultural values in decision-making pertaining to PC.

Theme 1: factors shaping the decision of whether to refer patients to PC

The interviews explore how participants’ referral of patients to PC is influenced by a wide range of factors, including personal, professional, and cultural aspects [44]. This theme includes two main categories referring to factors that either facilitate or hinder healthcare professionals in referring patients to PC focusing on the Arab society. While both of these categories will be discussed below, the second category, referring to barriers of PC referral was much more present and received more weight in the interviews.

Facilitators of PC referral

The interviews reveal two major factors that may facilitate referral to PC: patient age and the stage of the disease, Hence, participants share that they tend to refer elderly patients and those in advanced stages of illness to PC more frequently than younger patients or those in the acute phase of the disease. This pattern suggests that age and disease progression significantly influence referral practices. as mentioned by one of the participants:

If it’s someone whose condition is truly severe, I wouldn’t give false hope that’s something I would never do because it goes against my values. If I see, for example, an elderly patient with multiple illnesses, and continuing treatment would only prolong their suffering, personally, I am against continuing resuscitation and extending life in such cases (Aziz, male, 28 years).

Barriers to PC referrals

This rich category includes various factors that participants raised in their interviews as hindering PC referrals. First, most participants reported a lack of understanding regarding the nature of PC, with many believing it focuses solely on pain management. As a result, in many of the cases, participants prefer administering analgesics by department physicians or pain specialists rather than referring the patient to a more comprehensive PC that would have included physical, emotional, and social support to both patients and their families. As one healthcare provider mentioned:

Whenever I heard the term ‘PC’ or ‘supportive care,’ the first thing that came to mind was death. Essentially, I associated it with sedation, administering some pain relief medications like morphine, and, in most cases, the patients I encountered would not survive more than 24 h before passing away. My perception was always that these patients wouldn’t live beyond six months, and our role was to help them avoid suffering. I never thought of it as ending lives, but rather as alleviating suffering, that was my understanding. However, after my personal experience with my father, who was diagnosed with metastatic lung cancer in an advanced stage, I truly came to understand what PC is (Thaeer, male, 31 years).

In addition, the interviews reveal that cultural aspects, religious beliefs, and stigma surrounding PC held by healthcare providers, patients, and their family members can significantly shape participants’ referral of patients to PC. Believing, e.g. that PC equals giving up on treatment may result in reluctance to make such referrals. Additionally, religious beliefs can impact decision-making in this area. For instance, participants described how the belief that life and death are solely in God’s hands can create hesitancy in communicating prognoses or initiating EOL care discussions. Others expressed a strong hope for divine intervention, even in cases where medical knowledge indicates a terminal trajectory. These beliefs may delay or hinder appropriate referrals to PC and their understanding is crucial for improving decision-making processes and referrals to PC.

As a religious Muslim, it is difficult for me to say, ‘Your father will die in six months according to the literature…… I can’t say it because, from a religious perspective, the soul is in God’s hands. I cannot define it or set a time frame. What I can say is: ‘Your father’s condition is critical; he is in God’s hands. Based on our knowledge of the disease and its symptoms, he may have only hours, maybe days, maybe months, but his condition is severe and unstable.’ But I always leave open the possibility that it could be just hours. I present all possibilities, but I will never say definitively, ‘He has only a few hours left.’ … I will never set a specific time for death. I can’t hold on to that because that is our faith. (Thaeer, male, 31 years).

I always try to integrate my faith with medical knowledge…As a doctor, someone who has studied this field, I understand that the end is near in such cases. But at the same time, I always have this feeling that a divine miracle could still happen and save the patient (Salah, male, 43 years).

In our society, as I mentioned, awareness and perception of the EOL are significant issues. We don’t want to talk about it. We don’t want to hear about it. We don’t want to acknowledge that there is an end. Even in the face of severe illness, we don’t want to hear that in a year or six months, we might no longer see this person. It is difficult for us to process. It is a natural defense mechanism. (Thaeer, male, 31 years).

Participants’ cultural views are sharpened in the presence of a suffering patient, highlighting the inner conflict between religious beliefs and the ethical imperative to reduce suffering. The following quote illustrates this tension: We are not supposed to interfere in such matters because we know that they are determined by Allah, by God. That is the perspective we come from. In our faith, it is said that it is forbidden to hasten things, and in our religion, this is prohibited, it is not allowed. … When we work with patients and see them suffering, our goal is to minimize their suffering as much as possible. Maybe it’s different when I’m at home watching a lecture on this subject—it feels different to me, like it’s something else. On the other hand, it contradicts what our religion teaches us” (Mayson, female, 43 years).

Moreover, most participants indicated that their professional training during their studies or work is insufficient for dealing with EOL patients, including managing conversations about EOL care and referring patients to PC. The lack of knowledge or skill led staff members to experience apprehensions to avoid coordinating care for EOL patients. According to one participant:

Those who lack seniority, experience, and a sense of stability, both religiously and professionally, are less likely to address these topics. You can see that these staff members prefer to avoid these conversations and simply follow the written treatment protocols without considering alternative approaches, such as PC. …It always troubled me to care for such patients, and I believe this is strongly tied to both professional experience and life experience. You can also see that some staff members are more proactive and willing to engage in these conversations. Over time, I have noticed that as I gain more experience, I feel more confident in dealing with these situations“(Aziz, male, 28 years).

Furthermore, Death anxiety and emotional burden experienced by the participants may also shape their decision-making regarding PC referrals. Participants revealed that they sometimes avoid initiating EOL discussions and referring patients to PC due to fear of confronting death and feelings of inadequacy in aiding the patient, as well as the significant emotional burden associated with engaging in complex and emotionally charged conversations with the patient and/or their family members:

There is a profound confusion rooted in fear. And this fear is not only present among families and patients but also within us, the medical and nursing staff. I often observe doctors avoiding these patients, hesitating to approach them. Nurses, too, refrain from entering these rooms when they know the prognosis and the diagnosis. …. Patients and their families pick up on this fear, and it amplifies their own anxieties. (Ali, male, 39 years).

It was like an emotional roller coaster, packed into a fifteen- or twenty-minute conversation. It shakes you; it pulls you into that same emotional roller coaster. You start thinking, ‘Wow, what is happening to this person?’ One moment he’s laughing, the next he’s crying… It was an incredibly difficult conversation for me. I came out of it completely drained, and that day, I left work at one o’clock. I was supposed to stay until three, but I told my supervisor, ‘I need to leave early, I just can’t, this was too much for me to handle. (Ali, male, 39 years).

Theme 2: factors shaping patients and their family’s decision of whether to pursue PC within Arab society

This theme sheds light on the factors that shape PC decision making made by patients or their families as perceived by participants. It covers both those who demonstrate a high willingness to accept PC and those who are more hesitant or resistant to it.

The interviews explore several characteristics among patients who are more likely to seek PC. One of the primary factors in this regard is a high level of dying anxiety, leading patients to prefer symptom relief over aggressive treatment. As one participant described:

A person who fears the dying process is more likely to seek palliative care. Even if they have accepted that they are going to die, their fear of the process itself makes them seek more help, more support, and greater involvement from healthcare providers or others in their care in order to ease their suffering (Ali, male, 39 years).

Another key characteristic is patient’s level of education, providing them with greater exposure to medical information and a deeper understanding of the limitations of medicine. More educated patients tend to make more informed and rational medical decisions, increasing their likelihood of accepting PC.

Educated individuals tend to be more proactive when we approach them. Sometimes, there is a more common language, a shared understanding…. And when they understand that, we can have a meaningful discussion about what can be done, how we can ease their discomfort, how we can support them, and how they can come to terms with the EOL (Fatma, female, 47 years).

Additionally, participants share from their experience that very religious patients who believe that medicine has its limits and accept death as a natural process are more open to PC. Their belief that further medical intervention is futile at advanced disease stages leads them to focus on acceptance and suffering relief (“…they leave it in God’s hands, and that’s it. They acknowledge that the medical team has done everything possible, …. So, for them, accepting PC is okay” - Tony, male, 35 years).

Finally, another significant factor shaping patients and their family’s decision in favor of PC is their desire to end suffering. Patients who recognize that continued aggressive treatments will not improve their condition often prefer care that prioritizes comfort and quality of life

She said, ‘I just want to sleep. I am suffering so much. I haven’t been able to sleep for a long time. I just want to sleep. Give me the morphine.’ It was clear that her intention was to relieve her suffering. (Riham, female, 26 years).

But the interviews also explore other considerations that in their experience shape patients and their family’s refusal to opt for PC. One common characteristic is their young age, particularly patients in their forties and fifties who still have young children. According to some participants, young patients often express a strong desire to continue fighting the disease, fearing that accepting PC signifies giving up. They frequently articulate concerns about not having had the chance to fulfill personal and familial aspirations, such as raising their children, witnessing their milestones, and supporting their families. As one participant explained:

” It hits them in the middle of life, in their forties and fifties. They haven’t yet had the opportunity to fully enjoy their children, to see them grow up, get married, or have grandchildren. This pattern appears more frequently among younger patients and is less common among older individuals“(Khaleed, male, 31 years).

Beyond age, religious and cultural beliefs also play a crucial role in shaping patients’ attitudes toward PC. Traditional Muslim patients, for instance, may strongly believe that healing is solely in God’s hands and that divine intervention may still occur, providing a miracle that will restore their health. Such a belief may lead some patients to resist PC, perceiving it as an act of surrender rather than an approach aimed at enhancing their quality of life. As a result, discussions about transitioning to PC are often postponed or avoided, as both patients and their families hold on to religious hope:

Among Muslims, they continue treatment until the very last moment; they want medical intervention until the final second. The children constantly say, ‘I am doing everything I can because I don’t want to feel later on that I was part of the decision that led to their death.’ They don’t want to have regrets about saying, I told them not to treat.’ You see this more among Muslims, I think (Mohamed, male, 34 years).

Additionally, patients who lack trust in the healthcare system, feeling inferior to Jewish citizens or not equally deserved for healthcare services may perceive their referral to PC as a more general act of abandonment or a denial of their right to preserve the sanctity of life.

They question whether they are receiving proper treatment, whether they are being abandoned, whether the decision to stop curative treatments and transition to solely conservative care is influenced by the fact that they are Arab. There is a profound distrust that exists within the Arab community regarding the healthcare system. And it doesn’t matter if I, as an Arab physician, approach them the skepticism is something they bring with them when they enter the Israeli healthcare system……. For some Arab patients, the suggestion of PC may trigger underlying feelings of mistrust. For example: Are they giving up on me too soon? Am I no longer receiving the best possible care? Could there still be additional treatments?’ These thoughts reflect a deeper concern that decisions are being made prematurely, reinforcing a broader sense of medical mistrust (Fatma, female, 47 years).

Furthermore, according to participants, patients with a high level of death anxiety tend to refuse PC referrals as a means of postponing death for as long as possible. For them, accepting PC signifies surrender and an acknowledgment of impending death “…the fear of death, of not wanting to leave this world, right? So, I want to receive everything, don’t I? I want to receive every possible treatment, to help myself as much as I can.” (Tony, male, 35 years).

The interviews also reveal that family opposition to PC may also contribute to the patient’s refusal to seek it. In the Arab society, the family plays a central role in medical decision-making and, in many cases, dictates the course of treatment. Some of the participants shared that when family members oppose PC, there is a high likelihood that the patient will also refuse it, either out of respect for the family’s decision or due to the pressure exerted on them in other times, the patient is not even aware of her final moments:

The family in Arab society is a very powerful entity. The family holds significant influence, and sometimes, decisions are made collectively rather than individually…. There is also a significant ethical issue here, sometimes, the patient is unaware of their own diagnosis. In some cases, the family decides not to disclose the truth to the patient. I know of several patients who passed away without ever knowing their actual diagnosis. (Aziz, male, 28 years).

Finally, another significant factor shaping refusal for PC concerns limited awareness regarding the role and significance of PC among patients and their family members This lack of understanding can result in misconceptions and hesitation to pursue such treatment, as it may be mistakenly viewed as an act of giving up on life rather than a means of enhancing their quality. In some cases, PC is often misinterpreted as a life-shortening intervention, a notion that contradicts religious beliefs and moral principles, further discouraging its acceptance.

The first issue is how familiar they are and how aware they are of the options available for this type of care. In Jewish society, for example, people are often familiar with these options in advance. They may have had a family member who received hospice care, a friend who experienced it, or they simply know the concept. When I mention hospice to them, they recognize it. However, when I talk to someone from the Arab community about hospice and palliative care, in many cases, the concept is entirely new to them. So, this is one major barrier the level of awareness and how present this conversation is within the community (Fatma, female, 47 years).

Arabs find it more difficult to make these decisions. I don’t know if it’s because they may not fully understand what PC is. Maybe it’s related to religion, but I haven’t examined that. And maybe they also think that PC means the EOL, and they don’t want that. (Riham, female, 26 years).

Theme 3: The role of religious and cultural values in decision-making pertaining to PC

The final theme explores how religious and cultural perceptions shape decision-making regarding PC in the Arab society as reported by participants. These perceptions significantly influence patients’ and families’ willingness to seek PC, ultimately impacting the quality of EOL experiences. They are mostly notable among traditional Muslims, who widely believe that life and death are determined solely by divine will, leaving no room for human intervention. Such a belief is further reinforced by cultural stigma and misconceptions, particularly assuming that PC (and the use of morphine, specifically) accelerates death, thereby leading to strong opposition to seek it PC. This misconception is illustrated by the following account, in which one participant described a case where the patient’s family refused morphine believing that it would accelerate death:

There was an elderly patient with COVID-19 who was on a ventilator, and his condition kept deteriorating. We tried to wake him up because he was groaning a little, but he didn’t really regain consciousness. He started developing multi-organ failure despite the treatment he was receiving. In the end, we called the PC team, and their recommendation was to administer morphine as needed, in case he showed signs of distress. There was also an option to put him under sedation so that at least he wouldn’t suffer. Even though he was nearing the end of his life the family opposed the use of morphine. They had this belief, I don’t know where they got it from…that morphine could cause respiratory suppression. So, they insisted, saying that even if he was going to die, he should go at his own pace, and that God should take him in His own time.” (Nasser, male, 30 years).

Furthermore, in contrast to Western societies, in the Arab society, medical decision-making, particularly regarding EOL and PC, is typically a collective process led by the family members, with males such as the eldest son, the uncle, or grandfather often take the primary role.

Our study shows that when the family is not actively involved in decision-making process, the likelihood that the patient will receive necessary PC decreases. From a professional standpoint, this cultural pattern presents healthcare providers with ethical and practical dilemmas, particularly in balancing the principle of patient autonomy with the collective decision-making dynamics of the family. Such a dilemma increases when families resist sharing information with the patient regarding their own condition and treatment options, assuming full control over the decision-making process. The participants highlight that the tension between promoting the best interests of the patient and respecting cultural norms (especially as participants themselves share some of these norms) can lead to professional ambivalence and distress among participants:

” I always see this happening from the side, and now I’ll try to recall it. I remember that they always try to have the eldest son make the decision. Even when there is a daughter who is by her mother’s side throughout the entire hospitalization, and I tell her, ‘You seem to be the closest to your mother,’ she always responds, but…I especially notice this among religious families, among the Druze and religious Muslims. They say, ‘Let’s wait for the eldest son, maybe we should consult with him?’ This is something I just can’t grasp. Despite being the closest to her mother and understanding her condition best, she still defers to the eldest son’s on the matter decision” (Khaleed, 31 years).

Another finding explored under this theme concerns the involvement of religious figures in decision making at EOL. Our study shows that members of the Arab society tend to consult less with religious leaders such as a mufti or sheikh when deciding whether or not to seek PC. In these cases, families rely on verses from the Quran dealing with divine responsibility for life and death. Hence, if the patient’s family is convinced that PC may accelerate dying, they will firmly refuse it.

In Arab society, it) consultation with religious leaders regarding health issues and medical treatment) is less common. In the Jewish society, it happens more frequently, but in Arab society, I see it less often…I have seen it more in the context of organ donation rather than in decisions regarding PC. (Aziz, male, 28 years).

A significant cultural view reported by the participants involves the preference for receiving PC at home or in a hospital, alongside the opposition to transferring the patient to institutional hospice care. In the Arab society, especially among close family members, there is a deep sense of mutual familial obligation, rooted not only in social and cultural values ​​but also in religious principles that emphasize the duty of care, especially towards parents especially in old age, during illness, or at their final stages of life (mainly in Islam). This sense of religious duty often motivates family members to provide EOL care at home, viewing it not only as a personal responsibility but as a spiritual obligation that brings blessing and moral merit.

As a result, many see the patient remaining in a home environment, surrounded by family as a way to ensure a dignified death, in accordance with both religious and cultural values. Furthermore, the absence of access to culturally adapted services significantly impacts referral of patients to PC and the acceptance of such care within the Arab society:

They refuse to be in any other institutional setting outside of the hospital… A care facility is different. It’s like, ‘What? You want to put your father in a nursing home?’ That’s the perception… They usually refuse institutional care. You can’t even discuss it with them… The prevailing mindset in Arab society is that children do not place their parents in an institution (Khaleel, male, 32 years).

Discussion

This qualitative study sought to examine how cultural and religious factors influence Arab healthcare providers’ decisions regarding referral of Arab patients to PC at EOL. This section discusses three major issues, arising from its findings.

Healthcare attitudes regarding PC referrals

The study findings indicate that referrals to PC are not made consistently or uniformly, but are influenced by a wide range of clinical, systemic, and cultural considerations, which may encourage or inhibit referral for this type of care. Among the encouraging factors, the patient’s age and the severity of their medical condition play a significant role; older patients, especially those dealing with advanced or terminal illnesses, are more likely to be referred to PC than other patients. This finding is consistent with existing literature, which shows that the older the patient, the greater the probability of referral for PC. In addition, the more severe the patient’s health condition, the greater the likelihood that the healthcare providers will refer them for PC [44–48]. However, this study offers a unique contribution by highlighting how these clinical considerations intersect with cultural and religious sensitivities specific to the Arab population in Israel. As this study shows, decisions to refer Arab patients to PC are influenced not only by medical severity but also by family dynamics, perceptions of death, and trust in the healthcare system. These context-specific factors are often underrepresented in the broader literature on PC referrals.

Conversely, several inhibiting factors emerged from the findings, highlighting barriers that may prevent or delay referrals to palliative care. A key barrier is the limited knowledge among healthcare providers regarding the nature and scope of palliative care; unfortunately, as shown in this study, some clinicians are unfamiliar with the core principles and the holistic support that PC offers to both the patients and their families. This knowledge gap is often compounded by insufficient training in PC during medical education and clinical practice, which may result in underutilization of these services. Although medical and nursing training in PC in Israel is improving in recent years [49], recent studies demonstrate insufficient training and high volume of misconceptions concerning it among the healthcare team [20, 50]. Similar barriers have been identified in other studies, underscoring the need for improved education and awareness in this area [51, 52]. Additionally, the absence of clear guidelines regarding the appropriate timing for initiating PC referrals contributes to inconsistency and delays in care—an issue also noted in the broader literature [51, 53, 54].

Given these findings, it becomes evident that education and training may play a pivotal role in shaping healthcare professionals’ attitudes and competencies regarding PC [55]. Strengthening educational and training frameworks PC and EOL modules within both undergraduate and postgraduate nursing and medical curricula could address the existing knowledge and skill gaps identified in this study. This includes enhancing competencies in communication, cultural sensitivity, and ethical decision-making [56, 57]. Incorporating culturally sensitive and emotionally supportive approaches into healthcare education may enhance professionals’ preparedness for EOL care. Several systematic reviews highlight that structured PC education improves knowledge, confidence, and preparedness for EOL discussions among both nursing and medical professionals [58–60]. Simulation-based learning, reflective workshops, and interdisciplinary team discussions could provide safe environments for exploring values, emotions, and communication challenges related to death and dying. Evidence shows that such experiential approaches enhance healthcare providers’ confidence, empathy, and self-efficacy in PC contexts [61]. Mentorship programs and supervised clinical exposure to PC settings could further normalize EOL discussions, reduce death-related anxiety, and promote patient-centered care among diverse cultural and religious populations [62, 63].

Healthcare professionals’ cultural attitudes and values shaping EOL care and PC referrals

While religiosity level of medical staff has also been shown to influence clinical judgment, with higher levels of religious belief among providers associated with a lower likelihood of referrals [64], our findings do not align with such a pattern. Instead, it was participants’ cultural beliefs rather than religiosity levels that have been reported to significantly shape their clinical decision-making regarding PC referrals. A special role of these beliefs has been evidenced when participants witnessed or knew that such beliefs and values may contradict the patient’s best interest and their right to make autonomous and fully informed decisions, especially when the family dominated this process. Such conflicting situations evoked much distress, as being members of the Arab society themselves participants might have identified with these values themselves, while confronting their Western-liberal medical training and ethical values that give primacy to patient’s autonomy [65].

This type of inner conflict may be conceptualized through the lens of moral distress [66], which arises when professionals are constrained from acting according to their ethical convictions. In this case, a culturally grounded form of moral or cultural distress emerges, where the provider’s affiliation with communal values clashes with institutional expectations that prioritize patient autonomy, a dynamic particularly salient in multicultural care contexts [67, 68].

Another aspect by which participants’ cultural attitudes shaped their clinical handling of these situations involves a general discomfort or reluctance to engage in conversations about end-of-life care. Our study findings accord with previous studies suggesting that such reluctance is often driven by emotional, cultural, or institutional factors and—has been widely documented as a barrier to timely and appropriate PC referral [54, 69, 70]. Understanding these factors is essential for improving referral processes and ensuring the provision of high-quality, supportive care to patients in advanced stages of illness.

Additionally, the study findings highlight the significant influence of religious and cultural perceptions on the decisions of medical staff, patients, and their families regarding referral and acceptance of PC more generally. As our study shows, misconceptions, for example, regarding the use of morphine, such as the fear that it hastens death, may lead to avoidance of receiving PC. This raises the importance of providing a correct and comprehensive explanation of the meaning and nature of PC in order to increase the responsiveness to providing this type of care, especially to members in the Arab society.

Furthermore, and as has also reflected in our study, in Arab societies, the family plays a central role in decision-making especially at EOL. Such a reality may reach extreme but not exceptional situations in which the patient does not know about his medical condition, so that decisions, including referral and acceptance of palliative care, are made almost exclusively by the family. Therefore, it is crucial for healthcare providers to recognize the significant role of the family in healthcare decisions and adapt communication strategies accordingly to increase their support of PC. Culturally tailored communication has been shown to be key in engaging families in shared decision-making processes, especially in collectivist societies where the family is viewed as the primary unit of care and decision-making [9, 71]. Evidence also suggests that respectful, culturally-sensitive dialogue with family members can help align medical decisions with the patient’s best interests, even in situations where direct disclosure to the patient is not customary [9, 71, 72].

Alongside the family’s influence, our findings reveal that religiosity also plays a nuanced and sometimes contradictory role in shaping approaches to PC. For some individuals, strong faith reinforces hope for divine healing and delays acceptance of PC Similar findings have been explored in other studies [73, 74]; for others individuals, religiosity, others, it provides comfort and a moral framework that supports the transition to care focused on dignity and relief of suffering [74]. Moreover, as recent study shows [75], it is not only religiosity per se but also its interaction with religious identity that shapes individuals’ intention to seek PC. Hence, very religious Muslim had higher intention scores compared to less religious Muslim (predicted probabilities 0.58 and, 0.14, respectively). Recognizing this dual function of religiosity and the role it plays in the various religions within the Arab Society underscores the value of integrating spiritual care within PC services. In the Arab cultural context, trained chaplains who are familiar with Islamic, Christian, and Druze traditions could assist patients and families in reconciling faith with medical decision-making. Their involvement may strengthen communication, alleviate moral distress, and foster trust in PC as a compassionate and culturally aligned form of EOL care [76–78].

Finally, as previously reported in the literature, our findings indicate a preference for receiving care in the hospital or in the patient’s home, deterred by hospice institutions may be perceived as culturally and religiously inappropriate [54, 70, 79–82].

Patient’s attitudes shaping their wish to seek PC

The study provides additional findings to point to factors that encourage or inhibit patients’ willingness to seek and receive PC as reported by the participants. Encouraging factors include patient’s experience of high levels of dying anxiety high education and awareness of the limitations of medicine and understand the need for PC when medical options are limited, high religiosity levels confirming that the medical doctor did everything he could so that the rest is in God’s hands, and the wish to end suffering associated with aggressive treatments. Similar findings have been reported in previous studies, which emphasize the role of personal values, cultural and religious beliefs toward PC [48, 79, 83–86].

However, the current study offers a unique contribution by highlighting a less commonly explored aspect of religiosity. While most previous studies portray high levels of religiosity as a barrier to accepting PC, our findings suggest that, in some cases, religious belief can actually facilitate its acceptance. Participants described how the belief that “the doctor did everything possible” allowed them to transfer responsibility to God, making it easier to come to terms with the decision to receive palliative care. In this context, religiosity serves not only as a potential obstacle, but also as a coping mechanism that enables acceptance, a dual role that has received limited attention in prior research. Interestingly, the findings further reveal a paradoxical role of death anxiety in shaping patients’ engagement with PC as is also echoed in the literature. For some participant, heightened death anxiety generates denial and resistance accepting PC as PC symbolizes surrender and acknowledgment of impending death, leading them to pursue every possible treatment to prolong life [87–90]. Conversely, for others, the same fear becomes a motivator to seek relief, control, and dignity at EOL. This duality suggests that death anxiety operates along a continuum, ranging from avoidance to proactive engagement. Recognizing this dynamic may allow healthcare providers to harness patients’ fears as an entry point for sensitive communication with patients. By validating and reframing death anxiety through culturally attuned dialogue, clinicians can help patients and families redirect fear toward acceptance of PC, and facilitate choices that emphasize comfort, autonomy, and the possibility of dying in familiar, non-institutional settings. Furthermore, the current study integrates several key motivating factors such as dying anxiety, higher education, and the desire to avoid the suffering associated with aggressive treatments into a single interpretive framework.

This comprehensive perspective offers a deeper understanding of how personal, cultural, and religious factors interact to shape patients’ readiness to seek palliative care, particularly among Arab minority populations. Along with these findings, similar to previous studies [70, 78], our study also identified inhibiting factors to seek PC among patients, including young age, lack of knowledge among concerning the nature and meaning of PC and high levels of death anxiety. However, a unique finding of this study involves the exploration of additional factor to deter patients from turning to PC. This has to do with a Muslim affiliation and self-identity as traditional resulting in lack of trust in the healthcare system and fearing from abandonment or deprivation of life-saving treatments in case of PC.

Study contributions

This study provides in-depth insights into the factors influencing the referral of patients to palliative care, particularly concerning religious and cultural perceptions held by Arab care providers in Israel. The rich findings obtained in this research facilitate the development of culturally and religiously tailored strategies to improve access to and acceptance of PC specifically aimed at this population. Identifying key barriers, such as lack of knowledge among medical staff and misconceptions within the public, also underscores the need for professional training and awareness-raising in the Arab community. These measures can reduce resistance, correct misunderstandings, and encourage early referral to palliative care, thereby enhancing quality of life in EOL stages.

Limitations and future research

Despite the study’s contribution to the literature and clinical practice, its small sample makes it difficult to generalize a broad understanding of the researched question. However, this limitation is common in qualitative research, where the goal is often to gain depth of understanding rather than broad representativeness [91, 92]. For example, saturation-based approaches suggest that 9–17 interviews or 4–8 focus groups can be sufficient to reach data saturation in qualitative designs [93]. In addition, as with other qualitative studies, such a limitation could be overcome by the varied findings explored in this study and its heterogenous participants, as evidenced in its sample. A second limitation may have to do with the study’s focus on hospital-based healthcare providers, failing to analyze and discuss community-based medical professionals’ attitudes on PC referrals. Indeed, community healthcare providers play a crucial role and can significantly influence the development and expansion of PC services in general and within the Arab society, specifically. Incorporating their perspectives could provide additional insights into the barriers and challenges in implementing these services at the community level.

Therefore, we recommend future research that explores the barriers and challenges faced by community physicians in referring patients to PC. Such a study would enhance the existing understanding and provide further insights to support the development of more tailored and accessible PC services.

Conclusion

The study identified several key factors that shape patients’ referral to PC. Facilitating factors include patients’ advanced age, late-stage disease, and a shared desire among patients, families, and healthcare professionals to alleviate suffering and prioritize comfort over continued aggressive treatment. In such cases, PC was perceived as a more humane and appropriate option that aligns with the values of dignity and relief at the EOL. At the same time, the study revealed several barriers to PC referral. The main barriers relate to a lack of knowledge about the meaning and purpose of PC, both among medical staff, patients and their families. In addition, uncertainty about clinical guidelines for referring patients to PC and the influence of religious and cultural perceptions may also affect both healthcare providers’ referral decisions and the willingness of patients and families to receive such care.

Beyond these individual and cultural barriers, this study also highlights a structural paradox within the Israeli healthcare system. Although Arabs constitute approximately 21% of the general population, they represent about 24–25% of all physicians, 27% of nurses, and nearly half (49%) of pharmacists in Israel [94]. Broader estimates indicate that roughly 40% of the total healthcare workforce, including auxiliary staff, is Arab [95]. Despite this strong professional presence, many Arab patients continue to experience mistrust toward the healthcare system. These findings suggest that representation alone does not ensure recognition or equity. Rebuilding trust therefore requires not only linguistic and cultural concordance but also institutional transformation grounded in transparency, inclusivity, and shared decision-making. Promoting Arab leadership within PC services and strengthening communication that affirms dignity and respect may help reduce mistrust and enhance the quality and acceptance of PC among Arab patients in Israel.

The findings indicate that certain patient groups are less likely to seek PC, particularly young patients, traditional Muslim patients, patients with a low level of education and those with limited knowledge about PC While this study included a relatively small number of participants, like any other qualitative study [91, 92] its aim was not statistical representation of the research population or the generalization of its findings but achieving an in-depth exploration of experiences and its meanings. The rich narratives collected from professionals across different regions and religious backgrounds provide a nuanced understanding of how cultural, emotional, and systemic factors shape PC referral practices. These findings should therefore be interpreted as context-specific insights that can guide efforts to enhance cultural competence, professional training, and equitable EOL care. Developing a comprehensive understanding of these dynamics, as offered in other studies [75, 96], is essential for creating culturally appropriate strategies to improve access to and delivery of PC services within Arab society, ensuring that such care aligns with the needs, values, and expectations of this population.

Authors’ contributions

The current article was co-authored by both authors. Both contributed significantly to all stages of the research and the writing of the manuscript **.**.

Funding

This research was supported by the Israel National Institute for Health Research (R/285/2021) under Grant (R/285/2021). The funder had no role in the study design, data collection, analysis, or writing of the manuscript.

Data availability

The data supporting the findings of this study are available upon request from the authors, subject to the confidentiality and privacy of research participants.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and received ethical approval prior to data collection. Approval was granted by the University of Haifa’s Research Ethics Committee (Approval No. 254/22, dated July 17, 2022), as well as by the ethics committees of the participating medical centers:

• EMMS Nazareth Hospital (Approval No. 55-22-EMMS)

• Hadassah Medical Center (Approval No. HMO-0105-23)

• Galilee Medical Center (Approval No. 0152-22-NHR)

• Carmel Medical Center (Approval No. CMC-0160-22)

• Hillel Yaffe Medical Center (Approval No. 0119-22-HYMC)

• Soroka Medical Center (Approval No. 0103-23-SOR)

Informed consent to participate was obtained orally from all participants prior to their interviews. Verbal consent was recorded at the beginning of each interview.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.