We found that patients’ knowledge of their prognosis was significantly correlated with preferring palliative care. This is in line with previous research that suggests that patients who have awareness regarding their advanced disease status are less likely to opt for aggressive life-saving measures near the end of life9. Well-informed patients have reported a higher level of satisfaction with their choice of palliative care10. But, in Pakistani culture, it is believed that informing patients of bad news leads to severe psychological distress and hence, leads to a poor outcome of treatment. As a result, physicians often provide information about the diagnosis or prognosis to the patient’s family first, which then decides when to share it with the patient11,12. Almost all the patients in this study who did not know their prognosis previously, expressed their desire to be informed. Improved doctor-patient communication helps patients make informed choices that reflect their values and beliefs and minimize emotional and physical suffering13.
As expected, patients who believed that palliative care would improve their symptoms were more likely to prefer palliative care. Not surprisingly, all those patients who were bedridden chose to opt for palliative care. For cancer patients, immense pain and suffering are involved both as a result of the disease and the side effects of treatment. Previous studies have also reported that minimizing distress is of paramount importance to such patients, especially near the end of life14.
Culture and religion play a pivotal role in the decision-making process regarding end-of-life care11,15,16. In a Muslim-majority country like Pakistan, most people make decisions based on their faith11, emphasizing the need to incorporate religion into a palliative care treatment plan. Our study confirmed that people who believed that receiving palliative care is acceptable in their religion were more likely to choose palliative care. The discussions about palliative care must be individualized to the patient’s specific religious views. Incorporating Islamic end-of-life rituals into palliative care practices may allow more Muslims to be open to opting for palliative care 17.
A few research studies have shown that older patients were less likely to access palliative care18,19 as they might consider this care a hurdle to their independence20. Other studies suggest that death is considered a probable outcome of old age and this acts as an obstacle to receiving palliative care21. Notably, older people generally have less autonomy in Pakistan due to a cultural system where elderly members of the family are often financially and physically dependent on their offspring and healthcare decisions are made by their families22.
Patients consider it essential that their choice is considered when deciding on the location of end-of-life care23. Previous research suggests that most patients choose to receive palliative care in their own homes23,24, and very little preference is given to hospitals as an end-of-life care location25. The majority of the patients in our study preferred to receive palliative care at home. This highlights the need to develop the ability to deliver such services at home in Pakistan. To the best of our knowledge, our study is the first of its kind that shows the preference for palliative care among the Pakistani population. Even with the limitations mentioned below, this study provides important insight into end-of-life care practices in Pakistan.