Structural barriers to timely palliative care conversations in oncology: An audio-diary study

Background

Timely communication about palliative care (PC) is essential to ensure early, patient-centred integration of PC into cancer care. In practice, uncertainty about when and how to initiate these conversations contributes to delays and missed opportunities for holistic support.

Aim

To explore factors that enable or hinder timely palliative care conversations in oncology.

Methods

We conducted a qualitative audio-diary study (n = 28 entries) including ten healthcare professionals (oncologists, haematologists, nurses, psycho-oncologists, and coordinators) in an Austrian hospital. Participants recorded event-based diaries during or after shifts using a data‑secure mobile app, documenting key communication events (e.g., prognosis discussions, goal‑of‑care discussions, and (non-)referrals to PC). Audio entries were transcribed and thematically analysed.

Results

Participants reported a dominant curative focus that fostered continuation of active treatment, while PC was framed as “failure”. They described patient/family resistance to PC discussions due to stigma and misconceptions linking PC to imminent death and diminished control. Participants reported uncertainty about who should initiate PC conversations, and which PC pathway fits individual cases. Thorough counselling about PC was viewed as challenging and time-consuming, with insufficient formal recognition. It was noted that existing systems do not provide dedicated fields to document these conversations. Hierarchical dynamics were seen as inhibiting early PC conversations. Participants wished for more open, non-hierarchical, interprofessional dialogue to normalise timely PC involvement.

Conclusions

Delays in PC communication reflect structural barriers including time pressure, ambiguous roles and responsibilities, limited recognition and documentation of counselling, and knowledge gaps. To enable earlier PC integration, actions should target PC triggers, documentation, training, and referral pathways.

Key messages

• Timely conversations about palliative care are often delayed by structural barriers such as stigma, unclear responsibilities, hierarchy, time pressure, and lack of documentation/recognition.

• Early palliative care integration in cancer care needs clear triggers, defined roles and referral pathways, better training and documentation, and open, non-hierarchical interprofessional dialogue.