1. Background
Globally, there were about 19.3 million new instances of cancer and 10 million cancer-related deaths recorded in 2020 (1). Cancer is the third most common cause of death in Iran, after cardiovascular illnesses and accidents (2). These data have made cancer a global public health concern. A cancer diagnosis, the nature of the illness, and the effects of therapy may be very stressful for the patients and their families. During the illness, physical symptoms, in addition to mental discomfort, social demands, and spiritual pain, completely change their lives and result in symptom load, emotional, social, and spiritual suffering (3). Factors include physical symptoms, emotional, social, and spiritual suffering, drug toxicity, side effects, and irreversible problems (4). However, the protracted nature of the illness puts strain on the medical system, particularly in cases where resources and cutting-edge technology for cancer treatment are scarce (5). Palliative care, which controls cancer symptoms and consequences, is thus seen as a crucial component of cancer management (6). Palliative care is a holistic approach that aims to enhance the quality of life (QoL) for patients and their families who are facing challenges due to life-threatening illnesses. It does this by identifying problems early on, accurately diagnosing and treating physical, psychological, social, and spiritual issues, as well as by treating pain and other symptoms (7, 8). Research has shown that Palliative care for patients with cancer enhances their QoL (9-11), prolongs their survival (12-14), and increases their patient satisfaction (7-19) by lowering depression (9-14, 16), enhancing physical and psychological symptoms (17, 18), and increasing their QoL. Although Palliative care is relatively new in Iran, it faces many challenges, including inadequate training and knowledge gaps among Palliative care providers (20), low patient awareness (21), a dearth of centers specifically dedicated to Palliative care, and unstable funding sources. The conventional perspective on terminal illnesses like cancer is acknowledged (22), and because of the scarcity of resources, the unique requirements of these patients are disregarded. However, there are significant ethical issues in this profession as a result of societal and cultural disparities as well as family preferences to keep the patient's diagnosis a secret (22). Notwithstanding these obstacles, the emergence of the previously stated services in recent times suggests that the healthcare system is dedicated to provide Palliative care (23). The present state of Palliative care for patients with cancer may be examined using models, which can provide a clear image for putting required interventions into place and keeping an eye on both micro and macro-level activities. Strengths, weaknesses, opportunities, and threats (SWOT) is a straightforward conceptual framework that assesses the organization's performance as it stands (strengths and weaknesses) as well as its potential future opportunities and threats by taking into account several variables. It aids in determining whether an organization's primary issues call for a strategy review, better strategy implementation, or both (24). The issues of university education programs, workplace education, general awareness, and patient and family empowerment were highlighted in this respect by the findings of a research that examined the educational requirements of cancer patients with SWOT at the macro level (25).
2. Objectives
The purpose of this research project was to examine the state of Palliative care provision for cancer patients referred to one of Iran's referral institutions, Shohadai Tajrish Hospital, located in Tehran.
3. Methods
This qualitative study examines the type of contract content analysis and is a component of the doctoral dissertation research action in nursing that examines the impact of Palliative care services on breast cancer patients' satisfaction and quality of life in one of the cancer referral hospitals.
3.1. Participants
This research comprised a total of 19 participants, consisting of 8 patients, 7 patient caregivers, and 4 care providers. The individuals were recruited in a planned manner. The participants in the study were patients with cancer and their companions who visited Shohadai Tajrish Hospital. They attended the cancer clinic as outpatients and were also admitted to the oncology department for hospitalization. The care providers consist of the medical professionals employed in Shohadai Tajrish Hospital, namely in the Oncology Department and Cancer Clinic. The selection of participants continued until data saturation.
3.2. Data Collection Method
Data were collected between May and July 2023 through semi-structured interviews conducted at Shohadai Tajrish Hospital (Oncology Department and Comprehensive Cancer Control Clinic). After obtaining participants' consent, interviews were scheduled based on their preferences. Questions were tailored to the participants’ roles: Patients and caregivers were asked about their needs, expectations, and desired services, while healthcare providers were questioned about care procedures, patient needs, barriers, and requirements for palliative care. Follow-up questions were used when needed for clarification. All interviews and field notes were recorded with participants’ permission.
3.3. Data Analysis
Data analysis was conducted concurrently with data collection. The data administration was performed using MAXQDA software version 10. The data was examined using the methodology proposed by Granheim and Lundman (26, 27). Initially, the interviews were transcribed, and then, the written interviews were thoroughly scrutinized and analyzed multiple times to extract the overarching notion. This was conducted following the methodology proposed by Granheim and Lundman (27). Semantic statements reflecting participants’ understanding were selected and coded based on the study’s objectives. Similar main codes were grouped into broader categories to uncover hidden meanings in the data. For the SWOT analysis, divisions were made using standardized and open-ended questions to identify internal (strengths and weaknesses) and external (opportunities and threats) factors affecting the hospital. After qualitative analysis, subcategories of each main category were placed into the SWOT matrix to present the current state of Palliative care delivery for patients with cancer (27).
3.4. Trustworthiness
To ensure the rigor of the study, criteria such as credibility, dependability, confirmability, transferability (28) and trustworthiness were applied (29). Reliability was achieved through ample time for data collection, sustained presence at the research site, diverse participant selection, and collaboration among multiple researchers. Dependability was supported by active participant and observer involvement in data review. Detailed documentation of research steps improved verifiability, while maximum diversity sampling enhanced the transferability of findings. Researchers also conveyed participants’ words and experiences with accuracy and sincerity.
3.5. Ethical Considerations
This study was conducted as part of a project approved by Shahid Beheshti University of Medical Sciences and its Research Ethics Committee (code: IR.SBMU.CRC.REC.1400.018). Before their involvement in the investigation, the participants were provided with a clear explanation of the research aims and their agreement was sought to participate in the study. Enrollment in the research was entirely optional and had no impact on the treatment and care provided to patients and their caregivers. Every participant was guaranteed that their information would be kept secret.
4. Results
The mean age of patients and their family caregivers was 48.37 and 48.21 years, respectively. The care providers consisted of four individuals specializing in cancer surgery, oncology, and nursing, with an average age of 46 years. Through data analysis, a total of 462 codes were identified, which were then categorized into 14 subcategories and 5 major categories. Each subcategory was then assigned to its respective main category in the SWOT matrix as shown in Table 1. The primary categories identified were comprehensive support, effective communication, uncertainty, search for information, and infrastructure.
Table 1.Statements of Strengths, Weaknesses, Opportunities, and Threats Analysis Based on Study Subcategories
| Categories and Subcategories | Definition |
|---|---|
| Comprehensive support | |
| Strength | Management of physical complications: Completing the form of unwanted drug side effects after any drug side effects occur; pain relief, attention to religious and spiritual trends: The presence of a culture of trust and appeal to patients; spiritual dryness |
| Weakness | Failure to comprehensively assess the requirements of patients' families; ignoring the nonphysical requirements of patients; gradual loss of patient independence in the care process; changing the patient's role in terms of cancer; spiritual dryness |
| Opportunity | Presence of palliative care centers and home care with the active participation of nurses; participation of doctors and health care providers in providing care at home |
| Threat | Focusing on "disease" instead of "patient"; poor service insurance coverage |
| Effective communication | |
| Strength | Empathy of nurses |
| Weakness | Insufficient time to communicate effectively with the patient and his family; failure to provide necessary explanations to the patient and family; inappropriate treatment of nurses and doctors; failure to respect privacy due to simultaneous examination of several patients |
| Opportunity | - |
| Threat | Lack of doctors and nurses; quick doctor's visit; wasting nurses' time on care documentation |
| uncertainty | |
| Strength | Having experienced and literate nurses and doctors; willingness of family caregivers to learn care matters |
| Weakness | A large number of patients visit this center; incorrect culture of nonverification of doctors' orders by other doctors |
| Opportunity | Red crescent pharmacy; support from donors to provide medicine and equipment |
| Threat | Lack of medicine and medical equipment in terms of international sanctions; high cost of drugs; using drugs that replace the main drugs with less effectiveness; physical, mental and financial burden related to cancer treatment |
| Search for information | |
| Strength | Educational pamphlets are available in all departments |
| Weakness | Low health literacy of patients; the desire to get information from the internet instead of an expert; providing information from patients with similar diseases instead of specialists |
| Opportunity | Preparation of educational materials approved by the ministry of health; active presence of specialist doctors in educational programs on tv |
| Threat | Uncertainty of the main custodian of patient education in the country's medical centers; insufficient knowledge of care providers regarding palliative care in the health system; inadequate health literacy at the community level |
| Infrastructure | |
| Strength | The possibility of an online appointment; bed division according to specialists |
| Weakness | Absence of clinical guidelines for providing palliative care; unnecessary occupation of hospital beds; large volume of referred patients from cities, lack of teamwork; focusing treatment and care of bronchologists; uncertainty of the description of the duties of the palliative care team; hospitalization of cancer patients in general wards |
| Opportunity | Focusing the ministry of health and researchers on palliative care; adding palliative care to the curriculum; continuing education courses for health care workers and doctors; holding regional webinars; fellowship courses for professionals |
| Threat | Absence of clinical guidelines and palliative care guidelines in the country; long line of patients in need of advanced care; current palliative care is based on experience, not knowledge |
4.1. Comprehensive Support
Comprehensive support includes spiritual care, pain management, trust-building, and monitoring medication side effects. Participants emphasized the role of faith, with some feeling closer to God during illness. However, gaps in Palliative care remain, such as neglect of emotional and spiritual needs, limited family assessments, reduced patient autonomy, and spiritual distress. Some patients perceived their illness as punishment, leading to emotional suffering. Participants saw palliative care centers and home-based services by trained professionals as vital for comprehensive support. One noted that while hospital treatment is essential, many challenges arise at home, including unanswered questions and new side effects. They recommended assigning knowledgeable nurses to provide remote guidance and hospital-based support for serious complications. At the macro level, participants identified major challenges such as a healthcare focus on the disease rather than the patient, and inadequate insurance coverage. One participant highlighted the severe difficulty in accessing medication, noting that patients face both health and financial burdens: "Doctors only visit during scheduled appointments and seem indifferent to my concerns. I am currently at the location but have had no direct contact with the physician. The doctor prescribed four medications and left, and the nurse administered them without providing any further explanation. I would greatly appreciate information about the potential side effects of these medications, along with clear instructions on what to do and what to avoid while taking them."
4.2. Effective Communication
Effective communication pertains to the systematic establishment of verbal and non-verbal exchanges in order to educate the patient and their family members about self-care practices and alleviate the burden of the illness. The primary advantage in this domain was the nurses' capacity for empathy. One nurse commented on the significance of communication with the patient and the patient's family, as well as the barriers to communication: "Patients with cancer often experience significant psychological stress and need education and meaningful conversations to feel understood and reassured — especially regarding concerns like employment. They value our time and seek empathy, yet due to our limited availability and the demands of documentation, we are often unable to engage with them as much as they need." The majority of patients and their family members expressed dissatisfaction with the perceived lack of time dedicated by the treatment staff and the disregard for patient privacy. These concerns were seen as significant weaknesses in the delivery of Palliative care. One patient, commenting on the issue of privacy, stated: “It is my right to be examined without other patients present in the room, so I can fully explain my problems.” Another added: “It bothers me that others know about the illness I’m suffering from. I don’t understand why these matters are treated as unimportant by the staff.” Some challenges encountered in the provision of Palliative care included concise doctor's appointments, unsuitable nurse-physician interactions, and the diversion of the nurse's time towards paperwork rather than in-person treatment. One caregiver voiced frustration with the quality of care, stating: “The physician attending to my father is extremely impolite. He remains silent during visits, and when we ask questions, he fails to offer clear explanations. We’ve come to expect disappointment. When we seek clarification, the staff simply tells us to ask the doctor. I just wish they would show more empathy toward the patient and their family.”
4.3. Uncertainty
Uncertainty in cancer patients refers to the difficulty in understanding illness-related events and the unpredictability of the future, which can hinder their ability to make plans. This sense of uncertainty can persist throughout the cancer journey, from diagnosis and treatment to long-term survivorship. It often leads to feelings of anxiety, sadness, and fear. On a positive note, patients and their families appreciated the presence of skilled and knowledgeable nurses and highlighted caregivers' willingness to learn how to provide effective care. One patient remarked, “For example, look at Mrs. Kh’s shift — I think it’s very smooth. She has been in this unit from the beginning. When I ask a question, she answers it beautifully. She gives me my medication, explains what I need to do next, and even the vein extraction goes extremely well.” Reflecting the commitment of the staff, one nurse shared, “As a dedicated nurse, I always seek more information because our unit is specialized. I participate in workshops and enroll in several virtual continuing education programs relevant to my field.” It is thought that one of the shortcomings of the existing Palliative care system is the significant financial and psychological strain that patients and their families are experiencing due to the unpredictability of the nation's economic position. With rising prices and ongoing foreign sanctions, the financial burden on patients is worsening daily. One caregiver shared the hardship: “At the beginning of the illness, we asked everyone we knew to borrow money, but either they couldn't help or were in even worse situations than ours. Eventually, all our savings were exhausted. We had no choice but to sell our car, but even that wasn’t enough.” Philanthropists have offered a practical solution to these challenges by providing financial support to low-income patients and donating essential medications to Red Crescent pharmacies on behalf of the government. Regarding medication challenges, one caregiver shared, “Obtaining medication is extremely difficult. The patient is not only worried about their health and financial burdens but also deeply concerned about the availability of medicine, which is even more troubling. Most of the medications we receive are Iranian. Currently, only one of my medications, Erbitux — which I believe is European — is not locally produced. The rest are Iranian, like my father.” A significant concern is the lack of coordination among physicians, as many are reluctant to accept the prescriptions or treatment plans made by their colleagues. One caregiver expressed frustration: “We have had to change his medications multiple times. Each time, they question everything — ‘Which doctor prescribed this? Why was this medication given instead of another one?’ One doctor even asked why my father hadn’t eaten yet, saying, ‘You’ve already taken that medication; you should have taken this one now.’ It's all very confusing and stressful for us.”
4.4. Searching for Information
Patients and their families actively sought disease-related information and caregiving practices. Their search extended across multiple sources, including consultations with medical professionals, online platforms — which sometimes provided unreliable or inconsistent information — and conversations with individuals who had personal experience with similar illnesses. The inclusion of instructional brochures in various hospital departments proved to be a valuable resource in delivering Palliative care, particularly for patients seeking additional information. One patient noted that healthcare professionals often lack the time to offer detailed assistance. They emphasized the importance of educational materials, stating that having access to written information is better than receiving no guidance at all. Inadequate health literacy and reliance on untrustworthy sources posed a challenge in delivering Palliative care. One of the caretakers said that they get information from other patients who share similar circumstances. They inquire with the patients' roommates and sometimes receive input from the doctor or nurse on their level of boredom. Within the hospital setting, it is important to note that there are no available beds that may be allocated for personal use. We alone attend the meeting at the designated time, provide meals to him, and then go back to our place of residence. The broadcasting organization leverages the expertise of medical specialists by inviting them to participate in live television shows. During these programs, the experts discuss various ailments and answer viewers' questions, which are submitted via phone. One patient highlighted the value of Channel 3's weekly Wednesday presentations, where doctors provide insightful and practical information on cancer. This platform has proven especially beneficial for those affected by the illness, offering solutions to some of their concerns. On the other hand, the lack of a designated authority responsible for overseeing patient education in the country is a significant concern, leading to inconsistent and disorganized information being broadcast on television. One health authority mentioned that the main issue lies in education, as there is currently no dedicated domestic resource for Palliative care. As a result, they are forced to gather material from various international websites each time. If there were a clear custodian for education, the nation would not be facing this state of educational uncertainty.
4.5. Infrastructure
Infrastructure has several dimensions, referring to providing appropriate structures and prerequisites, as well as improving processes to ensure the equitable distribution of services and resources. One aspect involves offering training courses for specialists, revising the curriculum for students, and developing relevant guidelines. Additionally, this is one of the specialized centers for admitting patients with cancer nationwide. To ensure that all patients have equal access to care services, appointment scheduling has been made online, and hospital beds are allocated among specialist physicians, a strength of the current Palliative care provision at the center. However, this approach has weaknesses like the absence of clinical guidelines for fieldwork, unnecessary occupancy of beds, a high volume of patients, unclear roles of the care team, workload pressure on oncologists, and sometimes admitting cancer patients to general wards instead of specialized sections. Besides the Ministry of Health’s focus on Palliative care, the existence of distance learning programs and regional webinars, and the inclusion of Palliative care topics in textbooks provide an opportunity to advance optimal and effective Palliative care. However, the long queue of patients needing Palliative care and the lack of a national Palliative care guideline (which has led to care being provided based on experience and intuition rather than knowledge) may pose a threat. One of the department's representatives stated: "Anyone can say anything about Palliative care; no comprehensive book or website is available to everyone. Both the personnel's training needs and the subject matter they should be taught are unclear. We don't know how much of the work we conduct has a scientific foundation since our team mostly relies on experience and intuition. It's a complicated situation.
5. Discussion
This study was carried out with the aim of examining the status of Palliative care provision for patients with cancer referred to Shaohadaye Tajrish Hospital (located in Tehran, the capital of Iran). Five kinds of complete support, effective communication, uncertainty, information seeking, and structural-systemic elements were identified as a result of this research.
5.1. Comprehensive Support
The first class to be taken away from this research is all-encompassing assistance, which emphasizes pain management and spirituality as assets. Spirituality is the connection a person has to their religious choices, beliefs, and practices, which instills a genuine sense of goodness and inspiration. It strengthens their faith, fortitude, and hope, enabling them to overcome obstacles and challenges in life (30). The concept of "spiritual growth" was extracted from the findings of a research that examined the effects of spiritual care from the viewpoints of patients with cancer, patient family members, and oncology nurses. Given that over 98% of Iran’s population is Muslim, spirituality is an essential part of people’s lives (31). In a study by Nemati et al. aimed at designing and psychometrically evaluating the caring ability of family caregivers of patients with cancer using the scale (CAFCPCS) tool, one of the extracted dimensions was “Trust in God,” highlighting the spiritual nature of Iranian society and the role of religion in coping with life’s hardships, such as illness (32). The findings of the Young et al. research demonstrated the significance of spirituality for both patients and caregivers, as it influences the former's capacity and readiness to provide the latter kind of care (33). Higher-quality nursing care results from addressing holistic care and offering spiritual care according to the patient's requirements. The nurse's inner happiness and tranquility of mind are heightened when they see the patient and family at ease (34). One aspect of cancer-related pain is the fear that pain signifies the progression of the disease. This fear is rational, as pain may indeed indicate the spread of the disease. However, the variability of pain and the disease are not equivalent, and there may be a difference between the patient’s interpretation of the significance of the pain and the actual physical condition. Hence, healthcare providers should strive to understand the meaning of pain for each patient (35). In a situation when life is changing rapidly, patients and their families are attempting to strike a balance, a process known as "navigating unknown waters" (36). Losing independence, altering the patient's role, and ignoring the non-physical needs of patients and their families were identified as shortcomings. According to earlier research, the patient's roles and relationships with his family and friends alter as a result of asking for aid from them to satisfy his growing requirements; he feels like a "burden" to them (37-39). Furthermore, the loss of pride and dignity for the patient, as well as an incapacity to regulate life, are caused by this dependency on the most private daily routines (39). The findings of the study of Lavoei et al. on patients receiving Palliative care showed that as long as the people around them respect the patient's choices, values, and ability to act, their support does not lead to the loss of the patient's independence (40).
5.2. Effective Communication
The fundamental tenet of nursing practice is the nurse-patient connection, which was developed in the writings of interactional nurse theorists like Paterson and Zderad (1976) and King (1981). Furthermore, Peplau showed that the performance of nursing is more than physical care (41). Empathy (empathic relationship) was extracted as a strength in SWOT, which can lead to better therapeutic relationships. An empathetic relationship results in more self-disclosure of the patient's symptoms and concerns, more information, more accurate diagnosis, more understanding and responsibility of the therapist towards the patient's personal requirements, and makes the sense of being listened to, valued as an individual, and understood and accepted that it has a favorable effect on treatment outcomes (42). The findings of a study on 710 patients in Germany showed that there is a relationship between therapists' empathy with decreasing depression and improving patients' quality of life (43). The violation of privacy was one of the weaknesses of obtaining Palliative care. Respecting the privacy of the patient and the patient's family is a way to preserve human dignity, which results in increasing the intimacy and management of family mourning and facilitating the implementation of social, cultural, and spiritual rituals (44). An examination of the pertinent literature reveals that infringements on privacy lead to the following negative outcomes: Non-compliance with the physical examination, avoidance of disclosing the patient's clinical history, apprehension, distress, and anxiety, and treatment interruption (45-48). The fact that nurses spend the majority of their time writing nursing reports and the frequent and sometimes simultaneous visits of multiple patients constituted other of the greatest obstacles to Palliative care for cancer patients. Engaging in the practice of concurrently admitting multiple patients into the visit and examination room while questioning a single patient in the presence of other patients is deemed unprofessional and inappropriate. This practice is not observed in other literature reviews (49). Based on the observations of 507 nursing working hours, Michel et al. determined that patients receive care for a mere one-third of the nurses' working time. Due to the time constraints imposed by the manual system of document recording and report writing, nurses are unable to adequately engage in patient education and communication with the patient and their family (50).
5.3. Uncertainty
Cancer patients and their families often experience uncertainty and fear due to the awareness of limited time, accompanied by a constant sense of impending death (51). This often results in a shift from long-term planning to day-to-day survival, and caregivers feel that their lives are "suspended" (52). Palliative care is greatly improved by the presence of experienced therapists, as most patients are referred to well-equipped hospitals in Tehran, allowing clinicians to gain experience in treating a wide range of illnesses. However, the high volume of patients in these limited-capacity facilities poses a major challenge. Financial strain on patients and caregivers is also significant due to reduced working hours, frequent absenteeism, taking on additional jobs, and high medical expenses (53-56). The rising cost and limited availability of foreign medications, further exacerbated by economic inflation and sanctions, create additional barriers to Palliative care. However, Red Crescent pharmacies and support from charitable organizations help mitigate these challenges by providing financial aid and essential medications — turning obstacles into opportunities through collaboration between citizens and government representatives.
5.4. Information
Information plays a crucial role in understanding problems, developing strategies, minimizing discomfort, and improving well-being (57). While educational pamphlets have been developed in various hospital departments to address common questions from patients and their families, they do not fully meet patients' informational needs, and patients are generally dissatisfied with the information they receive (58). One reason for this dissatisfaction is that the quality and relevance of the provided information may be poor, and healthcare professionals may lack a full understanding of patients’ needs and fail to offer appropriate solutions (59). Acquiring information reduces patients’ anxiety and helps them make informed decisions about their treatment (60). In the study by Latifi et al., individual barriers (such as inadequate health literacy and shame) and contextual factors (such as lack of access to information resources and the attitude of healthcare staff) were identified as key obstacles to seeking health information among women with breast cancer (61). In another study, cancer patients were found to use the internet less frequently as a source of information because they considered online content to be too general, not tailored to their specific conditions, and potentially fear-inducing, leading to insecurity and uncertainty (62). Inadequate health literacy and reliance on information from other patients or the internet were noted as weaknesses in the provision of Palliative care. Study results reveal that doctors provide less information to patients with lower socioeconomic status (63, 64). Patients with low health literacy are often uninformed and less assertive, unable to make independent decisions, placing implicit trust in healthcare professionals, and thus do not seek necessary information elsewhere (65, 66). There is an opportunity in Iran to enhance Palliative care, as demonstrated by the participation of numerous physicians in television programs and the Ministry of Health’s distribution of educational materials on the topic.
5.5. Structural-Systemic Factors
In Palliative care, infrastructure refers to having a defined “structure” within the healthcare system, established job positions for care providers, and the inclusion of Palliative care education in formal university curricula. The absence of these elements in Iran’s healthcare system for delivering Palliative care is palpable (67). According to the European Commission (2003) and World Health Assembly (2014), equitable access to Palliative care based on individual needs is a moral obligation for governments and healthcare professionals and should be universally available (68, 69). In Iran, implementing online appointment systems and proper bed allocation is seen as a key step toward fairness, while nurse overwork, excessive referrals, and unnecessary bed use remain weaknesses. The Worldwide Hospice Palliative Care Alliance describes Palliative care as one of the most inequitable areas in health and calls for improved access (70). Equity in Palliative care means timely, appropriate, and high-quality services for all (71). Clearly defined job roles and teamwork are essential to avoid fragmented care and ensure patients don’t fall through the cracks (72). Iranian hospitals currently lack hospice units (73), but many universities have recently introduced specialized Palliative medicine courses. Efforts to promote this growing field include regional webinars, continuing education for healthcare providers, and the integration of Palliative care topics into nursing curricula (74). However, the absence of standardized training facilities and formal Palliative care education in general medical programs remains a significant challenge. In 2003, a Palliative medicine fellowship program was created to address this gap (67). According to studies conducted in Iran, healthcare providers lack sufficient knowledge regarding Palliative care and symptom management for patients (20, 75). Barasteh et al. emphasize that the first step in expanding Palliative care in Iran is to define its principles, scope, and aspects. Currently, the scope of Palliative care is limited to cancer patients, as cancer is the third leading cause of death in Iran and imposes significant costs (76). A qualitative study found that health professionals and educational leaders need easy access to policies and guidelines (77). Aldridge et al. identified barriers to Palliative care integration in the U.S., such as lack of training, personnel shortages, challenges in patient referral, and a fragmented healthcare system, along with a need for more funding for research. These barriers align with the findings of the current study (78). The study's limitation is that it was conducted at a single center, limiting the generalizability of results. Future research should assess Palliative care across various regions. The results suggest that strengths and opportunities should be enhanced, and actions should be taken to address weaknesses and threats.
5.6. Conclusions
Palliative care in Iran is still developing and has been assessed using a SWOT analysis to evaluate strengths, weaknesses, threats, and opportunities across several areas: Comprehensive support, communication, uncertainty, information, and infrastructure. While spiritual and religious support is strong, non-physical patient and family needs, as well as independence, require more attention. Communication is hindered by staff shortages and documentation burdens, despite nurses' empathy. High patient loads and poor coordination reduce care quality, although skilled staff and motivated caregivers are assets. Drug shortages persist, but government initiatives — like Red Crescent pharmacies and philanthropic support — aim to improve access. Although health literacy is low, educational materials and media efforts have had positive effects. Infrastructure challenges such as unnecessary bed occupancy are being addressed with new policies. A lack of nationwide clinical guidelines remains a threat, which the Ministry of Health is tackling through curriculum updates, professional training, webinars, and fellowships.
