Background: Palliative care is an essential component of modern healthcare, aiming to improve the quality of life for patients with life-limiting illnesses and their families. Despite its recognized importance, integration into routine clinical practice remains limited, particularly in low- and middle-income settings. This study explored the knowledge, perceptions, barriers, and ethical challenges of healthcare professionals regarding palliative care.

Methods: A cross-sectional survey was conducted among healthcare workers across multiple hospitals. A total of 447 participants completed a structured questionnaire addressing sociodemographic characteristics, knowledge and training in palliative care, perceptions toward its implementation, perceived barriers, strategies for improvement, and ethical considerations. Data were analyzed descriptively and presented in tables and graphs.

Results: The majority of participants were nurses (57%), followed by physicians (30%), with most respondents aged between 30 and 39 years. Only 5.6% reported strong knowledge of palliative care, while 51.2% demonstrated average knowledge and 43.2% poor knowledge. Formal training was limited, with just 39.4% receiving prior palliative care education. Overall, 79.4% expressed positive perceptions toward palliative care, recognizing its value in enhancing patient outcomes. Major barriers identified included lack of training (51.5%), inadequate resources (41.4%), heavy workload (29.1%), and cultural/system constraints (32.6%). Strategies proposed to address these challenges included expanded training programs (60.4%), stronger policy support (40.3%), improved resource allocation (33.6%), and community awareness initiatives (26.8%). Ethical dilemmas were reported by 62.6% of respondents, highlighting the need for clearer guidelines and support systems. Familiarity with the WHO definition and availability of institutional training were significantly associated with more favorable perceptions of palliative care integration (p = .001 and p = .023, respectively), while lack of training predicted higher perceived barriers (p = .002). Regression models explained 6.8% of the variance in perceptions and 11.0% in barriers.

Conclusion: Healthcare professionals demonstrated a generally positive attitude toward palliative care but lacked sufficient knowledge and training. Structural and cultural barriers remain significant obstacles to implementation. Addressing these gaps through education, policy support, and resource strengthening is essential for integrating palliative care into healthcare systems and ensuring dignified, patient-centered care.

• Palliative care • Intensive care units • Healthcare Administration • Knowledge and perceptions • Barriers • Ethical dilemmas

Zeinab E, Rita F, Jana K, Amani H, Jawad KA, et al. (2026) Integrating Palliative Care into Intensive Care Units: A Comprehensive Healthcare Administration Approach to Enhance Patient Outcomes and Optimize Resource Utilization in Lebanon. Arch Palliat Care 7(1): 1021.

In the intensive care units where life and death decisions are made on a daily basis, the question is no longer only how we can prolong life, but how well we can ensure dignity and quality in its final stages. The World Health Organization (WHO) estimates that roughly 56.8 million people worldwide require palliative care each year [1]. WHO defines palliative care as: “an approach that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness” [1]. Palliative care can help improve the quality of life as well as reduce aggressive interventions that may prolong suffering rather than improve outcomes. Despite this immense need, only 12-14% of those who need palliative care currently receive it, indicating a large unmet need globally [1]. This issue is especially urgent in Lebanon where its healthcare system faces resource constraints, cultural barriers, and lack of awareness and standardized palliative care policies.

On a global scale, international studies show that barriers to palliative care in ICUs include insufficient trainings, communication difficulties, and cultural/ religious influences all while lacking any institutional support [2]. Previous research has established a link between formal training and awareness (WHO definition) to improved perceptions and confidence among healthcare workers [3]. However, there is very limited data from the Middle East, with Lebanon lacking systematic research despite its cultural diversity and high ICU demand. Thus, the pre-existing knowledge gap in understanding how Lebanese healthcare workers perceive palliative care and what barriers they face had to be addressed.

This study is the first of its kind in Lebanon to comprehensively examine ICU palliative care integration from the perspective of healthcare workers. It is a cross-sectional survey of 447 healthcare workers across Lebanon, using validated tools, covering demographics, training, perceptions, barriers, and strategies for improvement. It aimed to assess the knowledge and familiarity with palliative care, perceptions and adequacy in ICU, perceived barriers including cultural and institutional challenges, and the influence of formal/ institutional training on perceptions, confidence, and reported barriers. Its importance is highlighted through providing evidence-based insights that can guide training programs, policy development, and ethical frameworks to strengthen palliative care integration in Lebanon’s ICU, while situating Lebanon within the global discourse. In doing so, it lays the groundwork for future research and practical steps to enhance palliative care integration in Lebanon and beyond.

Setting, study Design

We conducted a cross-sectional study among healthcare personnel and workers to assess their knowledge, perceptions, and attitudes toward integrating palliative care into intensive care units (ICUs) in Lebanon. An online self-administered Google Form in English was disseminated via communication platforms during June and July 2025, preceded by a pilot study conducted to ensure that all questions were clear before distributing the questionnaire.

Participants

Eligible participants were healthcare workers in Lebanon, including physicians/doctors, nurses, medical students, pharmacists, surgeons, and allied health professionals (e.g., physiotherapists, lab technicians), older than 18 years old. Participants who met the following exclusion criteria were ineligible for the study: non-healthcare professionals, individuals with no direct involvement in palliative care in ICUs, and those under 18 years old. All participants were informed that their participation was entirely voluntary and that their anonymity would be preserved. Since we addressed a large population from different sociodemographic and medical backgrounds, we made sure that all questions were clear and based on validated scales. The minimal sample size for this study was determined using the single-proportion formula (n=Z2p(1−p)/d2), assuming a 95% confidence level (Z=1.96), an expected proportion of 0.50 to maximize the required sample, and a margin of error of 0.05. This calculation yielded a minimum of 384 participants. To account for potential non-response, the required sample size was increased by 10–15%, resulting in an adjusted target of approximately 427–452 participants. The final sample obtained consisted of 447 healthcare workers, which exceeds the minimum requirement and is therefore considered adequate for the purposes of this study.

Data source measures

The questionnaire consisted of five main sections and was preceded by an informed consent statement outlining the study objectives, confidentiality measures, and the voluntary nature of participation. The questionnaire was developed using items adapted from previously validated instruments, including the Palliative Care Attitudes Scale (PCAS-9), the Self-Efficacy in Providing a Palliative Approach Scale for nurses and care assistants, the Caregiver Evaluation of the Quality of End-of-Life Care (CEQUEL) Scale, and the Attitudes of Physicians toward Palliative Care in Intensive Care Units Survey from Japan with modifications to fit the Lebanese healthcare context. (4–7) In adapting these instruments, core attitude items from the PCAS-9 were retained but reframed from the patient perspective to that of healthcare providers, while the Self-Efficacy scale contributed items on confidence in end-of-life care that were adjusted to reflect ICU-specific tasks. Ethical and communication principles were integrated from CEQUEL, whereas caregiver-focused questions were excluded. Similarly, the Japanese ICU survey informed items on barriers and institutional challenges, with Japan-specific elements omitted and additional questions developed to capture Lebanese cultural, religious, and societal influences. Furthermore, newly designed sections on sociodemographic characteristics, training, and recommendations for improvement were included to enable contextual analysis and generate policy-relevant insights. The content validity of the questionnaire was established through expert review by a panel of palliative care and critical care specialists, followed by a pilot test to ensure clarity and relevance of all items.

Section 1: Sociodemographic Information, which included the sex, age, area of residency, marital status, current role in the healthcare sector, number of experience years working in the healthcare sector, current sector practice (public, private institution), experience working in ICU.

Section 2: Knowledge and Training in Palliative Care, assessed prior exposure to palliative care concepts and training, including ICU work experience, familiarity with the WHO’s definition of palliative care, institutional training availability, personal receipt of formal training, and type of training

Section 3: Perceptions on Palliative Care in the ICU, evaluated participants’ attitudes toward palliative care integration through questions with 5-point Likert-scale items measuring agreement with statements on the benefits, impact, and adequacy of palliative care in ICUs, as well as confidence in managing end-of-life care and the presence of standardized protocols.

Section 4: Barriers to Palliative Care Integration, identified perceived obstacles through Likert-scale ratings of potential barriers.

Section 5: Recommendations for Palliative Care Improvement, assessed participants’ suggestions for enhancing palliative care integration in ICU. An open-ended question was included to allow additional comments.

Ethical consideration

This study received the Institutional Review Board (IRB) approval from Rafic Harire Hospital Ethical Committee under the IRB ref number: 2025-0801. The study respected participants’ anonymity and confidentiality and was conducted according to the research ethics guidelines in the Declaration of Helsinki. (8) Participants’ consent -was obtained from the first question of the questionnaire.

Patient and public involvement

This study did not include patient or public involvement in designing the study, commenting the outcomes, interpreting the results or reviewing this manuscript.

Statistical analysis

The collected data was entered in Microsoft Excel and was analyzed using the Statistical Package of the Social Sciences (SPSS) v.25. A p-value < 0.05 was considered statistically significant. Descriptive statistics were conducted where continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as numbers and percentages. Descriptive analysis was performed on all study variables, including sociodemographic factors.

Associations between categorical variables (e.g., demographic characteristics, prior training, perceptions, and identified barriers) were examined using Pearson’s chi-square test or Fisher’s exact test, as appropriate. For continuous or ordinal variables (e.g., Likert-scale scores), comparisons between two groups were conducted using the independent samples t-test or Mann–Whitney U test, and between more than two groups using one-way analysis of variance (ANOVA) or Kruskal–Wallis test, as appropriate. The choice between parametric and non-parametric tests was determined based on the results of normality testing (Shapiro–Wilk or Kolmogorov–Smirnov tests).

A composite perception score and the barriers score were calculated by summing responses to Likert-scale items, with higher scores indicating more favorable attitudes or barriers toward palliative care integration in ICUs. Mean perception scores were compared across demographic and professional subgroups. Internal consistency reliability of Likert-scale items was assessed using Cronbach’s alpha.

The internal consistency of the scales was assessed using Cronbach’s alpha. The Perceptions on Palliative Care in the ICU scale, which consisted of 10 items, demonstrated good reliability (α = .94). The Barriers to Palliative Care Integration scale, composed of 9 items, showed excellent reliability (α = .91). These results indicate that both instruments are reliable for assessing perceptions and barriers related to palliative care integration in the ICU setting (Table 1).

Table 1: Reliability Statistics for Study Scales

Reliability Statistics	Cronbach's Alpha	N of Items
Perceptions on Palliative Care in the ICU	0.944	10
Barriers to Palliative Care Integration	0.914	9

A total of 447 healthcare workers participated, with a mean age of 31.7 years. Gender distribution was nearly equal (51.2% male, 48.8% female). Most resided in Beirut (45.9%) or Mount Lebanon (33.8%), and over half were single (53.7%).

Professionally, the largest groups were nurses (35.6%), physicians (32.4%), and medical students (18.6%), with smaller proportions of surgeons, pharmacists, and allied health professionals. Regarding experience, 36.2% had 1–5 years, while 28.4% had more than 10 years.

The majority worked in private hospitals/clinics (62.0%), and three-quarters (75.4%) reported ICU experience (Table 2).

Table 2: Sociodemographic Characteristics of Participants (N = 447)

Variable	n (%) / M (SD)
Age	31.7 (8.9)
Sex
Male	229 (51.2%)
Female	218 (48.8%)
Area of Residency
Beirut	205 (45.9%)
Mount Lebanon	151 (33.8%)
North Lebanon/Akkar	57 (12.8%)
South Lebanon/Nabatieh	20 (4.5%)
Bekaa	14 (3.1%)
Marital Status
Single	240 (53.7%)
Engaged or Married	203 (45.4%)
Divorced	2 (0.4%)
Widowed	2 (0.4%)
Current Role in Healthcare
Physician/Doctor	145 (32.4%)
Medical Student	83 (18.6%)
Surgeon	10 (2.2%)
Nurse	159 (35.6%)
Pharmacist	10 (2.2%)
Allied Health Professional	10 (2.2%)
Other	30 (6.7%)
Years in Healthcare
Less than 1 year	61 (13.6%)
1to 5 years	162 (36.2%)
5 to 10 years	97 (21.7%)
More than 10 years	127 (28.4%)
Primary Workplace
Public hospital	94 (21.0%)
Private hospital/clinic	277 (62.0%)
Academic Institution	60 (13.4%)
Other	16 (3.6%)
ICU Experience
Yes	337 (75.4%)
No	110 (24.6%)

Most participants (352; 78.7%) reported being familiar with the WHO definition of palliative care. However, less than half (186; 41.6%) indicated that their institution provides training in palliative care. Similarly, only 175 (39.1%) had received formal training in palliative care, with the majority (272; 60.9%) reporting no such training (Table 3)

Table 3: Knowledge and Training in Palliative Care (N = 447)

Variable	n (%)
Familiarity with WHO Definition
Yes	352 (78.7)
No	95 (21.3)
Institution Provides Palliative Care Training
Yes	186 (41.6)
No	261 (58.4)
Received Formal Training in Palliative Care
Yes	175 (39.1)
No	272 (60.9)
Type of Training Received
Theoretical	104 (23.3)
Practical	24 (5.4)
Both	47 (10.5)
Not applicable	272 (60.9)
Should ICU Physicians Receive More Training?
Yes	425 (95.1)
No	22 (4.9)
Primary Palliative Care Should Be Strengthened in ICU
Yes	422 (94.4)
No	25 (5.6)
Ever Provided Palliative Care in ICU
Yes	305 (68.2)
No	142 (31.8)

Among those who had received training, 104 (23.3%) received it through theoretical instruction, 24 (5.4%) through practical training, and 47 (10.5%) through both. A substantial proportion (272; 60.9%) reported not receiving any training.

The vast majority of participants believed ICU physicians should receive more training in palliative care (425; 95.1%) and that primary palliative care should be strengthened in the ICU (422; 94.4%). Furthermore, 305 (68.2%) reported having provided palliative care to a patient in an ICU setting, while 142 (31.8%) had not.

When asked about potential strategies to improve palliative care integration in ICUs, the majority of participants emphasized the need for more structured training for ICU staff (81.7%), along with clear institutional policies on palliative care (77.2%). Increased involvement of palliative care specialists (74.0%) and greater public awareness of palliative care (74.0%) were also highly endorsed. Additionally, 72.7% supported the establishment of standardized guidelines for end-of-life care. About two-thirds (65.5%) recommended enhanced communication training for healthcare providers, while a small proportion (1.8%) suggested other strategies (Table 4).

Table 4: Perceived Strategies to Improve Palliative Care Integration in ICUs

What do you think would improve palliative care integration in ICUs?	% of Cases
More structured training for ICU staff	81.7
Clear institutional policies on palliative care	77.2
Increased involvement of palliative care specialists	74.0
Greater public awareness on palliative care	74.0
Standardized guidelines for end-of-life care	72.7
Improved communication training for healthcare providers	65.5
Other	1.8

Note. Participants could select more than one strategy; therefore, percentages represent % of cases rather than % of total responses.

Participants highlighted several key ethical considerations related to palliative care integration in ICUs. The most frequently cited concern was the need to communicate clearly with families about prognosis and treatment options (88.1%). This was followed by the importance of ensuring that patients are fully informed and involved in decision-making (76.7%) and providing care that benefits patients while minimizing harm (76.7%). Additionally, 64.4% emphasized the need for fair and efficient use of ICU resources, particularly in situations where treatment options are limited. A small portion (1.6%) identified other ethical issues (Table 5).

Table 5: Perceived Ethical Considerations in Palliative Care Integration in ICUs

In your opinion, what are the main ethical considerations when integrating palliative care into ICUs	% of Cases
Ensuring that patients are fully informed and involved in decisions	76.7
Providing care that benefits the patients while minimizing harm	76.7
Communicating clearly with families about prognosis and treatments	88.1
Ensuring fair and efficient use of ICU resources, especially when treatments are limited	64.4
Other	1.6

Note. Participants could select multiple ethical considerations; thus, percentages represent % of cases, not cumulative totals.

Participants familiar with the WHO definition of palliative care generally reported more favorable perceptions of palliative care integration in ICUs compared to those who were not familiar with the definition. Several items showed statistically significant differences between the two groups (p < .05), indicating that familiarity with the WHO definition was associated with more positive views on palliative care (Table 6).

Table 6: Perceptions of Palliative Care Integration in the ICU by Familiarity with the WHO Definition

Item	familiar M (SD)	Not familiar M (SD)	p value
The integration of palliative care in the ICU improves the quality of end-of-life care.	4.2 (1.1)	3.8 (.8)	< .001
The presence of palliative care shortens the length of stay and suffering in the ICU.	4.1 (1.1)	3.7 (.7)	< .001
Palliative care is an effective approach for withholding life-sustaining treatments that are painful to the patient.	4.0 (1.1)	3.7 (.8)	0.011
Palliative care reduces unnecessary procedures and interventions.	4.2 (1.1)	3.8 (.6)	< .001
Palliative care lowers admission costs and optimizes hospital resource utilization.	4.1 (1.1)	3.6 (.9)	< .001
Palliative care respects the patient’s right to receive the best possible care.	4.1 (1.1)	3.7 (.9)	0.005
The current presence of palliative care in my ICU is adequate.	3.2 (1.1)	2.9 (.8)	0.007
I feel confident in managing various aspects of end-of-life care.	3.2 (1.1)	2.6 (1.0)	< .001
My confidence in handling end-of-life care improved after educational interventions.	3.5 (1.0)	2.9 (.8)	< .001
My ICU has a standardized protocol for palliative care screening and symptom management.	3.1 (1.1)	2.3 (1.0)	< .001
Perceptions of Palliative Care Integration in the ICU	3.8 (.9)	3.3 (.7)	< .001

Note. M = mean; SD = standard deviation

For example, participants familiar with the WHO definition of palliative care were more likely to agree that its integration improves the quality of end-of-life care (M = 4.2, SD = 1.1) compared to those who were not familiar (M = 3.8, SD = .8), p < .001. Similarly, the presence of palliative care was seen to shorten the length of stay and suffering in the ICU by those familiar with the definition (M = 4.1, SD = 1.1) versus those who were not (M = 3.7, SD = .7), p < .001.

Participants familiar with the WHO definition also expressed higher confidence in managing aspects of end-of-life care (M = 3.2, SD = 1.1) compared to their counterparts (M = 2.6, SD = 1.0), p < .001. Furthermore, their confidence improved following educational interventions (M = 3.5, SD = 1.0 vs. M = 2.9, SD = .8), p < .001.

Participants who were familiar with the WHO definition of palliative care demonstrated significantly more favorable overall perceptions of its integration in ICUs compared to those who were not familiar (M = 3.8, SD = 0.9 vs. M = 3.3, SD = 0.7; p < .001). This finding highlights the positive influence of familiarity with the WHO definition on healthcare workers’ general attitudes toward palliative care integration.

The results suggest that greater familiarity with the WHO definition of palliative care is associated with more positive attitudes and perceptions towards its integration into ICU settings. These findings highlight the importance of ensuring that healthcare providers are well-informed about palliative care principles to improve end-of-life care in critical care environments.

The analysis reveals several significant differences in perceived barriers to palliative care integration in ICUs based on familiarity with the WHO definition of palliative care. Those who were familiar with the WHO definition of palliative care generally reported fewer barriers than those who were not (Table 7).

Table 7: Perceived Barriers to Palliative Care Integration in ICUs by Familiarity with the WHO Definition

Barrier	familiar M (SD)	Not familiar M (SD)	P value
Inadequate skills and training among ICU staff	3.6 (1.0)	4.1 (.8)	< .001
Discomfort with discussing prognosis and end-of-life care	3.7 (1.0)	4.0 (.8)	0.002
Cultural or religious beliefs of patients and their families	3.9 (1.0)	4.3 (.8)	< .001
Cultural or religious beliefs of healthcare providers	3.5 (1.1)	4.1 (.9)	< .001
Lack of institutional policies supporting palliative care	3.8 (1.1)	4.2 (.9)	< .001
Fear of legal or ethical implications in end-of-life decision-making	3.8 (1.1)	4.2 (.7)	< .001
Social values and stigma surrounding palliative care and death	3.7 (1.1)	4.0 (.9)	0.004
Shortage of dedicated palliative care specialists in ICUs	3.7 (1.0)	4.3 (.7)	< .001
High patient-to-staff ratio limiting palliative care discussions	3.6 (1.1)	4.1 (.9)	< .001
Perceived Barriers to Palliative Care Integration in ICUs	3.7 (.8)	4.1 (.5)	< .001

Note. M = mean; SD = standard deviation.

For instance, participants familiar with the WHO definition perceived fewer barriers related to inadequate skills and training among ICU staff (M = 3.6, SD = 1.0) compared to those unfamiliar with the definition (M = 4.1, SD = .8), with a statistically significant difference (p < .001). Similarly, those familiar with the WHO definition felt less discomfort with discussing prognosis and end-of-life care (M = 3.7, SD = 1.0) compared to their counterparts (M = 4.0, SD = .8), p = 0.002.

Cultural or religious beliefs of both patients and their families were seen as a more significant barrier by those not familiar with the WHO definition (M = 4.3, SD = .8) than by those familiar (M = 3.9, SD = 1.0), p < .001. Similarly, barriers related to healthcare providers' cultural or religious beliefs were more prominent in the "No" group (M = 4.1, SD = .9) than in the "Yes" group (M = 3.5, SD = 1.1), p < .001.

Participants familiar with the WHO definition of palliative care also reported fewer barriers related to the lack of institutional policies supporting palliative care (M = 3.8, SD = 1.1 vs. M = 4.2, SD = .9), fear of legal or ethical implications in end-of-life decision-making (M = 3.8, SD = 1.1 vs. M = 4.2, SD = .7), and the shortage of dedicated palliative care specialists in ICUs (M = 3.7, SD = 1.0 vs. M = 4.3, SD = .7), all with p-values less than .001. Social values and stigma surrounding palliative care and death were also perceived as fewer barriers by those familiar with the WHO definition (M = 3.7, SD = 1.1 vs. M = 4.0, SD = .9), p = 0.004.

Healthcare workers unfamiliar with the WHO definition of palliative care reported significantly higher overall barrier scores compared to those who were familiar (M = 4.1, SD = 0.5 vs. M = 3.7, SD = 0.8; p < .001). This indicates that lack of familiarity with the WHO definition is associated with a stronger perception of obstacles to palliative care integration in ICUs.

The findings suggest that familiarity with the WHO definition of palliative care is associated with a more positive perception of palliative care integration, with fewer perceived barriers in areas such as training, institutional policies, and cultural beliefs. These results highlight the importance of education and awareness in reducing barriers to palliative care integration in ICUs.

The analysis of perceptions based on the availability of institutional training in palliative care revealed some significant differences between those who reported having institutional training and those who did not (Table 8).

Table 8: Perceptions of Palliative Care Integration by Institutional Training Availability

Item	Trained M (SD)	Not trained M (SD)	p
The integration of palliative care improves EOLC	4.2 (1.1)	4.1 (1.0)	0.082
Palliative care shortens ICU stay and suffering	4.2 (1.1)	3.9 (.9)	0.005
Palliative care helps with withholding painful life-sustaining treatments	4.1 (1.2)	3.9 (1.0)	0.064
Palliative care reduces unnecessary procedures	4.3 (1.1)	4.0 (.9)	0.016
Palliative care lowers admission costs and improves resource use	4.1 (1.2)	3.9 (1.0)	0.102
Palliative care respects patients’ right to best care	4.2 (1.1)	3.8 (.9)	< .001
The current presence of palliative care in my ICU is adequate	3.2 (1.1)	3.1 (1.0)	0.097
I feel confident in managing EOLC	3.5 (1.0)	2.8 (1.0)	< .001
My confidence improved after educational interventions	3.6 (1.2)	3.2 (.8)	< .001
My ICU has a standardized palliative care protocol	3.5 (1.1)	2.6 (1.0)	< .001
Perceptions of Palliative Care Integration in the ICU	3.9 (.9)	3.5 (.8)	< .001

Note. M = mean; SD = standard deviation. EOLC = end-of-life care.

Participants with institutional training in palliative care generally had more favorable perceptions of its integration in the ICU, especially regarding the reduction of unnecessary procedures (M = 4.3, SD = 1.1 vs. M = 4.0, SD = .9), p = 0.016, and the positive impact on shortening ICU stay and suffering (M = 4.2, SD = 1.1 vs. M = 3.9, SD = .9), p = 0.005.

Regarding end-of-life care (EOLC) management, those with institutional training were significantly more confident in managing EOLC (M = 3.5, SD = 1.0 vs. M =2.8, SD = 1.0), p < .001, and reported that their confidence improved following educational interventions (M = 3.6, SD = 1.2 vs. M = 3.2, SD = .8), p < .001. Additionally, those with training were more likely to agree that palliative care respects the patient's right to the best possible care (M = 4.2, SD = 1.1 vs. M = 3.8, SD = .9), p < .001, and that their ICU has a standardized palliative care protocol (M = 3.5, SD = 1.1 vs. M = 2.6, SD = 1.0), p < .001.

However, there were no significant differences between the two groups in terms of the perceived improvement in the integration of palliative care for end-of-life care (EOLC) (p = 0.082) or the adequacy of current palliative care presence in the ICU (p = 0.097).

Healthcare workers who reported receiving institutional training in palliative care had significantly higher overall perception scores compared to those without such training (M = 3.9, SD = 0.9 vs. M = 3.5, SD = 0.8; p < .001). This suggests that institutional training is positively associated with more favorable attitudes toward the integration of palliative care in ICUs.

These findings highlight the importance of institutional training in enhancing healthcare providers' perceptions and confidence in palliative care practices, especially in improving resource utilization and managing end-of-life care in the ICU setting.

The analysis of barriers to palliative care integration based on the availability of institutional training in palliative care revealed significant differences. Participants who had received institutional training in palliative care reported fewer barriers across all areas compared to those without such training (Table 9).

Table 9: Perceived Barriers to Palliative Care Integration by Institutional Training Availability

Barrier	Trained M (SD)	Not trained M (SD)	P value
Inadequate skills and training among ICU staff	3.4 (1.1)	3.9 (.8)	< .001
Discomfort with discussing prognosis and EOLC	3.5 (1.0)	3.9 (.9)	< .001
Cultural/religious beliefs of patients and families	3.7 (1.0)	4.2 (.9)	< .001
Cultural/religious beliefs of healthcare providers	3.3 (1.2)	3.9 (1.0)	< .001
Lack of institutional policies	3.6 (1.1)	4.0 (1.0)	< .001
Fear of legal/ethical implications in EOL decision-making	3.6 (1.1)	4.0 (.9)	< .001
Social stigma surrounding palliative care and death	3.5 (1.1)	3.9 (1.0)	< .001
Shortage of dedicated palliative care specialists	3.5 (1.1)	4.1 (.9)	< .001
High patient-to-staff ratio limiting discussions	3.6 (1.1)	3.8 (1.0)	0.023
Perceived Barriers to Palliative Care Integration in ICUs	3.5 (.8)	4.0 (.7)	< .001

Note. M = mean; SD = standard deviation. EOLC = end-of-life care.

For example, those with training perceived fewer barriers related to inadequate skills and training among ICU staff (M = 3.4, SD = 1.1) compared to those without training (M = 3.9, SD = .8), p < .001. Similarly, discomfort with discussing prognosis and end-of-life care (EOLC) was less pronounced for those with training (M = 3.5, SD = 1.0) compared to those without training (M = 3.9, SD = .9), p < .001.

Cultural and religious beliefs of both patients and families were viewed as a more significant barrier by those without institutional training (M = 4.2, SD = .9) than by those with training (M = 3.7, SD = 1.0), p < .001. Likewise, cultural and religious beliefs of healthcare providers were seen as more of a barrier by those without training (M = receiving P value 4.0 (1.0) < .001 3.9 (1.0) < .001 4.1 (.9) < .001 3.8 (1.0) 0.023 4.0 (.7) < .001 3.9, SD = 1.0) compared to those with training (M = 3.3, SD = 1.2), p < .001.

Additional barriers related to institutional policies, fear of legal or ethical implications in end-of-life decision-making, social stigma surrounding palliative care and death, and shortage of dedicated palliative care specialists were also perceived as less of an issue by those with institutional training, with all differences being statistically significant (p < .001).

The only exception was the high patient-to-staff ratio, which showed a smaller, but still significant, difference between those with (M = 3.6, SD = 1.1) and without (M = 3.8, SD = 1.0) training, p = 0.023.

Healthcare workers who had received institutional training in palliative care reported significantly lower overall barrier scores compared to those without training (M = 3.5, SD = 0.8 vs. M = 4.0, SD = 0.7; p < .001). This finding indicates that institutional training is associated with reduced perceptions of obstacles to palliative care integration in ICUs.

These findings suggest that institutional training plays a crucial role in reducing perceived barriers to palliative care integration in ICUs, particularly in areas related to training, cultural/religious beliefs, and institutional support. Providing formal education on palliative care to healthcare providers may help address and reduce these barriers, facilitating better integration of palliative care in critical care settings.

The analysis of perceptions of palliative care integration based on formal training in palliative care revealed some significant differences between those who had received formal training and those who had not (Table 10).

Table 10: Perceptions of Palliative Care Integration by Formal Training in Palliative Care

Item	Trained M (SD)	Not trained M (SD)	P value
Improves quality of EOLC	4.2 (1.2)	4.1 (1.0)	0.374
Shortens ICU stay and suffering	4.1 (1.2)	3.9 (.9)	0.033
Helps with withholding painful life-sustaining treatments	4.0 (1.3)	3.9 (.9)	0.324
Reduces unnecessary procedures	4.2 (1.2)	4.1 (.9)	0.098
Lowers admission costs / optimizes resources	4.1 (1.2)	3.9 (1.0)	0.177
Respects patient’s right to best care	4.2 (1.1)	3.8 (.9)	< .001
Adequacy of current ICU palliative care	3.2 (1.1)	3.1 (.9)	0.300
Confidence in managing EOLC	3.4 (1.1)	2.9 (1.0)	< .001
Confidence improved after educational interventions	3.6 (1.1)	3.2 (.8)	< .001
ICU has a standardized palliative care protocol	3.5 (1.1)	2.6 (1.0)	< .001
Perceptions of Palliative Care Integration in the ICU	3.9 (1.0)	3.6 (.8)	< .001

Note. M = mean; SD = standard deviation. EOLC = end-of-life care.

While there were no significant differences in perceptions regarding the improvement of the quality of end-of-life care (EOLC) (p = 0.374) and the adequacy of current ICU palliative care (p = 0.300), several items showed statistically significant differences.

Participants who had received formal training in palliative care were more likely to agree that palliative care shortens ICU stay and suffering (M = 4.1, SD = 1.2 vs. M = 3.9, SD = .9), p = 0.033, and that palliative care respects the patient’s right to the best care (M = 4.2, SD = 1.1 vs. M = 3.8, SD = .9), p < .001.

Those who had received formal training also expressed higher confidence in managing end-of-life care (M = 3.4, SD = 1.1 vs. M = 2.9, SD = 1.0), p < .001, and reported that their confidence improved after educational interventions (M = 3.6, SD = 1.1 vs. M = 3.2, SD = .8), p < .001. Additionally, those with formal training were more likely to agree that their ICU had a standardized palliative care protocol (M = 3.5, SD = 1.1 vs. M = 2.6, SD = 1.0), p < .001.

Healthcare workers with formal training in palliative care demonstrated significantly higher overall perception scores than those without such training (M = 3.9, SD = 1.0 vs. M = 3.6, SD = 0.8; p < .001). This suggests that formal training is positively associated with more favorable attitudes toward the integration of palliative care in ICUs.

These findings suggest that formal training in palliative care plays a significant role in enhancing healthcare providers' perceptions and confidence in palliative care integration in ICU settings. However, some areas, such as perceptions of the adequacy of current ICU palliative care and the impact on reducing unnecessary procedures, did not show significant differences between the two groups.

The analysis of perceived barriers to palliative care integration based on formal training in palliative care indicates that those with formal training in palliative care generally perceive fewer barriers across several key areas compared to those without formal training (Table 11).

Table 11: Perceived Barriers to Palliative Care Integration by Formal Training in Palliative Care

Barrier	Trained M (SD)	Not trained M (SD)	P value
Inadequate skills and training among ICU staff	3.4 (1.1)	3.9 (.9)	< .001
Discomfort with discussing prognosis and EOLC	3.5 (1.0)	3.9 (.9)	< .001
Cultural/religious beliefs of patients and families	3.7 (1.0)	4.2 (.9)	< .001
Cultural/religious beliefs of healthcare providers	3.3 (1.2)	3.9 (1.0)	< .001
Lack of institutional policies	3.6 (1.1)	4.0 (1.0)	< .001
Fear of legal/ethical implications	3.6 (1.1)	4.0 (.9)	< .001
Social stigma surrounding palliative care	3.5 (1.1)	3.9 (1.0)	< .001
Shortage of dedicated palliative care specialists	3.5 (1.1)	4.0 (.9)	< .001
High patient-to-staff ratio limiting discussions	3.6 (1.1)	3.8 (1.0)	0.055
Perceived Barriers to Palliative Care Integration in ICUs	3.5 (.8)	4.0 (.7)	< .001

Note. M = mean; SD = standard deviation. EOLC = end-of-life care.

Significant differences were observed across all barriers, with those who received formal training reporting fewer perceived barriers. For example, those with formal training in palliative care viewed inadequate skills and training 

among ICU staff as a smaller barrier (M = 3.4, SD = 1.1) compared to those without formal training (M = 3.9, SD = .9), p < .001. Similarly, discomfort with discussing prognosis and end-of-life care (EOLC) was less pronounced in the group with formal training (M = 3.5, SD = 1.0) than in the group without training (M = 3.9, SD = .9), p < .001.

Cultural or religious beliefs of patients and their families were perceived as a smaller barrier by those with formal training (M = 3.7, SD = 1.0) than by those without (M = 4.2, SD = .9), p < .001. The same trend was observed for cultural or religious beliefs of healthcare providers (M = 3.3, SD = 1.2 vs. M = 3.9, SD = 1.0), p < .001.

Other significant barriers, such as lack of institutional policies supporting palliative care, fear of legal or ethical implications in decision-making, and social stigma surrounding palliative care, were also perceived as less of an issue by those with formal training in palliative care (all p-values < .001). The shortage of dedicated palliative care specialists was similarly perceived as less of a barrier by the trained group (M = 3.5, SD = 1.1 vs. M = 4.0, SD = .9), p < .001.

The only barrier that did not show a significant difference was the high patient-to-staff ratio limiting discussions (p = 0.055), though it did approach statistical significance.

Healthcare workers with formal training in palliative care reported significantly lower overall barrier scores than those without such training (M = 3.5, SD = 0.8 vs. M = 4.0, SD = 0.7; p < .001). This finding indicates that formal palliative care training is associated with a reduced perception of obstacles to palliative care integration in ICUs.

These findings suggest that formal training in palliative care can help reduce perceived barriers, making it easier for ICU staff to integrate palliative care practices. This highlights the importance of providing healthcare workers with formal education and training to address and overcome these barriers effectively.

A multiple regression analysis was conducted to identify predictors of healthcare workers’ perceptions of palliative care integration in the ICU. The model was statistically significant, F(3,443)=10.72,p<.001, explaining 6.8% of the variance in perception scores (R2=.068, adjusted R2=.061) (Table 12).

Table 12: Multiple Regression Predicting Perceptions of Palliative Care Integration in the ICU

Predictor	B	SE B	β	t	p
Constant	4.51	0.16	—	28.05	< .001
Familiar with WHO definition (Yes = 1, No = 2)	-0.35	0.10	-0.17	-3.41	.001
Institutional training available (Yes = 1, No = 2)	-0.31	0.13	-0.18	-2.28	.023
Formal training received (Yes = 1, No = 2)	0.04	0.14	0.02	0.27	.787

Familiarity with the WHO definition of palliative care significantly predicted more favorable perceptions (B=−0.35, SE=0.10, β=−.17, t=−3.41, p=.001), as did the availability of institutional training (B=−0.31, SE=0.13, β=−.18, t=−2.28, p=.023). Since the coding was Yes = 1 and No = 2, the negative coefficients indicate that respondents who were familiar with the WHO definition and who reported institutional training had higher perception scores compared to those who were not familiar or lacked institutional training. By contrast, prior receipt of formal training in palliative care was not a significant predictor (p=.787).

A multiple linear regression was conducted to examine predictors of perceived barriers to palliative care integration in ICUs. The model was statistically significant, F(3,443)=18.25,p<.001, accounting for 11.0% of the variance in barrier scores (R2=.110, adjusted R2=.104) (Table 13). Familiarity with the WHO definition of palliative care significantly predicted higher perceived barriers (B=0.28, SE=0.09, β=.15, t=3.13, p=.002), as did the availability of institutional training (B=0.26, SE=0.12, β=.16, t=2.17, p=.030). Prior receipt of formal training was not a significant predictor (B=0.17, SE=0.12, β=.10, t=1.38, p=.168). Since predictors were coded Yes = 1 and No = 2, positive 

coefficients indicate that participants who answered “No” (i.e., not familiar or not institutionally trained) perceived more barriers compared to those who answered “Yes.”

Even though it is widely agreed that palliative care has a tremendous effect on improving the suffering of patients approaching their end of life, it is still evident that Lebanon lacks the proper trainings and foundations needed to overcome its barriers. In addition to the desperate need for skill workshops and trainings, inability to properly communicate with patients and families about the prognosis and their options as well as certain cultural and religious beliefs all contribute to hindering the proper uniform adherence to palliative care in ICUs. It has been well established that improving this perception starts with formal trainings. Most participants are familiar with the WHO definition of palliative care, which proved a link to an improved perception but didn’t replace the need for a wider public awareness campaign nor for structured trainings. Reports of overcoming some of the cultural/social barriers with trainings have been noted. Not only do physicians feel more comfortable and capable of addressing the patient’s condition transparently, training creates a safe environment where more people can undertake the responsibilities of such regulations with confidence and efficacy. By taking the first step with trainings, clearer policies will emerge and more specialists will be encouraged to join. Implementations cannot disregard the necessity of ethics in minimizing harm and preserving patients’ integrity.

In agreement with previous evidence, the results of this study reveal a shortcoming regrading palliative care teaching, specifically a practical training [9,10]. Although participants exhibited a significant knowledge in WHO definition of palliative care, knowledge alone is not enough. Structured training must be included in students’ curricula, as well as into hospital-based programs. This was clearly demonstrated in a Chinese study describing the impact of palliative care education and training program on the resident physicians [11]. Another Chinese study confirmed that PC training was associated with higher confidence among ICU nurses [12]. Participants also emphasized the importance of the communication with families. Indeed, structured family-centered communication in the ICU has been shown to improve patient/family outcomes and to shorten ICU length of stay [13]. Clearly defined ICU palliative care pathways, bedside tools, and team processes are key facilitators of integration [14]. Our study also showed participants perceptions regarding the importance of improving quality of life and reducing unnecessary procedures and interventions. These findings are consistent with a systematic review done in May 2021 comparing hospital-based specialist palliative care with usual care for adults with advanced illness and their caregivers [15]. On the other hand, cultural and religious beliefs remain major barriers in Lebanon and other Arab countries. Families often choose costly, aggressive medical interventions as a way of expressing love for the patient [16]. A shortage of dedicated palliative care specialists and the absence of clear institutional policies are also important barriers [2].

Finally, as recommendations for improving PC, more structured training for ICU staff is highly needed as highlighted extensively in the literature [17,18], along with clearer institutional policies on palliative care [19,20]. Since every patient has the right to decide what kind of care they want to receive and to have those decisions respected, autonomy constitutes one of the most important ethical considerations when integrating PC in ICU [21]. In addition, participants focused on ensuring that patients are fully informed and actively involved in decision-making, as well as the relevance of clear communication with families regarding prognosis and treatment options.

It is noteworthy that this study has several limitations that need acknowledgement. The study was limited to physicians’ standards of care and perspective, even though we relied heavily on the barriers in communication and cultural and religious beliefs. The patients as well as the families are as involved and should be as targeted to raise awareness. Perhaps future studies can account for the remaining half of this equation. Also, the online nature of the survey can possibly predispose only the people who are interested and are already familiar with palliative care to fill the response, leading to a selection bias. People are also expected to self-assess their knowledge which might encourage “social desirability bias.” People provide the answers they think they should provide and the ones that reflect professionalism. Finally, the cross-sectional nature of the study design can affect establishing a true causality between barriers and perceptions, as both are measured at a single point in time. One cannot precisely conclude that training truly leads to more favorable perceptions and nor that people with favorable perceptions just seek out training. Studies can follow up with barrier regression viability after conducting proper training to secure the link. Finally, despite the use of multivariable analysis, residual confounding is still possible. Further studies that take into account these weaknesses are suggested.

However, one cannot disregard the obvious strengths. This study is examining integrating palliative care in the ICU setting in Lebanon while tackling a large sample size (N=447) and engulfing a diversity of roles (nurses, physicians, doctors…) most of which have ICU experience (75%). Reliability and a methodological rigor are both achieved via using validated tools for data collection. The study encompasses a large comprehensive scope that includes: barriers, perceptions, solutions, and ethical considerations. By suggesting a direct actionable link between training, confidence, and implementation, it provided a concrete base for a plan of action and improvement. Since such study is the first to provide evidence from Lebanon, correlating our findings with broader regional and international scopes can provide a foundation for extending the global discussion into the Lebanese context.

The integration of palliative care into healthcare systems remains hindered by gaps in knowledge, insufficient training, and structural limitations, despite healthcare professionals demonstrating overall positive attitudes toward its importance. Barriers such as inadequate resources, workload pressures, and cultural or systemic constraints continue to restrict the delivery of effective palliative services, while the frequent encounter with ethical dilemmas underscores the need for clearer guidelines and institutional support.

Sustainable progress requires a comprehensive strategy that combines structured educational initiatives, supportive health policies, and appropriate resource allocation. Interdisciplinary collaboration and community engagement are equally essential to ensure cultural alignment and foster public awareness. By strengthening these domains, healthcare systems can evolve toward a patient-centered model that emphasizes dignity, comfort, and holistic care at the end of life.

1. Implementing World Health Assembly Resolution on Palliative Care. 2025.
2. Janczewski LM, Chandrasekaran A, Abahuje E, Ko B, Slocum JD, Tesorero K, et al. Barriers and Facilitators to End-of-Life Care Delivery in ICUs: A Qualitative Study. Crit Care Med. 2024; 52: e289-e298.
3. Peng M, Guan Q, Zhu X. Moral distress, attitude toward death, and palliative care core competencies among ICU nurses: a cross-sectional study. BMC Palliat Care. 2025; 24: 16.
4. Phillips J, Salamonson Y, Davidson PM. An instrument to assess nurses' and care assistants' self-efficacy to provide a palliative approach to older people in residential aged care: a validation study. Int J Nurs Stud. 2011; 48: 1096-1100.
5. Perry LM, Hoerger M, Malhotra S, Gerhart JI, Mohile S, Duberstein PR. Development and Validation of the Palliative Care Attitudes Scale (PCAS-9): A Measure of Patient Attitudes Toward Palliative Care. J Pain Symptom Manage. 2020; 59: 293-301.
6. Tanaka Y, Kato A, Ito K, Igarashi Y, Kinoshita S, Kizawa Y, et al. Attitudes of Physicians toward Palliative Care in Intensive Care Units: A Nationwide Cross-Sectional Survey in Japan. J Pain Symptom Manage. 2022; 63: 440-448.
7. Higgins PC, Prigerson HG. Caregiver evaluation of the quality of end-of-life care (CEQUEL) scale: the caregiver's perception of patient care near death. PLoS One. 2013; 8: e66066.
8. Association WM. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. Bull World Health Organ. 2003; 79: 373.
9. Stokman AI, Brown SL, Seacrist MJ. Baccalaureate nursing students' engagement with end-of-life curriculum: A grounded theory study. Nurse Educ Today. 2021; 102: 104914.
10. Gonçalves RG, Oliveira LPBA, Silva CJA, Elias TMN, Nogueira ILA, Menezes RMP. Palliative care in nursing training: higher education course coordinators' perception. Rev Bras Enferm. 2023; 76: e20220222.
11. Chang J, Qi Z, Jiang S, Li L, Sun Q. The impact of palliative care education and training program on the resident physicians. Ann Palliat Med. 2021; 10: 2758-2765.
12. Ko E, Lowie S, Ni P. Confidence in carrying out palliative care among intensive care nurses. Nurs Crit Care. 2023; 28: 13-20.
13. Levin TT, Moreno B, Silvester W, Kissane DW. End-of-life communication in the intensive care unit. Gen Hosp Psychiatry. 2010; 32: 433-442.
14. Meddick-Dyson SA, Boland JW, Pearson M, Greenley S, Gambe R, Budding JR, et al. Implementing palliative care in the intensive care unit: a systematic review and mapping of knowledge to the implementation research logic model. Intensive Care Med. 2024; 50: 1778-1790.
15. Oluyase AO, Higginson IJ, Yi D, Gao W, Evans CJ, Grande G, et al.Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review. Southampton (UK): NIHR Journals Library; 2021.
16. Osman H, Yamout, R. Palliative Care in the Arab World. In: Al-Shamsi, H.O, Abu-Gheida, I.H, Iqbal, F, Al-Awadhi, A. (eds) Cancer in the Arab World. Springer, Singapore. 2022;
17. Saft HL, Richman PS, Berman AR, Mularski RA, Kvale PA, Ray DE, et al. Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life. J Grad Med Educ. 2014; 6: 44-49.
18. Kurnia TA, Trisyani Y, Prawesti A. The relationship between nurses' knowledge and self-confidence in implementing palliative care in an intensive care unit. Int J Palliat Nurs. 2020; 26: 183-190.
19. Kuschner WG, Gruenewald DA, Clum N, Beal A, Ezeji-Okoye SC. Implementation of ICU palliative care guidelines and procedures: a quality improvement initiative following an investigation of alleged euthanasia. Chest. 2009; 135: 26-32.
20. Sandy Whitelaw, Anthony Bell, David Clark. The expression of ‘policy’ in palliative care: A critical review. Health Policy. 2022; 126: 889-898
21. Akdeniz M, Yard?mc? B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Med. 2021; 9: 20503121211000918.