Shin Hye Yoo; Yu Jung Kim; Ye Sul Jeung; Jung Sun Kim; Kwonoh Park; Eun Mi Nam; Si Won Lee; Jun Ho Ji; Jwa Hoon Kim; Joon Young Hur; Song Ee Park; Jung Lim Lee; Su-Jin Koh

doi:10.4143/crt.2025.158

Articles

Page Path: HOME > J Korean Cancer Assoc > Ahead-of print articles > Article

Original Article Exploring Oncologists’ Perspectives on the Early Integration of Specialty Palliative Care in Korea: Challenges, Needs, and Clinical Implications: Shin Hye Yoo¹, Yu Jung Kim², Ye Sul Jeung¹, Jung Sun Kim³, Kwonoh Park⁴, Eun Mi Nam⁵, Si Won Lee⁶, Jun Ho Ji⁷, Jwa Hoon Kim⁸, Joon Young Hur⁹, Song Ee Park¹⁰, Jung Lim Lee¹¹, Su-Jin Koh¹²; DOI: https://doi.org/10.4143/crt.2025.158
Published online: April 10, 2025

¹Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea

²Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

³Division of Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea

⁴Division of Hematology-Oncology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea

⁵Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea

⁶Division of Medical Oncology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

⁷Division of Hematology and Oncology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea

⁸Division of Medical Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea

⁹Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

¹⁰Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea

¹¹Division of Hematology and Medical Oncology, Department of Internal Medicine, Daegu Fatima Hospital Cancer Center, Daegu, Korea

¹²Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

Correspondence: Su-Jin Koh, Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, 25 Daehakbyeongwon-ro, Dong-gu, Ulsan 44033, Korea
Tel: 82-52-250-8978 E-mail: sujinkoh@uuh.ulsan.kr

• Received: February 11, 2025 • Accepted: April 9, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

1,004 Views
73 Download

Full Article

Download PDF

Abstract

Purpose
This study aimed to explore the practices, perceptions, and barriers related to specialty palliative care (SPC) referrals among oncologists in Korea, highlighting the clinical implications of early integration.
Materials and Methods
A cross-sectional online survey targeting board-certified hemato-oncology specialists was conducted between August 1-25, 2024. The survey assessed referral practices, attitudes toward early SPC integration, referral criteria, barriers, and institutional characteristics.
Results
A total of 227 oncologists participated (response rate, 36.7%). Among them, 68.7% reported frequent SPC referrals, with higher referral rates observed among younger physicians, those in tertiary hospitals, and institutions with in-house SPC teams (p < 0.001). Although 74.9% supported early SPC integration, referrals were often inconsistently timed, frequently occurring after disease progression or at the discontinuation of chemotherapy. For time-based referrals, the most commonly endorsed triggers were disease progression despite palliative second-line treatment and a prognosis of expected mortality within 6-12 months. Need-based referral triggers such as patient or family requests (96.5%), psychological distress (89.9%), or uncontrolled symptoms (83.3%), were also widely endorsed. The major barriers to early SPC integration included patient and family resistance (70.0%) and limited availability of SPC teams (34.4%).
Conclusion
This study emphasizes the importance of systematic efforts to promote timely SPC integration in Korea, including education to raise patient awareness, improved referral systems, and enhanced infrastructure. The positive attitudes toward early SPC among oncologists reflect a growing recognition of its value, highlighting the need for strategies that align with international standards.
Key words: Oncologists, Palliative care, Cross-sectional studies, Surveys and questionnaires

Introduction

The provision of palliative care—a medical approach focused on enhancing the quality of life for patients with advanced cancer and their families [1]—is a cornerstone of high-quality cancer care. Historically rooted in hospice care provided during end-of-life (EOL) situations, palliative care has evolved into a broader, holistic approach that begins at the time of diagnosis of a serious illness [2]. This paradigm shift has positioned palliative care in cancer treatment as a patient-centered approach addressing needs throughout the disease trajectory [3]. Studies performed since the early 2000s have consistently shown improvements in quality of life, reductions in aggressive care during EOL scenarios, enhanced understanding of illness, and increased understanding and facilitation of advance care planning related to early palliative care, supporting its integration into standard oncology practice [4]. Reflecting these findings, the updated 2024 American Society of Clinical Oncology guidelines emphasize the importance of timely referral to specialty palliative care (SPC), beyond the primary support provided by oncology clinicians [5]. The guidelines recommend the early referral of patients with advanced cancers to interdisciplinary palliative care teams to address unresolved physical, psychosocial, or spiritual distress alongside ongoing cancer treatment. Additionally, caregivers are encouraged to access SPC services to ensure comprehensive support.

Despite existing guidelines advocating for the early integration of SPC, a significant gap persists between these recommendations and actual clinical practice. Numerous studies have reported that palliative care is often introduced late and in a fragmented manner, rather than being integrated early in the course of illness [6]. Various factors—including limited awareness of the scope of palliative care, insufficient resources, cultural resistance within healthcare settings, and reimbursement or policy constraints—have been identified as barriers that contribute to the gap between ideal practice guidelines and real-world implementation of early SPC [7]. Addressing these challenges and developing strategies for improvement are therefore of critical importance to the field. Establishing appropriate referral criteria has emerged as a key priority in ensuring the timely delivery of SPC [8].

Despite the availability of hospice care services specifically for patients with cancer in Korea since 2004 [9], referrals to SPC have neither been frequent nor initiated early [10]. Furthermore, hospice utilization has reached only about one-quarter of eligible patients [11]. This limited uptake may partially stem from the traditional restriction of SPC services to inpatient hospice settings. The legislative landscape changed in 2018 with the enactment of the Hospice-Palliative Care and Life-Sustaining Treatment Decision-Making Act, which expanded the scope of palliative care services to include inpatient hospice, home-based hospice, and consultative hospice services [12]. A recent study [13] demonstrated the positive impact of early palliative care interventions on outcomes such as improved symptom control, enhanced quality of life, and increased satisfaction with care, further strengthening the evidence for the benefits of early SPC integration in Korea.

Nevertheless, it remains unclear whether current clinical practices and healthcare provider readiness are sufficient to support the practical implementation of early SPC integration. This study aims to examine the perceptions of Korean oncologists regarding the early integration of SPC, including their referral patterns, perceived barriers, and clinical needs.

Materials and Methods

1. Study design and participants

This study used a cross-sectional design, with an online survey conducted between August 1-25, 2024. The participants included members of the Korean Society of Medical Oncology who met specific eligibility criteria. The inclusion criteria were board-certified hemato-oncology specialists who were currently practicing in a clinical setting. The exclusion criteria were those who did not provide written informed consent to participate in the survey and those who were unable to read and understand Korean. A total of 618 participants were recruited.

2. Questionnaire

The questionnaire was developed by the Education Committee of the Korean Association for Supportive Care in Cancer, based on a review of literature and existing surveys related to palliative care. The final version of the survey was confirmed after a pilot test was conducted among a sample of five clinicians. The survey’s items include the following areas: (1) the current status of referrals to SPC services; (2) attitudes and expectations regarding the early integration of SPC; (3) opinions on the appropriate criteria for referral to SPC; (4) perceived barriers to SPC referral and priority needs for implementation or early integration; and (5) the demographic and institutional characteristics of the participants—including age, sex, years in practice, experience with SPC, institutional characteristics, and the availability of SPC services within their institution. Regarding referral criteria, the time-based and trajectory-based criteria were adapted from the international Delphi study criteria outlined by Hui et al. [14]. The need-based criteria were revised from items recommended in the 2024 National Comprehensive Cancer Network palliative care guidelines as indications for considering referrals to SPC [1].

3. Statistical analysis

The demographic and clinical data of the participants were analyzed using descriptive statistics. Continuous variables are expressed as medians with ranges, whereas categorical ones are presented as numbers and percentages. Responses on a 4-point Likert scale based on frequency were categorized as follows: “always” and “usually” were classified as “yes,” whereas “rarely” and “never” were classified as “no.” Responses on a 5-point Likert scale were categorized as positive [4,5], neutral [3], or negative [1,2] attitudes. Associations between the frequency of referrals, preferred methods of referral, attitudes toward the early integration of SPC, and a range of influencing factors were analyzed using Fisher’s exact test or Pearson’s χ² test, to determine any significant relationships. All analyses were performed using STATA SE ver. 15 (StataCorp LP).

Results

Survey responses were received from 227 participants, yielding a response rate of 36.7%. The majority of respondents (70%) were in their 30s and 40s. Among all participants, 67.4% were employed at tertiary care hospitals, with 66.5% of these institutions located in metropolitan areas. Of the hospitals represented in the survey, 67.8% provided SPC services, and 42.3% of respondents reported having direct experience with SPC services (S1 Table).

1. Experiences and preferences regarding referrals to specialty palliative care

Among the respondents, 68.7% reported frequent direct experience with SPC referrals. Younger physicians, particularly those in their 30s and 40s, were significantly more likely to make frequent referrals compared to those in older age groups (p < 0.001). Frequent referrals were also associated with larger hospitals, with respondents who worked in institutions with ≥ 1,000 beds reporting the highest rates (p=0.008). Institutions with in-house SPC teams had substantially higher referral rates (77.9%) compared to those without such teams (49.3%, p < 0.001). Similarly, respondents who treated a greater proportion of patients with advanced cancer (≥ 90%) were more likely to report frequent referrals than those with fewer advanced cases (p=0.001) (Table 1).

Regarding referral preferences, 30.4% of the respondents preferred to refer their patients to an in-house SPC team, 26.4% favored co-management with internal SPC teams, and 43.2% opted for external referrals. The participants who worked in metropolitan hospitals predominantly chose in-house (37.1%) or external referrals (46.4%), whereas those in non-metropolitan ones generally preferred co-care (46.1%, p < 0.001). Respondents working in institutions with in-house SPC teams predominantly favored in-house management (37.7%), whereas those without such teams preferred external referrals (75.3%, p < 0.001). Physicians with SPC experience preferred co-care (39.6%), whereas those without SPC experience leaned heavily toward external referrals (53.4%, p < 0.001) (Table 2).

2. Attitudes and expectations for early integration of specialty palliative care

Among our 227 respondents, 74.9% responded that early integration of SPC is necessary. Those who reported frequent referrals to SPC were significantly more likely to indicate the necessity of early SPC integration (p=0.002). Otherwise, no other significant associating factors were identified (S2 Table).

Most of the respondents perceived that the early integration of SPC was helpful, particularly for areas such as advance care planning (97.8%), EOL care support (96.5%), and transition to hospice services (97.4%). High expectations were also noted regarding emotional support (92.5%) and symptom control (85%). However, relatively few considered it helpful for dealing with socioeconomic issues (59.9%), existential issues (71.4%), and prognostic communication (73.6%).

3. Patterns and perceptions concerning referrals to specialty palliative care

Regarding actual referral practices to SPC, > 70% of our respondents indicated that they make referrals in cases of disease progression or poor prognosis, termination of chemotherapy, poor performance status, patient states that suggest imminent mortality, decision-making regarding life-sustaining treatment, patient or family requests, and uncontrolled symptoms. Conversely, 60% of the respondents reported not referring their patients to SPC at the moment of an incurable cancer diagnosis. Furthermore, the percentage of referrals made for socioeconomic or existential issues was relatively low, at 55% and 62%, respectively (Fig. 1).

Regarding perceptions of time-based criteria for SPC referrals, our results indicated that 60% of respondents considered a prognosis of 6-12 months to represent an adequate timeframe for referral, followed by 50% for a prognosis of 3-6 months. By contrast, for prognoses of < 3 months, 80% of the respondents deemed referrals to be late or too late. For longer prognoses, such as 12-24 months, 40% of the respondents viewed the timing as too early, and this proportion increased to 60% for prognoses of ≥ 24 months. Referrals after disease progression despite palliative second-line treatment were considered adequate by 67.4%, whereas progression after first-line treatment was seen as early by 70% of the respondents (Fig. 2).

When asked about need-based criteria for SPC referrals, > 70% of the respondents agreed on the following triggers: patient or family request (96.5%), psychological distress (89.9%), uncontrolled symptoms (83.3%), recurrent emergency department visits or hospitalizations (78.4%), inadequate familial support systems (76.2%), existential issues (74.9%), and the need to clarify goals of care (71.8%). By contrast, the criteria with the highest rates of disagreement included the need for critical care (31.3%), the need for invasive procedures or operations (29.1%), communication issues between healthcare professionals (15.4%), and inter-/intra-professional conflicts or ethical issues regarding care coordination (15.0%) (Fig. 3).

4. Identified barriers to referrals to SPC and perceived priorities for implementation of early integration

The most frequently reported barrier to SPC referral was patient and/or family refusal (70.0%). This was followed by concerns that discussing palliative care might convey to patients and families that the physician is giving up on treatment (46.3%), or that the discussion might lead to disappointment (17.2%). Additionally, 34.4% of the respondents indicated that the absence of an available SPC team represented a substantial reason for not referring patients (Table 3).

For the successful implementation of early integration of SPC, the highest priority identified was promoting and improving awareness of palliative care among patients and their families. The second most important factor was ensuring that hospitals are adequately staffed with SPC providers, followed by the establishment of reimbursement structures for early palliative care services (Table 4).

Discussion

To the best of our knowledge, this is the first study to explore the practices and perceptions of oncologists in Korea regarding SPC referrals, providing critical insights into the current landscape of this practice in the country. Our findings highlight a strong recognition of the benefits of early SPC integration, while also revealing significant barriers—such as patient and family resistance and limited availability of SPC teams—that may complicate the introduction of palliative care. Referral preferences varied widely among our respondents, influenced by institutional characteristics and access to in-house SPC teams. These results underscore the need for targeted strategies to address these challenges, including educational initiatives to improve awareness among patients and families, expanding the availability of SPC services, and developing systematic frameworks to streamline referrals and support early integration.

Our study highlights positive attitudes toward the early integration of palliative care among Korean oncologists, consistent with findings from previous related studies [15,16]. Notably, these attitudes appear more favorable than those reported in a Swedish survey-based study, which included a more heterogeneous group of physicians not predominantly composed of oncologists [16]. Despite the differences in participant groups, the attitudes observed in our study are significantly more positive than those reported in a 2014 survey of 440 physicians in Korea regarding palliative care consultation teams [17]. These findings suggest that positive attitudes toward SPC referral have increased over the past decade, potentially reflecting improved awareness and knowledge of palliative care among healthcare providers [18].

Although hospice utilization in Korea remains < 25% as of 2023 [11], data on SPC referral rates is limited. Retrospective single-center studies report an increase in in-house palliative care consultation referrals, from 30% in the 2010s [10] to up to 50% in recent years [19]—though these findings may not fully represent overall practice patterns. Our study reveals that a substantial number of oncologists frequently refer patients to SPC, yet these referrals often do not lead to hospice service utilization. The observed delays in SPC referrals, which themselves often occur later than expected or recommended, align with findings from other studies that highlight a prevalent gap between ideal and actual referral timing [15,16]. These delays may partially explain the low level of hospice service utilization we observed, as earlier referrals tend to facilitate more appropriate EOL care. These findings reinforce the need to promote earlier integration of SPC to improve EOL care.

Importantly, we observed that Korean oncologists tend to refer patients later than recommended by international consensus. While global guidelines suggest initiating SPC within three months of diagnosing incurable cancer with a life expectancy of ≤ 1 year [14], our respondents most frequently selected a prognosis of 3-6 months as the optimal referral window. For trajectory-based criteria, there was a predominant preference for referral after the failure of second-line palliative chemotherapy, which aligns more closely with international recommendations [14]. This trend likely reflects practical constraints within the Korean healthcare system, such as inadequate palliative care staffing and the lack of reimbursement for palliative care services outside of hospice care [20]. These limitations make earlier referrals, such as those made at the onset of incurable cancer, challenging. While the timing favored by Korean oncologists may be later than international recommendations, it highlights the need to develop locally applicable guidelines that account for existing infrastructure and resources.

The referral patterns and attitudes toward needs-based criteria observed in this study highlight the significant value that many oncologists place on addressing the subjective suffering and care planning of patients and their families. This aligns with the international consensus [14], where severe symptoms and care planning issues form major criteria for early palliative care referrals. However, oncologists appear less attuned to identifying socioeconomic and spiritual needs, which corresponds to the lower reported demand for assistance in these areas [21]. Similarly, broader indications such as healthcare utilization and interprofessional conflicts are relatively undervalued in the country compared to what has previously been reported elsewhere [16], suggesting a gap in the perception of what comprehensive palliative care can offer. Addressing these overlooked needs through SPC is critical, as such situations often involve complex symptom management, decision-making challenges, and significant emotional distress for patients and their families. Effective SPC referrals can enhance quality of care, align treatment goals among healthcare teams, and provide essential support to patients and their families [3,22].

Patient and family resistance emerged as the most significant barrier to SPC referral, echoing prior studies in both Korean and international contexts [23,24]. The need for education and awareness campaigns targeting patients and families was deemed critical for implementation, reflecting common challenges in Korea—where the term “palliative care” is unfamiliar, and “hospice” is often associated with death. According to the 2023 Hospice Palliative Care Annual Report in Korea [11], a survey of Korean adults aged 20-80 years revealed that 72.9% viewed hospice positively and 91.7% acknowledged its necessity. However, 35.8% associated palliative care with care provided only at impending death, and 28.1% believed it is appropriate solely when death is imminent. Although public perceptions are gradually improving, a significant proportion still limits hospice to EOL care, posing challenges to the adoption of early palliative care. Similar barriers have been noted even in countries where palliative care is more widely recognized [21]. To address these issues, there is a pressing need to raise awareness and broaden understandings of palliative care among patients, families, and healthcare providers [15]. This may require redefining terminology and reframing the concept of palliative care to extend beyond EOL contexts. Oncologists should develop effective strategies to introduce palliative care to patients and families to overcome these barriers and facilitate early integration [23,24].

In addition to clinical and institutional efforts, national policy-level support is essential to ensure the sustainable and equitable integration of SPC in Korea. Our study identified key barriers—such as limited staffing, insufficient institutional incentives, and delayed referrals—that require multifaceted solutions. First, financial incentives, including expanded reimbursement for outpatient and consultative SPC services and the inclusion of early referral rates in hospital quality assessments [25], could encourage hospitals to establish and maintain in-house teams. This is particularly relevant given the relatively low accessibility to SPC in our study compared to previous reports [26], considering that consultative models offer a resource-efficient approach to cancer care [7]. In Korea, consultative hospice services are already reimbursed by national insurance, suggesting that scaling and expanding these services could support broader SPC implementation. Second, automatic referral systems embedded in electronic medical record platforms [27] may promote timely, needs-based referrals by reducing reliance on individual clinician discretion. This approach is supported by recent evidence that automated, criteria-driven referrals achieve outcomes comparable to universal early palliative care [28-30]. Strengthening institutional capacity for systematic needs assessment may further enhance these strategies. In parallel, targeted education for oncologists—particularly on systematic needs screening and referral processes—can help embed early SPC referral into routine clinical practice [29-31]. Notably, our findings indicate that oncologists who frequently refer to SPC are more likely to recognize its necessity, pointing to the complementary roles of clinical experience and education in fostering referral readiness. Finally, as SPC services remain concentrated in tertiary centers, expanding access to secondary and regional hospitals is critical. This will require government investment and national standards to monitor SPC team quality alongside existing hospice policies [7,9]. Ultimately, the success of early palliative care integration depends on aligning infrastructure, policy, and workforce development with real-world oncology practice.

This study has several key limitations worth noting. First, although we provided definitions of palliative care, SPC, and early palliative care within the survey, the respondents may still have had varying interpretations, potentially affecting the accuracy of their responses. Second, as the study relied on self-reported data from oncologists, there was a possibility of response bias, with respondents potentially overestimating or underestimating their actual referral practices and attitudes toward palliative care. Finally, the response rate was limited to a subset of eligible specialists, which may affect the generalizability of our findings. In particular, the response rate of 36.7% raises the possibility of nonresponse bias, as oncologists with more favorable views toward SPC may have been more likely to participate.

This study revealed that, although SPC referrals in Korea still predominantly occur at later stages, many oncologists express positive attitudes toward the early referral and integration of SPC. While the results should be interpreted with caution due to the self-reported nature of the data and the relatively low response rate, they underscore the need to establish practical guidelines and policy frameworks that account for Korea’s specific healthcare environment and resource limitations. Strengthening public awareness, expanding institutional capacity, and enhancing referral systems—including national-level support—are all critical to advancing the timely and equitable delivery of SPC services across the country.

Electronic Supplementary Material

Supplementary materials are available at Cancer Research and Treatment website (https://www.e-crt.org).

crt-2025-158_S1_Table.pdf

crt-2025-158_S2_Table.pdf

NOTES

Ethical Statement

This study was approved by the Institutional Review Board of Seoul National University Hospital (approval number: H-2404-015-1525). Informed consent was obtained from all participants upon enrollment. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Author Contributions

Conceived and designed the analysis: Yoo SH, Kim YJ, Kim JS, Park K, Nam EM, Lee SW, Kim JH, Koh SJ.

Collected the data: Yoo SH, Jeung YS, Koh SJ.

Contributed data or analysis tools: Yoo SH, Jeung YS, Koh SJ.

Performed the analysis: Yoo SH, Koh SJ.

Wrote the paper: Yoo SH, Kim YJ, Jeung YS, Kim JS, Park K, Nam EM, Lee SW, Ji JH, Kim JH, Hur JY, Park SE, Lee JL, Koh SJ.

Acquired the funding: Yoo SH.

Conflicts of Interest

Conflict of interest relevant to this article was not reported.

Acknowledgments

We are deeply grateful to the Korean Society of Medical Oncology and the Korean Academy for Supportive Care in Cancer for their invaluable cooperation in facilitating this survey.

Funding

This research was supported by a grant from the Patient-Centered Clinical Research Coordinating Center (PACEN), funded by the Ministry of Health & Welfare of the Republic of Korea (grant number: RS-2023-KH137917).

Fig. 1.

Actual patterns of referral to specialty palliative care among the study respondents.

Fig. 2.

Attitudes toward time- and trajectory-based referral criteria among the study respondents.

Fig. 3.

Attitudes toward need-based referral criteria among the study respondents.

Table 1.

Factors associated with the frequency of referral to SPC

Variable	Frequently referred	Less frequently referred	p-value
Total	156 (68.7)	71 (31.3)
Sex
Male	77 (63.7)	44 (36.4)	0.077
Female	79 (74.5)	27 (25.5)
Age group
30s	36 (65.5)	19 (34.5)	< 0.001
40s	86 (80.4)	21 (19.6)
50s	29 (58.0)	21 (42.0)
≥ 60s	5 (33.3)	10 (66.7)
Type of institution
Tertiary hospital	110 (71.9)	43 (28.1)	0.138
Secondary/Primary hospital	46 (62.2)	28 (37.8)
No. of beds
≥ 1,000	66 (80.5)	16 (19.5)	0.008
500-999	78 (64.5)	43 (35.5)
300-499	10 (55.6)	8 (44.4)
< 300	2 (33.3)	4 (66.7)
Region of institution
Capital area	105 (69.5)	46 (30.5)	0.709
Non-capital area	51 (67.1)	25 (32.9)
Presence of SPC service in the institution
No	36 (49.3)	37 (50.7)	< 0.001
Yes	120 (77.9)	34 (22.1)
Proportion of patients with advanced cancer (%)
≥ 90	37 (80.4)	9 (19.6)	0.001
50-89	95 (72.5)	36 (27.5)
< 50	24 (48.0)	26 (52.0)
Experience with SPC services
No	84 (64.1)	47 (35.9)	0.081
Yes	72 (75.0)	24 (25.0)

Values are presented as number (%). SPC, specialty palliative care.

Table 2.

Factors associated with preferred methods of referral to SPC

Variable	Refer to palliative care team in the same institution	Co-care with palliative care team	Transfer to other palliative care institution	p-value
Total	69 (30.4)	60 (26.4)	98 (43.2)
Sex
Male	39 (32.2)	31 (25.6)	51 (42.1)	0.813
Female	30 (28.3)	29 (27.4)	47 (44.3)
Age group
30s	14 (25.4)	16 (29.1)	25 (45.4)	0.937
40s	35 (32.7)	27 (25.2)	45 (42.1)
50s	14 (28.0)	14 (28.0)	22 (44.0)
≥ 60s	6 (40.0)	3 (20.0)	6 (40.0)
Type of institution
Tertiary hospital	49 (32.0)	41 (26.8)	63 (41.2)	0.648
Secondary/Primary hospital	20 (27.0)	19 (25.7)	35 (47.3)
No. of beds
≥ 1,000	29 (35.4)	23 (28.0)	30 (36.6)	0.232
500-999	37 (30.6)	29 (24.0)	55 (45.4)
300-499	3 (16.7)	7 (38.9)	8 (44.4)
< 300	0	1 (16.7)	5 (83.3)
Region of institution
Capital area	56 (37.1)	25 (16.6)	70 (46.4)	< 0.001
Non-capital area	13 (17.1)	35 (46.1)	28 (36.8)
Presence of SPC service in the institution
No	11 (15.1)	7 (9.6)	55 (75.3)	< 0.001
Yes	58 (37.7)	53 (34.4)	43 (27.9)
Proportion of patients with advanced cancer (%)
≥ 90	15 (30.0)	13 (26.0)	22 (44.0)	0.755
50-89	37 (28.2)	34 (26.0)	60 (45.8)
< 50	17 (36.9)	13 (28.3)	16 (34.8)
Experience with SPC services
No	39 (29.8)	22 (16.8)	70 (53.4)	< 0.001
Yes	30 (31.2)	38 (39.6)	28 (29.2)

Values are presented as number (%). SPC, specialty palliative care.

Table 3.

Barriers to referring patients to specialty palliative care services

Barriers	No. (%)
Refusal on the part of the patient/Family	159 (70.0)
Fear of giving up the patient/Family perception that the doctor is giving up on them	105 (46.3)
Lack of specialty palliative care team	78 (34.4)
Fear of disappointing the patient/Family	39 (17.2)
No time for referrals during practice	34 (15.0)
Concern that the patient/Family may refuse necessary treatment	28 (12.3)
Belief that I can adequately provide specialty palliative care myself	26 (11.5)
Other^a)	18 (7.9)
Uncertainty concerning the appropriate timing for referral	17 (7.5)
Difficulty assessing which patients may benefit from it	16 (7.1)
Lack of detailed knowledge on the referral process (i.e., procedures)	8 (3.5)
Limited understanding of what specialty palliative care entails	4 (1.8)

^a) Other reasons included limited resources of the specialty palliative care team (n=7), excessive delays in actual linkage to the team (n=6), lack of trust in the specialty palliative care team (n=2), and uncertainty (n=3).

Table 4.

Priority areas for implementing early integration of specialty palliative care

	First choice	Second choice^a)	Third choice^b)	Total score	Order
Promotion and awareness improvement regarding palliative care for patients and families	92 (40.5)	18 (8.1)	32 (14.6)	344	1
Ensuring hospitals are staffed with specialized palliative care providers (such as physicians, nurses, and social workers)	52 (22.9)	67 (30.2)	44 (20.0)	334	2
Establishing reimbursement for early palliative care services	46 (20.3)	59 (26.6)	39 (17.7)	295	3
System and framework that connects early palliative care to hospice	13 (5.7)	36 (16.2)	61 (27.7)	172	4
Education of healthcare providers on palliative care	14 (6.2)	23 (10.4)	20 (9.1)	108	5
Domestic guidelines on the timing and eligibility of patients for early palliative care	7 (3.1)	18 (8.1)	22 (10.0)	79	6
Other	3 (1.3)	1 (0.5)	2 (0.9)	13	7

Values are presented as number (%).

^a) n=222,

^b) n=220.

REFERENCES

1. National Comprehensive Cancer Network. Palliative care (version 1.2025) [Internet]. National Comprehensive Cancer Network; 2024. [cited 2024 Dec 22]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
2. Clark D. From margins to centre: a review of the history of palliative care in cancer. Lancet Oncol. 2007;8:430–8. Article PubMed
3. Hui D, Bruera E. Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol. 2016;13:159–71. Article PubMed PDF
4. Haun MW, Estel S, Rucker G, Friederich HC, Villalobos M, Thomas M, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6:CD011129.Article PubMed
5. Sanders JJ, Temin S, Ghoshal A, Alesi ER, Ali ZV, Chauhan C, et al. Palliative care for patients with cancer: ASCO guideline update. J Clin Oncol. 2024;42:2336–57. PubMed
6. Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, et al. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med. 2020;18:368.Article PubMed PMC PDF
7. Von Roenn JH, Voltz R, Serrie A. Barriers and approaches to the successful integration of palliative care and oncology practice. J Natl Compr Canc Netw. 2013;11 Suppl 1:S11–6. PubMed
8. Hui D, Heung Y, Bruera E. Timely palliative care: personalizing the process of referral. Cancers (Basel). 2022;14:1047.Article PubMed PMC
9. Kim HS, Hong YS. Hospice palliative care in South Korea: past, present, and future. J Hosp Palliat Care. 2016;19:99–108. Article
10. Jho HJ, Nam EJ, Shin IW, Kim SY. Changes of end of life practices for cancer patients and their association with hospice palliative care referral over 2009-2014: a single institution study. Cancer Res Treat. 2020;52:419–25. Article PubMed PDF
11. Ministry of Health and Welfare. 2023 National hospice and palliative care annual report. Ministry of Health and Welfare; 2023.
12. Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life [Internet]. Korea Legislation Research Institute; 2018. [cited 2025 Jan 8]. Available from: https://elaw.klri.re.kr/eng_service/lawView.do?hseq=49372&lang=ENG
13. Kang E, Kang JH, Koh SJ, Kim YJ, Seo S, Kim JH, et al. Early integrated palliative care in patients with advanced cancer: a randomized clinical trial. JAMA Netw Open. 2024;7:e2426304Article PubMed PMC
14. Hui D, Mori M, Watanabe SM, Caraceni A, Strasser F, Saarto T, et al. Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol. 2016;17:e552–9. Article PubMed
15. Charalambous H, Pallis A, Hasan B, O’Brien M. Attitudes and referral patterns of lung cancer specialists in Europe to Specialized Palliative Care (SPC) and the practice of Early Palliative Care (EPC). BMC Palliat Care. 2014;13:59.Article PubMed PMC PDF
16. Adolfsson K, Kreicbergs U, Bratthall C, Holmberg E, Bjork-Eriksson T, Stenmarker M. Referral of patients with cancer to palliative care: attitudes, practices and work-related experiences among Swedish physicians. Eur J Cancer Care (Engl). 2022;31:e13680Article PubMed PMC PDF
17. Shim HY, Chang YJ, Kawk KS, Mai TT, Choi JY, Ahn EM, et al. Do Korean doctors think a palliative consultation team would be helpful to their terminal cancer patients? Cancer Res Treat. 2017;49:437–45. Article PubMed PDF
18. Cha E, Lee S, Lee J, Lee I. Health personnel’s knowledge, attitudes, and self-efficacy related to providing palliative care in persons with chronic diseases. Hanguk Hosupisu Wanhwa Uiryo Hakhoe Chi. 2020;23:198–211. Article PubMed PMC
19. Kim JH, Yoo SH, Keam B, Heo DS. The impact of palliative care consultation on reducing antibiotic overuse in hospitalized patients with terminal cancer at the end of life: a propensity score-weighting study. J Antimicrob Chemother. 2022;78:302–8. Article PubMed PDF
20. Yoon SJ. Barriers to early palliative care. Hanguk Hosupisu Wanhwa Uiryo Hakhoe Chi. 2020;23:252–5. Article PubMed PMC
21. Coym A, Oechsle K, Kanitz A, Puls N, Blum D, Bokemeyer C, et al. Impact, challenges and limits of inpatient palliative care consultations - perspectives of requesting and conducting physicians. BMC Health Serv Res. 2020;20:86.Article PubMed PMC PDF
22. Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer. 2014;120:1743–9. Article PubMed
23. Collins A, Gurren L, McLachlan SA, Wawryk O, Philip J. Communication about early palliative care: a qualitative study of oncology providers’ perspectives of navigating the artful introduction to the palliative care team. Front Oncol. 2022;12:1003357.Article PubMed PMC
24. Sarradon-Eck A, Besle S, Troian J, Capodano G, Mancini J. Understanding the barriers to introducing early palliative care for patients with advanced cancer: a qualitative study. J Palliat Med. 2019;22:508–16. Article PubMed
25. Health Insurance Review and Assessment Service. Cancer quality assessment: expansion to comprehensive cancer care [Internet]. Health Insurance Review and Assessment Service; 2021. [cited 2025 Jan 8]. Available from: https://www.hira.or.kr/bbsDummy.do?brdBltNo=10449&brdScnBltNo=4&pageIndex=1&pgmid=HIRAA020041000100
26. Feld E, Singhi EK, Phillips S, Huang LC, Shyr Y, Horn L. Palliative care referrals for advanced non-small-cell lung cancer (NSCLC): patient and provider attitudes and practices. Clin Lung Cancer. 2019;20:e291–8. Article PubMed
27. Parikh RB, Ferrell WJ, Li Y, Chen J, Bilbrey LE, Johnson N, et al. BE-a-PAL: a cluster-randomized trial of algorithm-based default palliative care referral among patients with advanced cancer. J Clin Oncol. 2024;42(16 Suppl):12002.Article
28. Hui D, Mori M, Meng YC, Watanabe SM, Caraceni A, Strasser F, et al. Automatic referral to standardize palliative care access: an international Delphi survey. Support Care Cancer. 2018;26:175–80. Article PubMed PDF
29. Temel JS, Jackson VA, El-Jawahri A, Rinaldi SP, Petrillo LA, Kumar P, et al. Stepped palliative care for patients with advanced lung cancer: a randomized clinical trial. JAMA. 2024;332:471–81. Article PubMed PMC
30. Zimmermann C, Pope A, Hannon B, Bedard PL, Rodin G, Dhani N, et al. Symptom screening with Targeted Early Palliative care (STEP) versus usual care for patients with advanced cancer: a mixed methods study. Support Care Cancer. 2023;31:404.Article PubMed PDF
31. Sorensen A, Le LW, Swami N, Hannon B, Krzyzanowska MK, Wentlandt K, et al. Readiness for delivering early palliative care: a survey of primary care and specialised physicians. Palliat Med. 2020;34:114–25. Article PubMed PDF

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Exploring Oncologists’ Perspectives on the Early Integration of Specialty Palliative Care in Korea: Challenges, Needs, and Clinical Implications

DOI: https://doi.org/10.4143/crt.2025.158

XML Download

Abstract
Introduction
Materials and Methods
Results
Discussion
Electronic Supplementary Material
NOTES
REFERENCES

Exploring Oncologists’ Perspectives on the Early Integration of Specialty Palliative Care in Korea: Challenges, Needs, and Clinical Implications

Fig. 1. Actual patterns of referral to specialty palliative care among the study respondents.

Fig. 2. Attitudes toward time- and trajectory-based referral criteria among the study respondents.

Fig. 3. Attitudes toward need-based referral criteria among the study respondents.

Fig. 1.

Fig. 2.

Fig. 3.

Exploring Oncologists’ Perspectives on the Early Integration of Specialty Palliative Care in Korea: Challenges, Needs, and Clinical Implications

Variable	Frequently referred	Less frequently referred	p-value
Total	156 (68.7)	71 (31.3)
Sex
Male	77 (63.7)	44 (36.4)	0.077
Female	79 (74.5)	27 (25.5)
Age group
30s	36 (65.5)	19 (34.5)	< 0.001
40s	86 (80.4)	21 (19.6)
50s	29 (58.0)	21 (42.0)
≥ 60s	5 (33.3)	10 (66.7)
Type of institution
Tertiary hospital	110 (71.9)	43 (28.1)	0.138
Secondary/Primary hospital	46 (62.2)	28 (37.8)
No. of beds
≥ 1,000	66 (80.5)	16 (19.5)	0.008
500-999	78 (64.5)	43 (35.5)
300-499	10 (55.6)	8 (44.4)
< 300	2 (33.3)	4 (66.7)
Region of institution
Capital area	105 (69.5)	46 (30.5)	0.709
Non-capital area	51 (67.1)	25 (32.9)
Presence of SPC service in the institution
No	36 (49.3)	37 (50.7)	< 0.001
Yes	120 (77.9)	34 (22.1)
Proportion of patients with advanced cancer (%)
≥ 90	37 (80.4)	9 (19.6)	0.001
50-89	95 (72.5)	36 (27.5)
< 50	24 (48.0)	26 (52.0)
Experience with SPC services
No	84 (64.1)	47 (35.9)	0.081
Yes	72 (75.0)	24 (25.0)

Variable	Refer to palliative care team in the same institution	Co-care with palliative care team	Transfer to other palliative care institution	p-value
Total	69 (30.4)	60 (26.4)	98 (43.2)
Sex
Male	39 (32.2)	31 (25.6)	51 (42.1)	0.813
Female	30 (28.3)	29 (27.4)	47 (44.3)
Age group
30s	14 (25.4)	16 (29.1)	25 (45.4)	0.937
40s	35 (32.7)	27 (25.2)	45 (42.1)
50s	14 (28.0)	14 (28.0)	22 (44.0)
≥ 60s	6 (40.0)	3 (20.0)	6 (40.0)
Type of institution
Tertiary hospital	49 (32.0)	41 (26.8)	63 (41.2)	0.648
Secondary/Primary hospital	20 (27.0)	19 (25.7)	35 (47.3)
No. of beds
≥ 1,000	29 (35.4)	23 (28.0)	30 (36.6)	0.232
500-999	37 (30.6)	29 (24.0)	55 (45.4)
300-499	3 (16.7)	7 (38.9)	8 (44.4)
< 300	0	1 (16.7)	5 (83.3)
Region of institution
Capital area	56 (37.1)	25 (16.6)	70 (46.4)	< 0.001
Non-capital area	13 (17.1)	35 (46.1)	28 (36.8)
Presence of SPC service in the institution
No	11 (15.1)	7 (9.6)	55 (75.3)	< 0.001
Yes	58 (37.7)	53 (34.4)	43 (27.9)
Proportion of patients with advanced cancer (%)
≥ 90	15 (30.0)	13 (26.0)	22 (44.0)	0.755
50-89	37 (28.2)	34 (26.0)	60 (45.8)
< 50	17 (36.9)	13 (28.3)	16 (34.8)
Experience with SPC services
No	39 (29.8)	22 (16.8)	70 (53.4)	< 0.001
Yes	30 (31.2)	38 (39.6)	28 (29.2)

Barriers	No. (%)
Refusal on the part of the patient/Family	159 (70.0)
Fear of giving up the patient/Family perception that the doctor is giving up on them	105 (46.3)
Lack of specialty palliative care team	78 (34.4)
Fear of disappointing the patient/Family	39 (17.2)
No time for referrals during practice	34 (15.0)
Concern that the patient/Family may refuse necessary treatment	28 (12.3)
Belief that I can adequately provide specialty palliative care myself	26 (11.5)
Other^a)	18 (7.9)
Uncertainty concerning the appropriate timing for referral	17 (7.5)
Difficulty assessing which patients may benefit from it	16 (7.1)
Lack of detailed knowledge on the referral process (i.e., procedures)	8 (3.5)
Limited understanding of what specialty palliative care entails	4 (1.8)

	First choice	Second choice^a)	Third choice^b)	Total score	Order
Promotion and awareness improvement regarding palliative care for patients and families	92 (40.5)	18 (8.1)	32 (14.6)	344	1
Ensuring hospitals are staffed with specialized palliative care providers (such as physicians, nurses, and social workers)	52 (22.9)	67 (30.2)	44 (20.0)	334	2
Establishing reimbursement for early palliative care services	46 (20.3)	59 (26.6)	39 (17.7)	295	3
System and framework that connects early palliative care to hospice	13 (5.7)	36 (16.2)	61 (27.7)	172	4
Education of healthcare providers on palliative care	14 (6.2)	23 (10.4)	20 (9.1)	108	5
Domestic guidelines on the timing and eligibility of patients for early palliative care	7 (3.1)	18 (8.1)	22 (10.0)	79	6
Other	3 (1.3)	1 (0.5)	2 (0.9)	13	7

Table 1. Factors associated with the frequency of referral to SPC

Values are presented as number (%). SPC, specialty palliative care.

Table 2. Factors associated with preferred methods of referral to SPC

Values are presented as number (%). SPC, specialty palliative care.

Table 3. Barriers to referring patients to specialty palliative care services

Other reasons included limited resources of the specialty palliative care team (n=7), excessive delays in actual linkage to the team (n=6), lack of trust in the specialty palliative care team (n=2), and uncertainty (n=3).

Table 4. Priority areas for implementing early integration of specialty palliative care

Values are presented as number (%).

n=222,

n=220.