Barriers to timely transitions to comfort care in cancer patients: a review.

Introduction: "Comfort care" is a holistic approach for patients with terminal conditions, such as cancer, who are not expected to recover. It focuses on managing pain, among other end-of-life symptoms, and providing support to both the patient and their family during the dying process, which can last unpredictably from hours to days. End-of-life care concepts are often shaped by personal judgment and culture and thus lack a single consensus. This can lead to ambiguity in the term "comfort care" itself as well as create confusion in medical communication and treatment, making the transition to comfort care more challenging. In this review, we strive to evaluate the barriers preventing the timely conversion of end-stage cancer patients to comfort care. We also discuss the possible measures to limit these sensitive barriers to avoid futility in treatment and to ensure an ambiguity-free transition to ensure the best possible outcome for the patient. In this paper, we aim to systematically identify and categorize the key barriers that delay comfort care transitions in terminal cancer patients and to propose actionable strategies grounded in current evidence to address these challenges. Methodology: We conducted a literature search using PubMed and MEDLINE, covering studies published between January 2020 and March 2025. Search terms included a combination of MeSH terms and keywords such as "Palliative Care," "Terminal Care," "Hospice Care," "Communication Barriers," "Cultural Factors," "Cancer," and "Prognostic Uncertainty." Eligible studies were peer-reviewed, published in English, and focused on adult cancer patients receiving palliative or end-of-life care, with a clear emphasis on barriers to timely transitions to comfort care. Studies unrelated to cancer, lacking a focus on barriers, or published in non-English languages were excluded. A total of 156 articles were identified; titles and abstracts were screened for relevance, followed by full-text review based on inclusion criteria. Data from the selected studies were analyzed using a thematic synthesis approach, in which two authors independently categorized findings under three main themes: prognostic uncertainty, communication challenges, and cultural factors. Discrepancies were resolved through discussion. Findings: Based on our extensive search, we classified the barriers for transition to comfort care into three main headings: Prognostic uncertainty, Challenges to Communication, and cultural factors. High levels of distress were observed in both patients and healthcare providers due to prognostic uncertainty, which complicates the prediction of illness trajectories, negatively affecting quality of life and delaying the transition to comfort care. Communication challenges, such as short consultations, language barriers, and difficult conversations about care goals, were also prevalent. The COVID-19 pandemic exacerbated these issues; there was lingering apprehension surrounding end-of-life discussions. Additionally, cultural factors play a significant role in shaping patients' perceptions of cancer, pain, treatment, and death. Family involvement in decision-making varies across cultures, and systemic inequalities in access to palliative care disproportionately affect racialized groups. Conclusion: To overcome these barriers, the study emphasizes the need for effective policy-making to improve the quality of life for cancer patients during their care transition. It also becomes crucial to implement measures to improve communication protocols, validate culturally sensitive interventions, and routinely integrate palliative care in oncological practice early. We also need to work towards culturally appropriate interventions and strive to incorporate appropriate communication techniques to eliminate disparity for access to equitable palliative care.