Healthcare provider perceptions and barriers to palliative care in Pakistan: A narrative synthesis.

e13640 Background: Palliative care integration in Pakistan remains limited despite a high cancer burden in this low-resource setting. Knowledge gaps, cultural/religious ethical concerns, socioeconomic barriers, and opioid restrictions lead to delayed engagement, late diagnoses, and poor symptom control. This review synthesizes provider, caregiver, and trainee perceptions and systemic obstacles to delivery. Methods: Targeted PubMed/MEDLINE search using MeSH terms (“Palliative Care,” “Terminal Care,” “Health Personnel,” “Pakistan,” etc.). Narrative synthesis of observational, survey, qualitative, and guideline studies from Pakistan or relevant South Asian contexts. Results: Non-oncologists show major gaps in hospice awareness, referrals, and pain management despite cancer involvement (Shaikh et al.). Caregivers often misunderstand palliative principles (~45% adequately informed), but support disclosure and holistic care when educated (Shah et al.). Oncologists increasingly recognize time toxicity, with 85% modifying regimens to reduce patient burden (Hameed et al.). Ethical hesitancy limits end-of-life decisions due to legal, religious, and cultural factors (Zaheer et al.). Recent evidence highlights depression in up to 52% of palliative patients (moderate-severe common), with adaptive coping but need for psychological integration (Ali et al., 2025); undertreated cancer pain reliant on weak opioids (tramadol 69%), minimal strong opioids/alternatives (3%) due to regulations/costs (Sami, 2025); persistent student misconceptions and stagnant knowledge across training (Bilal et al., 2024); South Asian emphasis on family care, religious rites, poverty-moderated choices, and pain-free death (Wijeyaratne et al., 2025); high neonatal treatment withdrawal rates (47%) but parental overrides leading to poor survival (Iqbal et al., 2025); localized NCCN guideline adaptations addressing primary care gaps (Hashmi et al., 2024); and emerging non-opioid analgesics offering potential to overcome opioid access limitations in restricted environments. Conclusions: Palliative care in Pakistan faces persistent knowledge gaps, limited training, socioeconomic/religious barriers, and symptom undertreatment (especially opioids). Growing oncologist awareness of holistic needs offers promise, but progress requires standardized education, policy reforms, guideline localization, and innovative alternatives to enable equitable, timely access in resource-limited settings.