Physicians’ Agreement on the Use of NECPAL as a Tool for Identifying Patients Suitable for Palliative Care: A Cross-Sectional Study

Abstract

Background:

Palliative care aims to optimize the quality of life of critically ill patients.

Objectives:

This study assessed Lebanese physicians’ attitudes toward palliative care and their use of NECPAL tool in clinical decision-making.

Methods:

A cross-sectional design was adopted among 259 physicians using a structured questionnaire. Data analysis was conducted using IBM SPSS Statistics software.

Results:

Among 259 physicians, 83.4% used NECPAL tool, with a mean attitude score toward palliative care of 4.37 (SD = 0.39). Higher attitude scores were significantly associated with NECPAL use (p < .001), presence of institutional policies supporting advanced care planning (p = .017). Multivariable regression confirmed NECPAL use, facility policies, and availability of palliative care units as independent predictors of attitudes (p < .05).

Conclusion:

The findings highlight the role of institutional infrastructure and validated assessment tools in shaping physician’s perceptions and promoting better integration of palliative care in Lebanon.

Keywords

palliative care physicians’ attitudes end-of-life care chronic diseases medical education cross-sectional survey Lebanon

Application of study findings

• This study supports the need to integrate validated prognostic tools, like NECPAL, into the clinical practice, especially in settings where there is a lack of standardized palliative care assessment protocols.

• The study findings could inform hospital administrators and policymakers about the importance of institutional support in shaping the attitudes of their practicing physicians.

Introduction

Palliative care is an essential component of healthcare, focused on enhancing the quality of life for patients facing life-threatening illnesses through the prevention and relief of suffering. This is achieved by addressing the multifaceted needs of patients—physical, emotional, social, and spiritual (Teoli et al., 2023). As the global burden of chronic diseases continues to rise, the need for palliative care is becoming increasingly recognized (Knaul et al., 2025). The WHO estimates that around 40 million people require palliative care annually, yet only a small fraction of these patients, about 14%, receive the care they need (World Health Organization, 2020). This discrepancy underscores the necessity for reliable tools and methodologies to identify patients who could benefit from palliative care interventions.

Globally, it is known that palliative care is underutilized, and this is due to various barriers in decision making. These barriers include the lack of awareness, the inadequate training among healthcare workers, especially doctors, and the cultural boundaries and stigmas associated with an individual’s death (Flieger et al., 2020). Studies conducted on this topic have found that positive attitudes toward palliative care in many healthcare workers is important to deliver this type of care effectively (Altarawneh et al., 2023). Hence, these attitudes can affect the quality of care provided by physicians, nurses, and can influence their decisions related to pain management approaches, patient communications, as well as the overall medical support they provide within their work (Givler et al., 2023; Rafiee et al., 2024).

Within the Lebanese context, the integration of palliative care into the healthcare system presents many challenges. For instance, Lebanon is known by its cultural and religious diversity, which can influence the perceptions, as well as the practices of individuals when it comes to end-of-life care (Mouhawej et al., 2017). In addition, the infrastructure of healthcare, alongside the available resources for palliative care can widely vary across the country, and this can consequently impact the accessibility and the quality of services provided (Aoun & Tajvar, 2024).

Patients and families in Lebanon demonstrate variable and generally limited awareness of palliative care, often equating it with imminent death rather than symptom relief and quality-of-life support. This limited understanding contributes to late referrals, continued pursuit of curative treatments until very advanced stages, and occasional recourse to alternative therapies when prognosis is disclosed. Community NGOs and specialist centers (e.g., national hospice and home-care initiatives) have developed outreach and home-based services that improve awareness locally, but national coverage remains incomplete and access to opioids and multidisciplinary teams is uneven, particularly outside major urban centers. These patient-level factors interact with physician attitudes and institutional policies to shape referral timing and care pathways.

For physicians to be able to decide whether a patient is eligible for palliative care or not, a variety of prognostic tools are utilized. One known tool that has garnered significant attention in recent years is the NECPAL tool, developed in Spain (ElMokhallalati et al., 2020). The NECPAL tool is a comprehensive screening instrument designed to identify patients with advanced chronic conditions who are likely to benefit from palliative care (Gómez-Batiste et al., 2013). The tool encompasses a wide range of criteria, including clinical indicators, disease progression, frailty, and psychosocial factors, making it a holistic approach to patient assessment. Its versatility allows it to be used across various healthcare settings, including hospitals, primary care, and nursing homes, providing a consistent method for identifying palliative care needs (Gómez-Batiste et al., 2013).

Across the Arab region, family-centered decision making, reluctance to discuss prognosis openly, and variable policy support are recurrent themes that shape palliative care uptake. Many neighboring countries report nascent services, workforce training gaps, restricted opioid availability, and stigma around end-of-life discussions; Lebanon’s experience—while sharing these cultural influences—benefits from stronger NGO and academic engagement that has enabled pilot training and community programs. Framing Lebanese findings within this regional context clarifies that cultural and religious norms influence disclosure and referral practices similarly across neighboring Arab states, reinforcing the manuscript’s broader relevance.

The utility of NECPAL lies in its ability to synthesize multiple indicators into a single, actionable assessment, offering healthcare providers a clear pathway for integrating palliative care into patient management plans (Esteban-Burgos et al., 2021). The tool is particularly valuable because it can be applied to patients with a variety of chronic conditions, such as dementia, heart failure, chronic obstructive pulmonary disease (COPD), and cancer (Gómez-Batiste et al., 2013). By facilitating the early identification of palliative care needs, NECPAL allows for more timely and effective care planning, ultimately improving patient outcomes and satisfaction (ElMokhallalati et al., 2020).

Despite its potential benefits, the adoption of NECPAL has been inconsistent across different healthcare systems and among physicians. This variation in utilization may be attributed to several factors, including the clinician’s knowledge and experience with palliative care, their familiarity with the NECPAL tool, and their overall attitudes toward the concept of palliative care (Murtagh et al., 2014). Understanding the level of agreement among physicians regarding the use of NECPAL is crucial for promoting its broader adoption and ensuring that patients who need palliative care are appropriately identified.

This study aims to assess the level of agreement among physicians on the use of NECPAL as a tool for identifying patients suitable for palliative care. Additionally, the study will explore physicians’ attitudes and beliefs regarding the tool’s effectiveness in various clinical scenarios, such as oncology cases, dementia, Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF), and investigate the factors influencing their agreement.

Methodology

Study Design

The present study, conducted in Lebanon, is based on a cross-sectional design, where the data was collected among Lebanese physicians to assess their attitudes toward the utilization of NECPAL as a tool to decide whether a patient is suitable for palliative care or not.

Population

The population of this study included Lebanese physicians from different specialties, practicing in Lebanon. The inclusion criteria included the physicians that are currently practicing in different Lebanese healthcare settings. Participants included in the study were physicians in practice for at least 1 year of experience in managing patients with chronic or terminal illnesses, and who voluntarily accepted to participate in the present study. On the other hand, excluded from this study were physicians who are not registered under the Lebanese Order of Physicians, those who have less than 1 year of experience, and those who refuse to participate in the study.

The sample size was estimated using Epi Info™ version 7.2.7.0 (CDC, Atlanta, USA), assuming a physician population of 15,059 in Lebanon (registered in 2023), an expected frequency of 25%, a 5% margin of error, a 95% confidence level, and a design effect of 1.0. The minimum required sample size was 283 physicians. The final sample included 259 physicians, which is slightly below the required size. Although adequate for exploratory and bivariate analyses, the achieved sample should not be described as sufficiently representative, given the dominance of internal medicine physicians (89.2%), the gender imbalance, and the absence of comparison with national physician demographics.

Data Collection

Data collection occurred from May 2016 to May 2017 using an online survey, structured by the researchers based on different studies reviewed in the literature, as well as on the NECPAL diagnostic tool widely published (Gómez-Batiste et al., 2011). The survey was disseminated to the physicians either by email or through professional networks. It included sections on demographic characteristics, education and work-related characteristics, clinical experience with palliative care, attitudes toward palliative care in different scenarios including dementia, oncology, CKD, COPD, and CHF (Appendix 1). It is worth noting that the questionnaire was designed based on different items in the NECPAL diagnostic tool in order to capture the attitudes and beliefs of the physicians without making them address all the items of this tool.

Data Analysis

All data were analyzed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the demographic characteristics of the participating physicians, as well as their medical education background, residency type, subspecialty, and experience in palliative care. Continuous variables were reported using means and standard deviations (or medians and interquartile ranges, where appropriate), while categorical variables were presented as frequencies and percentages. The internal consistency of the overall attitude scale toward palliative care, which included items related to diagnostic disclosure and clinical scenario-based responses, was assessed using Cronbach’s alpha, which demonstrated acceptable reliability (α = .727). Normality of the overall attitude score was tested using Kolmogorov–Smirnov and Shapiro–Wilk tests, both indicating non-normal distribution (p < .001). For reporting consistency, p-values smaller than .001 are reported as p < .001.

Given the non-parametric distribution of the attitude scores, Mann–Whitney U tests and Kruskal–Wallis H tests were employed to compare attitudes across physician groups categorized by demographic variables (e.g., age, gender), educational background (e.g., medical school, graduation year), and clinical experience (e.g., use of NECPAL, presence of a palliative care unit or committee). Additionally, Spearman’s rank-order correlation was used to explore the association between physicians’ attitudes toward disclosing the diagnosis and their overall attitude toward palliative care.

To further identify the factors independently associated with overall attitude scores, a multiple linear regression analysis was conducted. Two models were developed: an Enter model that included all variables with bivariate associations at a threshold of p < .20, and a Stepwise model that retained only the significant predictors. Statistical significance was set at p < .05 for all analyses.

Ethical Considerations

This study was approved by the Institutional Review Board of a tertiary healthcare institution on May 2016. All participants provided written informed consent prior to enrollment in the study. This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Anonymity and confidentiality were respected. Participants were invited to voluntarily participate to this study, with a freedom to withdraw at any time with no consequences. Data was secured in encrypted files and used for scientific purposes only.

Results

Demographic Characteristics

The study sample consisted of 259 Lebanese physicians who completed the survey. Participants were distributed across five age groups. The youngest age group, those under 35 years, represented 4.6% (N = 12) of the respondents. Physicians aged 36 to 40 years accounted for 17.4% (N = 45), while those aged 41 to 45 years and 46 to 50 years each made up 23.2% (N = 60) of the total sample. The largest group comprised physicians over 50 years old, representing 31.7% (N = 82) of participants. In terms of gender distribution, the majority of respondents were male, comprising 74.1% (N = 192).

Education and Work Data

The analysis of graduation timelines revealed a balanced distribution across four categories of clinical experience. Physicians who had graduated less than 20 years ago constituted the largest group (31%, n = 81), followed closely by those with more than 30 years of experience (28.6%, n = 74). Respondents with 20 to 25 years of experience represented 24.7% (N = 64), while those in the 26 to 30-year category comprised 15.4% (N = 40). Regarding residency training, Internal Medicine emerged as the predominant field, with 89.2% (N = 231) of respondents identifying it as their primary specialty. The predominance of Internal Medicine reflects the relevance of chronic disease management and complex patient care within the context of palliative care. Other specialties were represented in smaller proportions: Surgery at 4.6% (N = 12), Obstetrics and Gynecology at 2.3% (N = 6), Family Medicine and Pediatrics each at 1.2% (N = 3), and other specialties at 1.5% (N = 4).

Sub specialization was also diverse but showed clustering around key domains closely associated with palliative care needs. Pulmonary Medicine was the most commonly reported subspecialty, accounting for 35.9% of the respondents (N = 93). Neurology and Cardiology followed at 17.0% (N = 44) and 16.2% (N = 42). Oncology, a core discipline in palliative care, was represented by 10.4% (N = 27) of the sample, while Nephrology specialists made up 9.7% (N = 25). Geriatrics, despite its close association with palliative principles, was underrepresented at 1.9% (N = 5), due to the small number of geriatricians in Lebanon. The remaining 8.9% (N = 23) reported affiliation with other subspecialties.

Experience With Palliative Care

Among the 259 participating physicians, 83.4% (N = 216) reported using the NECPAL tool to assess the severity of patients’ illnesses, while 16.6% (N = 43) indicated that they do not use such a tool. In terms of facility-level policies, 39.8% (N = 103) of physicians reported that the institution they work in has policies encouraging physicians to engage in advanced care planning and palliative care services. The remaining 60.2% (N = 156) stated that no such policies exist in their workplace. Only 8.5% reported the availability of a dedicated palliative care unit within the hospital. Membership in a palliative care committee was reported by only 1.9% of physicians surveyed.

Attitudes Toward Palliative Care

Telling the Diagnosis

The survey results reveal nuanced insights into the attitudes of Lebanese physicians toward disclosing diagnoses to patients (Table 1). The data reflect the attitudes of Lebanese physicians regarding the disclosure of diagnoses to patients in palliative care contexts. When asked whether patients may stop treatment if they know how severe their illness is, 67.6% (N = 175) expressed concern, while 32.4% (N = 84) did not share this concern. Regarding the use of alternative medicine, 56.0% (N = 145) of physicians indicated that patients might turn to alternative options upon learning their diagnosis, whereas 44.0% (N = 114) did not express such concern. In terms of the potential impact on the patient-physician relationship, 61.0% (N = 158) of respondents believed that disclosing the diagnosis may disrupt this relationship.

Table 1.

Attitudes of Physicians in Different Scenarios.

Scenario	Attitudes
Telling the diagnosis	Mean (SD)	3.57 (0.56)
Telling the diagnosis	Min–Max	2.1–4.9
Dementia Scenario	Mean (SD)	4.00 (0.46)
Dementia Scenario	Min–Max	2.0–4.9
CKD scenario	Mean (SD)	4.56 (0.50)
CKD scenario	Min–Max	2.0–5.0
COPD scenario	Mean (SD)	4.24 (0.63)
COPD scenario	Min–Max	2.4–5.0
Congestive heart failure (CHF) scenario	Mean (SD)	4.38 (0.52)
Congestive heart failure (CHF) scenario	Min–Max	2.6–5.0
Oncology patient scenario	Mean (SD)	4.70 (0.38)
Oncology patient scenario	Min–Max	3.0–5.0

Note. SD = standard deviation; Min-Max = minimum–maximum.

The majority of physicians, 68% (N = 176) did not believe that diagnosis disclosure would lead to depression. A lower proportion, 59.1% (N = 153), believed that disclosure could lead to suicidal attempts. When asked about the influence of personal values, only 35.9% of physicians (N = 93) acknowledged that their personal values impact their ability to communicate a diagnosis. Regarding concerns about continuity of care and financial implications, 66.0% (N = 171) believed that disclosing the diagnosis may cause patients to switch providers, thereby affecting follow-up and financial reimbursement, while 34.0% (N = 88) did not express this concern. Finally, when examining the role of religious beliefs in initiating end-of-life care discussions, only 23.2% (N = 60) indicated that their religious beliefs prohibit them from such discussions.

The mean score for the composite domain “Telling the Diagnosis” was 3.57 (0.56), and individual scores ranged from 2.1 to 4.9, reflecting the spread of attitudes across participants.

Dementia Scenario

In cases involving advanced dementia, where patients are no longer able to recognize or converse with loved ones, 85.3% (N = 221) of physicians indicated they would not consider cardiopulmonary resuscitation (CPR) or intensive care unit (ICU) management, and 87.3% (N = 226) would not recommend mechanical ventilation. When spoon feeding is no longer possible, 69.5% (N = 180) of respondents did not consider nasogastric feeding appropriate. Among patients with severe cognitive and functional decline, 96.9% (N = 251) did not support aggressive interventions. In relation to ADL loss or refusal to eat, 91.1% (N = 236) recognized these as triggers for palliative care. 67.6% (N = 175) of respondents also cited frequent hospitalizations due to aspiration pneumonia or sepsis as reasons to consider palliative care. Nearly all physicians—95.8% (N = 248)—agreed that patients with two or more such criteria should receive palliative care, and an equal proportion supported using both survival probability and clinical criteria to guide decisions.

The domain-specific mean score was 4.00 (SD = 0.46), ranging from 2.0 to 4.9. This statistical summary underscores a strong, consistent inclination among physicians toward using dementia related questionnaire in NECPAL questionnaire to identify patients suffering from severe dementia who benefit from palliative care.

CKD Scenario

In the CKD scenario, 88.8% (N = 230) of physicians used 1-year survival probability as a palliative care criterion. For patients with advanced renal failure (creatinine clearance < 15 mL/min) ineligible for renal replacement, 96.5% (N = 250) endorsed considering palliative care. The same proportion, 96.5% (N = 250), utilized both clinical and survival criteria to guide decisions. The mean score for this domain was 4.56 (SD = 0.50), with a range of 2.0 to 5.0. This narrow range of scores reflects a high level of agreement among physicians regarding the use of criteria in NECPAL tool to identify CKD patients who could benefit from palliative care.

COPD Scenario

Survival probability was used by 84.9% (N = 220) of respondents when evaluating COPD patients for palliative care. For breathlessness at rest or on minimal exertion, 69.9% (N = 181) agreed this was a valid criterion. Persistent symptoms despite optimal therapy were cited by 73.4% (N = 190). Severe pulmonary function impairments (FEV1 <30%, CVF < 40%, or DLCO < 40%) were recognized by 93.8% (N = 243) as a trigger for palliative care. Home oxygen use and symptomatic COPD were endorsed by 69.5% (N = 180) and 62.9% (N = 163) respectively. 81.5% (N = 211) acknowledged recurrent hospitalizations as relevant. A total of 94.6% (N = 245) believed that two or more such indicators justified initiating palliative care, and the same proportion endorsed combining survival probability with clinical criteria. The mean domain score was 4.24 (SD = 0.63), ranging from 2.4 to 5.0. This relatively narrow range of scores reflects a strong alignment among physicians regarding the use of criteria in NECPAL questionnaire to identify COPD patients that are eligible for palliative care.

CHF Scenario

The majority of physicians, 86.9% (N = 225), used 1-year survival probability to assess palliative care needs in CHF. Difficult symptoms, even with optimal therapy, were acknowledged by 79.2% (N = 205). Severe echocardiographic findings (EF < 30% or pulmonary pressure > 60 mmHg) were flagged by 94.6% (N = 245). Renal failure (CrCl < 30 mL/min) and recurrent hospitalizations were each cited by more than 79.5% (N = 206) and 82.2% (N = 213) respectively. Shortness of breath at rest was cited by 60.6% (N = 157). NYHA stage III/IV or severe/inoperable cardiac disease was considered by 95.8% (N = 248) as a palliative care indicator. 95.4% (N = 247) supported initiating palliative care when two or more of these were present, and 96.9% (N = 251) used survival probability alongside clinical factors. The mean score was 4.38 (SD = 0.52), with values ranging from 2.6 to 5.0. This relatively narrow range of scores reflects a high level of agreement among physicians regarding the criteria for palliative care in CHF patients.

Oncology Patient Scenario

In the cancer scenario, 92.3% (N = 239) reported using 1-year survival probability to guide palliative care decisions. For patients with metastatic or progressive stage III/IV cancers, 98.1% (N = 254) agreed on the need for palliative care. A total of 96.1% (N = 249) cited functional decline (PPS < 50%) as a criterion, and 92.7% (N = 240) endorsed unmanageable symptoms despite treatment. 96.9% (N = 251) supported initiating palliative care if two or more such indicators were present. Additionally, 94.6% (N = 245) utilized a combined approach incorporating both prognosis and clinical condition. The oncology domain had the highest mean score: 4.70 (SD = 0.38), ranging from 3.0 to 5.0. This narrow range of scores reflects a high level of agreement among physicians regarding the use of such criteria in the NECPAL tool to identify oncology patients suitable for palliative care.

Overall Attitude Toward Palliative Care

The overall attitude score toward palliative care (Figure 1), which aggregates the scores from telling the diagnosis and all the specific medical scenarios (dementia, CKD, COPD, CHF, and oncology), provides a comprehensive overview of Lebanese physicians’ perspectives on palliative care. The mean overall attitude score is 4.37 (SD = 0.39), indicating a generally positive outlook toward palliative care among the physicians surveyed. The median score of 4.4 suggests that half of the respondents have a score above this value, further emphasizing the prevalent positive attitudes within the group.

Figure 1.

Representation of the overall attitude score toward palliative care.

Factors Associated With the Physicians’ Attitude Toward Palliative Care

The mean overall attitude score toward palliative care was examined across various demographic and professional subgroups of physicians (Table 2).

Table 2.

Attitudes Toward Palliative Care Based on Physicians’ Demographics and Educational Characteristics.

Physicians’ demographics and educational characteristics		N	Mean	Std. deviation	Minimum	Maximum	p Value
Age	<35 years	12	3.90	0.68	3.0	4.6	.104
	36–40 years	45	4.38	0.34	3.5	4.8
	41–45 years	60	4.44	0.34	2.9	4.9
	46–50 years	60	4.38	0.35	3.0	4.9
	Over 50 years	82	4.38	0.38	3.1	4.9
Gender	Male	192	4.39	0.36	2.9	4.9	.321
Gender	Female	67	4.33	0.45	3.0	4.9	.321
Graduation year	<20 years	81	4.41	0.32	3.5	4.9	.298
	20–25 years	64	4.34	0.37	2.9	4.9
	26–30 years	40	4.46	0.25	3.7	4.8
	>30 years	74	4.31	0.51	3.0	4.9
Type of residency	Internal medicine	231	4.35	0.40	2.9	4.9	.058
	Family medicine	3	4.50	0.26	4.2	4.7
	Surgery	12	4.62	0.19	4.3	4.8
	Pediatrics	3	4.40	0.17	4.2	4.5
	Obstetrics & Gynecology	6	4.33	0.08	4.3	4.5
	Other	4	4.60	0.00	4.6	4.6
Type of residency	Internal Medicine	231	4.35	0.40	2.9	4.9	.060
Type of residency	Other	28	4.52	0.19	4.2	4.8	.060
Type of subspecialty	Pulmonary	93	4.40	0.32	3.5	4.9	<.001
	Cardiology	42	4.36	0.37	3.0	4.8
	Nephrology	25	4.28	0.20	3.8	4.8
	Oncology	27	4.54	0.25	3.9	4.9
	Geriatrics	5	3.36	0.80	3.0	4.8
	Neurology	44	4.53	0.17	4.1	4.8
	Others	23	4.12	0.62	2.9	4.8
Type of subspecialty	Oncology	27	4.54	0.25	3.9	4.9	.014
Type of subspecialty	Others	232	4.35	0.40	2.9	4.9	.014

Note. Tests used in the bivariate analysis: Kruskal-Wallis/Mann-Whitney U. Bold: Significance set at 5%

Physicians across all age categories exhibited relatively high mean attitude scores, ranging from 3.90 (SD = 0.68) among those under 35 years to 4.44 (SD = 0.34) among those aged 41 to 45 years. The highest mean score was observed in the 41 to 45-year age group, whereas the lowest was noted among the youngest physicians (<35 years). However, the difference in mean scores across age groups was not statistically significant (p = .104). Male physicians (n = 192) had a slightly higher mean score (4.39, SD = 0.36) compared to their female counterparts (n = 67), who had a mean score of 4.33 (SD = 0.45). The difference was not statistically significant (p = .321). Additionally, the type of residency training did not affect attitude toward palliative care (p = .060), neither did years of practice (p = .298).

Attitude toward palliative care scores significantly varied by subspecialty (p < .001). The highest mean scores were recorded among neurologists (4.53, SD = 0.17) and oncologists (4.54, SD = 0.25), while geriatricians had the lowest average score (3.36, SD = 0.80). When oncologists were compared as a group to all other subspecialties, a statistically significant difference was observed (p = .014), with oncologists reporting more favorable attitudes toward palliative care.

Attitudes toward palliative care were further assessed in relation to physicians’ experience with palliative care systems, tools, and institutional support mechanisms. Physicians who reported using a structured scale to assess the severity of patients’ illness, such as the NECPAL tool, demonstrated significantly higher attitudes toward palliative care. Their mean score was 4.50 (SD = 0.21), compared to a notably lower mean score of 3.74 (SD = 0.45) among those who did not use such scales (p < .001). This result highlights the strong positive association between the systematic use of prognostic tools and favorable attitudes toward integrating palliative care. The presence of institutional policies encouraging advanced care planning did not significantly influence attitude scores (p = .157).

Spearman correlation analysis was conducted to assess the relationship between physicians’ attitudes toward disclosing a terminal diagnosis to patients (“telling the diagnosis”) and their attitudes toward the appropriateness of palliative care in five clinical scenarios: dementia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and oncology. Additionally, the correlation with the overall attitude score toward palliative care was evaluated (Table 3).

Table 3.

Correlation Between Attitudes Toward Telling the Diagnosis and Attitudes Toward Palliative Care Across Clinical Scenarios.

Clinical scenarios		Dementia scenario	CKD scenario	COPD scenario	Congestive heart failure (CHF) scenario	Oncology patient scenario	Overall attitude toward palliative care
Telling the diagnosis	Spearman correlation coefficient	.200	0.058	.196	.134	−.013	.212
	p Value	.001	.354	.002	.031	.830	.001
	N	259	259	259	259	259	259

Note. Tests used in the bivariate analysis: Spearman Correlation test. Bold: Significance set at 5%.

The results demonstrated a statistically significant positive correlation between attitudes toward telling the diagnosis and attitudes in the dementia scenario (r = .200, p = .001), COPD scenario (r = .196, p = .002), and CHF scenario (r = .134, p = .031). These findings suggest that physicians who support transparent communication with patients are also more inclined to favor palliative care in these specific conditions.

A significant positive correlation was also found between the attitude toward telling the diagnosis and the overall attitude score toward palliative care (r = .212, p = .001), reinforcing the association between disclosure practices and a broader acceptance of palliative approaches.

However, no significant correlations were observed between telling the diagnosis and attitudes in the CKD scenario (r = .058, p = .354) or the oncology scenario (r = −.013, p = .830), indicating that attitudes toward palliative care in these contexts may be influenced by factors other than physicians’ views on diagnostic disclosure.

These findings highlight that physician communication preferences, particularly regarding disclosure of serious diagnoses, are positively associated with their overall orientation toward palliative care in selected clinical contexts.

A multiple linear regression model was performed to determine the factors that significantly influence Lebanese physicians’ overall attitude toward palliative care (Table 4). The analysis included demographic and professional variables such as age, type of residency and subspecialty, and experiences with palliative care systems and tools. The Enter model included all the variables that were associated to the attitudes in the bivariate settings, with p < .20.

Table 4.

Multiple Linear Regression for the Factors Affecting the Overall Attitude Toward Palliative Care.

Model		Unstandardized coefficients		Sig.	95.0% Confidence interval for B		Collinearity statistics
Model		B	Std. error	Sig.	Lower bound	Upper bound	Tolerance	VIF
Enter	(Constant)	3.849	0.178	<.001	3.497	4.200
	Age	−0.011	0.013	.421	−0.037	0.016	0.944	1.059
	Type of residency	0.036	0.055	.516	−0.073	0.144	0.883	1.133
	Type of subspecialty	−0.041	0.054	.445	−0.148	0.065	0.940	1.063
	Do you use any scale to assess the severity of patient’s illness (NECPAL)?	0.708	0.047	<.001	0.615	0.800	0.846	1.182
	Are there any policies in the facility you work in that encourage physicians to do advanced care planning	0.086	0.036	.017	0.015	0.158	0.826	1.211
	Is there any palliative care unit in the hospital that you practice in	−0.308	0.064	<.001	−0.433	−0.183	0.818	1.223
	Telling the diagnosis	0.001	0.030	.975	−0.059	0.061	0.887	1.127
Stepwise	(Constant)	3.771	0.042	<.001	3.687	3.855
	Do you use any scale to assess the severity of patient’s illness (NECPAL)?	0.712	0.044	<.001	0.625	0.798	0.959	1.043
	Is there any palliative care unit in the hospital that you practice in	−0.309	0.063	<.001	−0.433	−0.185	0.826	1.211
	Are there any policies in the facility you work in that encourage physicians to do advanced care planning	0.086	0.035	.016	0.016	0.155	0.858	1.165

Note. Dependent Variable: Overall Attitude toward Palliative Care.

In the Enter model, the use of a diagnostic severity assessment scale, specifically the NECPAL tool, was the strongest positive predictor of favorable attitudes toward palliative care (B = 0.708, p < .001). Physicians who reported using NECPAL had significantly higher attitude scores compared to those who did not. Additionally, the presence of institutional policies that encourage advanced care planning was associated with a more positive attitude (B = 0.086, p = .017).

The stepwise regression model, which retained only statistically significant predictors, confirmed the same three variables: usage of the NECPAL tool (B = 0.712, p < .001), and existence of advanced care planning policies (B = 0.086, p = .016). These findings underscore the critical influence of clinical practice tools and institutional frameworks on shaping physicians’ attitudes toward palliative care, beyond demographic or specialty differences. Multicollinearity diagnostics showed acceptable tolerance and variance inflation factor (VIF) values across all predictors, indicating no concerns for collinearity.

Discussion

The results of the present study demonstrated the favorable attitudes of physicians toward palliative care, especially in scenarios like oncology (mean score = 4.7 ± 0.38) and CKD (mean score = 4.56 ± 0.50). Therefore, it is worth mentioning that these attitudes were significantly variable and this due to clinical, ethical, and cultural influences, as well as institutional support and communication challenges that exist within the medical practice.

Comparative evidence from Lebanon indicates that nurses—particularly oncology and specialist palliative nurses—often report knowledge and attitudes toward palliative care that are as favorable or more favorable than physicians, and they frequently lead symptom management, family communication, and bedside advocacy. National nursing surveys have documented reasonable baseline knowledge but persistent gaps in formal training and role clarity; oncology nurses typically demonstrate the most positive attitudes toward disclosure and patient autonomy. These interprofessional differences underscore the importance of team-based education, formalized nurse-led referral pathways, and leveraging nursing leadership to operationalize earlier palliative referrals in routine practice.

Generally, the overall attitude of physicians toward palliative care was shown to be high, with a mean score of 4.37 ± 0.39. Thus, across proposed advanced cancer, end stage COPD or CKD, severe CHF, and advanced dementia, the majority of the physicians acknowledged the importance of survival probability and clinical criteria outlined in NECPAL tool when faced to a decision for palliative care in a critically ill patient. This was significantly evident in patients suffering from CKD and oncology (96.5% and 92.3%, respectively). Similar agreement was observed for CHF and COPD when multiple indicators to adopting palliative care were present. Furthermore, there was a strong consensus among more than 95% of the physicians for the use of NECPAL criteria pertaining to functional and cognitive decline in order to identify advanced demented patients for palliative care. These findings are aligned with those reported in similar studies like Hui and Bruera (2020), Stubbe (2020), and Combs and Davison (2015), highlighting the growing awareness of palliative care’s role in increasing the quality of life of patients within different conditions.

On the other hand, regardless of this general alignment, hesitations still persist, in particular in non-oncological cases. Scenarios of COPD and CHF have challenges due to their unpredictable trajectories, which can complicate the timing of the palliative care initiation. In this regard, physicians also expressed concerns that discussing the prognosis or palliative options can lead patients to abandon their treatment or to seek alternative medicine like unconventional treatments, and this is consistent with previous studies talking about stigmas surrounding palliative care, such as the study of Hawley (2017).

Palliative care education in Lebanon is expanding but not yet uniformly embedded in undergraduate or residency curricula. Major academic centers and national NGOs offer diplomas, short courses, and continuing-education modules, and pilot adaptations of international certification programs have been implemented; however, mandatory palliative rotations and standardized residency competencies remain limited across most specialties. Strengthening undergraduate and postgraduate curricula and formalizing residency competencies would likely increase early identification, NECPAL uptake, and appropriate referrals, and would support sustainable integration of palliative principles into routine clinical practice.

Furthermore, demographic and institutional factors also played a role in the attitudes of physicians toward palliative care. The results showed that the attitudes of physicians toward palliative care is not affected by the age, gender, graduation year, and training of physicians (p > .05). Notably, these results seem to be divergent from those of Cheung et al. (2019) who found that older physicians generally have more positive attitudes toward palliative care than younger ones (p < .001). However, our results seem to be aligned with those of Hamdan et al. (2023) who didn’t find any significant association between demographic characteristics of physicians and/or institutional factors and attitudes toward palliative care (p > .05).

Conversely, the subspecialty of physicians in oncology was shown to be significantly associated with higher attitudes toward palliative care (p = .014). This result shows that oncology physicians have more supportive views compared to other specialties like geriatricians and nephrologists in what it concerns palliative care. These differences can reflect different exposures to end-of-life care, as well as differing training experiences, as showed in the study of Okimoto et al. (2021). For instance, oncology’s field is known for its longstanding integration of palliative care principles, as well as more frequent exposure to terminally ill patients. This makes oncologists more adept at working in multidisciplinary teams where palliative interventions are normalized and actively coordinated, which fosters a culture of early palliative engagement (Rangachari & Smith, 2013).

Notwithstanding, the utilization of NECPAL tool was shown as a significant predictor of more positive attitudes of physicians toward palliative care (p < .001). Physicians who generally used NECPAL have higher attitudes scores when compared to those who do not (4.50 ± 0.21 vs. 3.74 ± 0.45). This indicates that structured tools can increase the confidence and the clarity in palliative care decisions. This highlights the value of the tool in identifying the patients who can benefit from early palliative care integration within the professional care. This was mentioned and supported by international research such as Bharmal et al. (2022) and Wittenberg et al. (2018).

Moreover, the existence of institutional policies that support palliative care was shown to be a significant predictor of more positive attitudes toward palliative care (p = .017). This result suggests that when healthcare institutions actively implement guidelines and protocols to commit to palliative care, the physicians become more likely to view such services as integral and legitimate components in patient management. This result seems to be aligned with earlier studies conducted in the Middle East showing that the presence of palliative care policies correlates with higher utilization rates and thus with higher attitudes of physicians (Mobarki et al., 2025).

Limitations

This cross-sectional, self-reported online survey is subject to selection bias (physicians with an interest in palliative care may have been more likely to respond) and social-desirability bias (respondents may overstate favorable attitudes). The final sample (n = 259) fell short of the calculated target (n = 283) and was dominated by internal medicine and male respondents, which limits representativeness across specialties, regions, and practice settings. Because national physician-demographic benchmarks were not used for comparison, the claim of representativeness should be interpreted cautiously and should not be inferred from this sample alone. Attitudes and reported NECPAL use were not validated against objective referral or clinical-practice data, so results reflect perceptions rather than measured behavior. These factors constrain generalizability beyond the surveyed cohort; future studies should use stratified, multi-center sampling, link survey responses to referral metrics, and consider longitudinal designs to assess change after training or policy interventions.

Implications for Practice and Policy

The strong association between NECPAL use and favorable attitudes suggests that implementing validated screening tools can both standardize identification and positively influence clinician acceptance of palliative approaches. Hospitals should consider integrating NECPAL (or equivalent screening) into routine workflows, pairing tool adoption with targeted interprofessional training and clear institutional policies for advanced care planning. Given nurses’ central role in palliative delivery, nurse-led referral pathways and team-based education can accelerate appropriate referrals. At the education and policy level, embedding palliative competencies into medical and residency curricula and expanding community awareness campaigns will help shift care earlier in the disease trajectory and improve access to symptom control and psychosocial support. Monitoring referral patterns and patient outcomes after implementation is essential to demonstrate clinical benefit and sustain institutional investment.

The present study highlights that Lebanese physicians largely support the principles of palliative care, and are aggregable at using validated tools such as NECPAL to identify patients fit for palliative care. Providing a structured education inclusive of palliative care training, utilizing validated palliative care tools such as NECPAL would be helpful in early identification of patients suffering from terminal illnesses that are appropriate for palliative and end of life services.

Footnotes

Appendix

Appendix 1.

Telling the diagnosis for Different Scenarios.

	Negative attitude		Positive attitude
	Frequency	Percent	Frequency	Percent
Telling the diagnosis
Patient may stop treatment if he knows how severe his illness is	84	32.4	175	67.6
Patient May Use Alternative Medicine	114	44.0	145	56.0
Diagnosis knowledge may disrupt patient physician relationship	158	61.0	101	39.0
Patient may become depressed if he knows his diagnosis	83	32.0	176	68.0
Patient may have suicidal attempts if he knows his diagnosis	153	59.1	106	40.9
My personal values impact my ability to tell the diagnosis to the patient	93	35.9	166	64.1
Telling the diagnosis may affect follow-up of the patient (patient may switch providers) and continuity of care and in turn affect financial reimbursement	171	66.0	88	34.0
My own religious beliefs prohibit me from initiation end of life care discussions	60	23.2	199	76.8
Telling the diagnosis	Mean (SD)		3.57 (0.56)
Telling the diagnosis	Min–Max		2.1–4.9
Dementia scenario
Patient is demented and had progressed to the point where he could not recognize or converse with loved ones. Do you consider CPR for him?	38	14.7	221	85.3
Your patient is demented and had progressed to the point where he could not recognize or converse with loved ones. Do you consider ICU Management for him	38	14.7	221	85.3
The patient is demented and had progressed to the point where he could not recognize or converse with loved ones. Do you consider mechanical ventilation for him	33	12.7	226	87.3
The patient is demented and had progressed to the point where he could not recognize or converse with loved ones. When spoon feeding is no longer possible, would you consider Nasal Gastric (NG) feeding, for him?	180	69.5	79	30.5
Unable to dress, wash or eat without assistance, urinary and fecal incontinence or unable to communicate meaningfully −6 or less intelligible words	8	3.1	251	96.9
Loss of 2 or more activities of daily living (ADL’s) in the last 6 months, despite adequate therapeutic intervention (not during an acute illness) or difficulty swallowing, or denial to eat, in patients who will not receive enteral o	23	8.9	236	91.1
Use of resources criteria: multiple admissions (>3 in 12 months, due to concurrent processes –aspiration pneumonia, pyelonephritis, sepsis, etc.- that cause functional and/or cognitive decline)	84	32.4	175	67.6
Do you consider a demented patient with two or more of the above mentioned criteria fit for palliative care	11	4.2	248	95.8
Do utilize the combination of probability of survival and presence of the above-mentioned criteria as a rule to indicate if patient ready for palliative care	11	4.2	248	95.8
Dementia Scenario	Mean (SD)		4.00 (0.46)
Dementia Scenario	Min–Max		2.0–4.9
CKD scenario
Do you utilize probability of survival of a CKD patient over the coming year as criteria to consider palliative care?	29	11.2	230	88.8
Serious renal failure (creatinine clearance < 15 mL/min) in patients to whom renal replacement therapy or transplant is contraindicated	9	3.5	250	96.5
Do utilize the combination of probability of survival and presence of the above-mentioned criteria as a rule to indicate if patient ready for palliative care	9	3.5	250	96.5
CKD scenario	Mean (SD)		4.56 (0.50)
CKD scenario	Min–Max		2.0–5.0
COPD scenario
Do you utilize probability of survival of a COPD patient over the coming year as criteria to consider palliative care?	39	15.1	220	84.9
Breathlessness at rest or on minimal exertion between exacerbations	78	30.1	181	69.9
Difficult physical or psychological symptoms despite optimal tolerated therapy	69	26.6	190	73.4
In case of having functional respiratory tests, disease assessed to be severe: FEV1 <30% or criteria of restricted severe deficit: CVF < 40% / DLCO < 40%	16	6.2	243	93.8
In case of oxygen therapy at home criteria or such treatment underway	79	30.5	180	69.5
Symptomatic heart failure	96	37.1	163	62.9
Recurrent hospital admissions (>3 admissions in 12 months due to exacerbations of COPD)	48	18.5	211	81.5
Do you consider a COPD patient with the two or more of the above-mentioned criteria fit for palliative care	14	5.4	245	94.6
Do utilize the combination of probability of survival and presence of the above-mentioned criteria as a rule to indicate if a COPD patient ready for palliative care	14	5.4	245	94.6
COPD scenario	Mean (SD)		4.24 (0.63)
COPD scenario	Min–Max		2.4–5.0
Congestive heart failure (CHF) scenario
Do you utilize probability of survival a CHF patient over the coming year as criteria to consider palliative care?	34	13.1	225	86.9
Difficult physical or psychological symptoms despite optimal tolerated	54	20.8	205	79.2
In case of having echocardiography: ejection fraction severely affected (<30%) or severe pulmonary hypertension (Pulmonary pressure > 60 mmHg)	14	5.4	245	94.6
Renal failure (creatinine clearance < 30 l/min)	53	20.5	206	79.5
Repeated hospital admissions with symptoms of heart failure/ (>3 in last year)	46	17.8	213	82.2
Shortness of breath at rest or minimal exertion	102	39.4	157	60.6
Heart failure NYHA stage III or IV, severe valve disease or inoperable coronary artery disease	11	4.2	248	95.8
Do you consider a CHF patient with the two or more of the above-mentioned criteria fit for palliative care criteria ready for palliative care	12	4.6	247	95.4
Do utilize the combination of probability of survival and presence of the above-mentioned criteria as a rule to indicate if patient ready for palliative care	8	3.1	251	96.9
Congestive heart failure (CHF) scenario	Mean (SD)		4.38 (0.52)
Congestive heart failure (CHF) scenario	Min–Max		2.6–5.0
Oncology patient scenario
Do you utilize the probability of survival of a cancer patient over the coming year as criteria to consider palliative care?	20	7.7	239	92.3
Patients with confirmed diagnosis of metastatic cancer (stage IV; and also stage III in some cases—e.g., lung, pancreas, stomach and esophagus cancers) who present low response or contraindication of specific treatment, progressive outbreak during treatment	5	1.9	254	98.1
Significant functional deterioration (Palliative Performance Status (PPS) < 50%)	10	3.9	249	96.1
Persistent, troublesome symptoms, despite optimal treatment of underlying condition(s)	19	7.3	240	92.7
Do you consider a cancer patient with the two or more of the above-mentioned criteria fit for palliative care criteria ready for palliative care	8	3.1	251	96.9
Do utilize the combination of probability of survival of a cancer patient and presence of the above-mentioned criteria as a rule to indicate if patient ready for palliative care	14	5.4	245	94.6
Oncology patient scenario	Mean (SD)		4.70 (0.38)
Oncology patient scenario	Min–Max		3.0–5.0

Acknowledgements

The authors wish to thank Mr. Bashir ATALLAH and Mrs. Pamela AL KHOURY for their help in reviewing and editing this manuscript.

ORCID iD

Iyad Bou Mehdi

Ethical Considerations

This study was approved by the Institutional Review Board of a tertiary healthcare institution on May 2016. This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Consent to Participate

All participants provided written informed consent prior to enrollment in the study.

Author Contributions

All authors participated equally in the enrollment of the study and the preparation of this manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Upon request.*

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