Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13398 Developing a culture-based palliative nursing care model in hospitals: a phenomenological study Israfil Israfil, Ni Luh Putu Inca Buntari Agustini, I Ketut Swarjana Department of Nursing, Faculty of Health, Institute of Technology and Health Bali, Indonesia Abstract Palliative care serves as a framework for nurses to provide quality care. A cultural approach is essential for helping palliative care patients access maximum health services. This study aimed to determine the important aspects of developing a culture-based pal- liative nursing care model. Utilizing a qualitative, phenomenolog- ical design, this research involved 11 participants, including nurs- es, palliative care patients, and their families. Data collection was conducted through focus group discussions, and analysis was per- formed using the thematic method with the Colaizzi approach. Five key themes emerged to develop a culture-based palliative nursing care model: i) patient condition (knowledge, psychologi- cal challenges, education, and age); ii) family support (psycholo- gical state, knowledge, communication, assistance, and economic status); iii) role of nurses (advocacy, education, caring attitude, help with Activity of Daily Living [ADL], and give realistic expectations); iv) health service policies (no code blue, supportive therapy, entertainment, availability of resources, teamwork, che- motherapy, and health insurance); and v) cultural influence (spiri- tual needs, fear of death, desire not to die at home, Internet use, and alternative medicine). All these components are crucial for the enhancement of palliative nursing care. Introduction Palliative care is a type of healthcare service that focuses on providing care to patients with terminal illnesses to maintain their quality of life.1 Palliative care patients have very complex health problems and require special attention, including physiological, psychological, social, spiritual, cultural, and existential problems.2 Cultural diversity in palliative care practices is a challenge and an interesting issue to pay attention to.3 Complex cultural issues can influence the progression of the disease, the effectiveness of treat- ment, and the satisfaction of patients and families with palliative care services.4 Palliative care has become a national health service policy in Indonesia.5 However, the progress of palliative care service prac- tices still varies and continues to develop in each region. The suc- cess of implementing palliative care is affected by patient percep- tions, the limited availability of caregivers, and national standards of palliative care that are not yet widely accessible. Hospitals that are dedicated to considering culture in applying effective pallia- tive care principles and practices will find it easier to achieve suc- cess in palliative care.6,7 Key factors for an effective palliative nursing care model include social, economic, and cultural dimensions that significant- ly impact patients’ quality of life.8 Cultural determinants are among the aspects of palliative care that have been less extensive- ly researched.1 Understanding culture helps nurses see how it influences patients’ health and can support their well-being.9,10 Despite the critical role of culture in influencing palliative care outcomes, structured frameworks that integrate cultural con- siderations into nursing models in hospital settings are lacking. The research and development of palliative nursing practices from a cultural perspective are important for enhancing collaboration among patients, families, and communities, facilitating the identi- fication and negotiation of culturally significant care to improve Correspondence: Ni Luh Putu Inca Buntari Agustini, Department of Nursing, Faculty of Health, Institute of Technology and Health Bali, Indonesia. Email: incaagustini@gmail.com Key words: palliative care; palliative care nurses; phenomenology. Contributions: II, research design, data collection, data analysis, and writing original draft; NLPIBA, study conception, data collection, man- uscript writing; IKS, review and editing. Conflict of interest: the authors have no conflict of interest to declare. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Committee of the Bali Mandara Regional General Hospital, Bali Province (No. 066/EA/KEPK.RSBM.DISKES/2024). During the research, the researchers paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and non-maleficence. Consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: this study was funded by the Directorate of Higher Education, Ministry of Education and Culture of the Republic of Indonesia; Directorate of Research, Technology and Community Service (DRTPM), with master contract number 110/E5/PG.02.00.PL/2024; derivative con- tract number 2927/LL8/AL.04/2024; DL.02.02.2361.TU.VI.2024. Acknowledgments: the research team would like to thank Bali Mandara Hospital’s leadership and the nurses involved. We also express our grat- itude to the patients and families who participated in this research. Received: 18 November 2024. Accepted: 3 March 2025. Early access: 15 April 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13398 doi:10.4081/hls.2025.13398 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 100] [Healthcare in Low-resource Settings 2025;13(s1):13398] patients’ quality of life and ensuring palliative nursing practices align with community needs.11 This study aimed to determine piv- otal factors to consider when developing a culture-based palliative nursing care model in hospitals. Materials and Methods Research design This study employs a qualitative design with a phenomenolog- ical approach to analyze the experiences of patients, nurses, and families of palliative care patients, aiming to recommend the development of a culture-based palliative nursing care model in hospitals. Participants and sampling The study included 11 participants comprising nurses, pallia- tive care patients, and their families, aligning with the criteria for phenomenological research.12 Sampling utilized a purposive tech- nique, selecting participants among nurses who directly cared for palliative care patients, individuals diagnosed with conditions requiring palliative care, and the families of these patients. All par- ticipants had a good cooperative attitude, were willing to partici- pate, and were actively involved until the end of the group discus- sion session. Data collection and instruments Data collection was conducted using the face-to-face Focus Group Discussion (FGD) method. Participants were divided into three groups: the nursing discussion group, the patients’ discussion group, and the family discussion group. Focus group discussions were conducted separately at different times and places. Data col- lection was conducted at Bali Mandara General Hospital, Bali Province. No other parties were involved in the discussion besides the participants, who had been selected based on the inclusion cri- teria. The FGDs lasted for one to nearly two hours, as the partici- pants displayed significant enthusiasm for the discourse. All partic- ipants remained present for the entirety of the session. The research instruments used were FGD guidelines, notebooks, and voice recorders. The research instruments were supplied by the research team and evaluated to confirm that the questions in the FGD could yield substantial information to address the study’s objectives. The FGD questions encompassed the patient’s experi- ence as a palliative care recipient, the family’s feelings and support for these patients, the nurses’ roles in palliative care, and the per- spectives of each FGD group regarding the factors contributing to the efficacy of palliative care. The FGD data were transcribed and verified for accuracy and validity. Data analysis The research data were analyzed using a thematic analysis approach with the Colaizzi approach13 without software. Nurse participants were coded “PN”, patient participants were coded “PP”, and family participants were coded “PF”. Ethical clearance This study was conducted at the Bali Mandara Regional General Hospital, Bali Province, in October 2024, with an ethical clearance letter from the Health Research Ethics Committee of the Bali Mandara Regional General Hospital, Bali Province, No. 066/EA/KEPK.RSBM.DISKES/2024. Results The participants were aged 29-44 years, with the lowest edu- cation level being junior high school and the highest a bachelor’s degree. The sample included one male nurse (PN1), four female nurses (PN2, PN3, PN4, PN5), one male patient (PP1), two female patients (PP2, PP3), one male family member (PF1), and two female family members (PF2, PF3) (Table 1). In developing a culture-based palliative care model in hospi- tals, five important themes — patient conditions, family support, nurses’ roles, service policies, and cultural influence — and sub- themes must be considered (Table 2). Theme 1: patient condition This theme centers on patient conditions and the creation of a palliative nursing care model. Additionally, it will highlight crucial considerations for nurses when assessing the conditions of pallia- tive care patients. Subtheme 1: knowledge The patient’s level of knowledge about the disease is related to the speed of diagnosis, treatment program, and worsening of the condition. “Our experience is that low patient knowledge makes the dis- ease worse because of late treatment.” (PN2) Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13398] [page 101] Table 1. Participant characteristics (n=11). No. Age (years) Gender Education level Status Code 1 32 Male Bachelor’s Degree Nurse PN1 2 39 Female Bachelor’s Degree Nurse PN2 3 32 Female Bachelor’s Degree Nurse PN3 4 33 Female Bachelor’s Degree Nurse PN4 5 28 Female Diploma III Nurse PN5 6 32 Male Senior High School Patient PP1 7 56 Female Junior high school Patient PP2 8 41 Female Bachelor’s Degree Patient PP3 9 44 Male Senior High School Family member PF1 10 35 Female Bachelor’s Degree Family member PF2 11 29 Female Senior High School Family member PF3 “I never thought my illness would last this long.” (PP2) “Previously we didn’t know about this disease, and didn’t expect it to be like this.” (PF3) Subtheme 2: psychological challenges The psychological issues encountered by palliative care patients exhibit significant complexity, leading to feelings of help- lessness, entitlement, apathy towards treatment, fatigue, sadness, and a sense of undervaluation by their families. “…tendency to be psychological, so lazy to seek treatment, no longer enthusiastic, sometimes spoiled, sometimes feel no longer appreciated by the family, there are even patients who cry.” (PN1) “I feel shocked and can’t do anything.” (PP1) “Tiring, have no choice but to continue.” (PP3) Subtheme 3: education The patient’s level of education is related to their readiness to receive and understand information. Patients with a high level of education are more open to information, enthusiastic about seeking information, and have a better quality of life. Meanwhile, patients with a low level of education tend to be closed, dishonest, and usu- ally prioritize alternative medicine. “There is a gap between patients who have a high and low edu- cational background. Experience shows that the patient’s readi- ness to receive information provided by the nurse is different.” (PN3) “Patients who have a good level of education are usually more open, enthusiastic about asking questions, and have a better qual- ity of life, while patients who have low education are usually closed, dishonest, and usually go to alternative medicine first and then come in severe condition.” (PN5) Subtheme 4: age Young patients have high hopes for recovery and influence their families to have the same hopes. Older patients tend to be more accepting of their illness, and so do their families. “Usually, young patients have more enthusiasm to recover, while older patients, generally over sixty years old, often have families who accept the situation.” (PN1) “Some patients who are still in the productive age usually have very high hopes for health even though sometimes the condition of the disease is already in the final stage.” (PN5) Theme 2: family support This theme emphasizes the significance of diverse familial supports in developing palliative nursing care model. It will show nurses the different aspects that must be considered in the families of palliative care patients who will become the patient’s primary caregivers. Subtheme 1: psychological state Families of palliative care patients face complex psychological challenges, such as burden and fatigue. “The tendency for patients to become spoiled can eventually burden the family, as the patient may sulk at them despite the fam- ily’s constant help.” (PN1) “When the patient starts to sulk or get angry, usually the family members start to have headaches, and their psyche is disturbed.” (PN4) “The family also feels hurt because of the extra effort, such as time and costs.” (PP2) Subtheme 2: knowledge Family knowledge is related to the ability to receive and under- stand the information provided. Therefore, it is very important to assess the level of knowledge of the family of palliative care patients. “My experience from the family’s perspective is how the family receives communication, education, and information from hospital services, and how they can accept it or not.” (PN2) “The family must also serve as anamnesis, particularly regard- ing their understanding of the patient’s illness and treatment.” (PN1) Subtheme 3: communication The patient’s health condition and treatment program are pri- marily conveyed to the immediate family, who are responsible for making decisions concerning their care. “We typically communicate or convey information to the nuclear family, as we believe they are the ones who can make deci- sions.” (PN4) “Not only the nuclear family but also distant families also take part in making decisions.” (PN3) Subtheme 4: assistance Family assistance is very much needed by patients during the treatment program. Family support is related to patient calmness, increasing patient happiness, reducing anxiety, and reducing stress. Special issue Pathways of Change Table 2. Overview of themes and subthemes. Theme Subtheme Patient condition Knowledge Psychological challenges Education Age Family support Psychological state Knowledge Communication Assistance Economic status Role of nurses Advocacy Education Caring attitude Helping with ADL Realistic expectations Health service policies No code blue Supportive therapy Entertainment Availability of resources Teamwork Chemotherapy services Health insurance Cultural influence Spiritual needs Fear of death Desire not to die at home Internet use Alternative medicine [page 102] [Healthcare in Low-resource Settings 2025;13(s1):13398] Families who are busy with work can arrange alternating schedules to accompany patients during the treatment program. “How often do they accompany the patient to help keep them calm?” (PN3) “The accompanying family members usually change because they work. The patients are happy to have family accompanying them.” (PN2), “There is a family who faithfully accompanies the patient dur- ing consultations with doctors and listens to the doctor’s advice.” (PN5) “I accompany and comfort patients so that they are not stressed and depressed with their current illness and condition.” (PF2) “I have a shift to be with my mother during chemotherapy. Sometimes when my mother returns from chemotherapy, I also take care of her because after chemotherapy, her condition sometimes drops.” (PF3) “My family is good, always supports me and asks about what actions to take next and is always by my side.” (PP1) “My family’s role is very important.” (PP3) Subtheme 5: economic status The economic status of patients and families is related to the speed of decision-making. Patients from families with low finan- cial status tend to be slower in making decisions, and the patient’s condition becomes worse. “Patients from families with a good economy usually find it easier to accept information, and decisions about treatment and care are easier, while patients from families with a poor economy usually only listen and make decisions when their complaints are very severe.” (PN2) Theme 3: role of nurses This theme focuses on the critical role of nurses in developing a palliative care model. Subtheme 1: advocacy Nurses serve as patient advocates, acting as a bridge between the needs of patients and families and the doctors responsible for the patient’s treatment program. Nurses also act as mediators among families when there are differences in understanding infor- mation and differing opinions about the patient’s condition and treatment plan. “We act as a mediator when problems or differing opinions arise between the patient and their family, serve as a director to control the patient’s needs during treatment, and advocate for the patient with the doctor.” (PN1) “We act as a bridge between patients and doctors. There are some things that patients want to tell the doctor but don’t have time, so we as nurses will help convey what the patient feels.” (PN5) Subtheme 2: education Nurses educate patients about treatment timelines, examina- tion appointments, and necessary preparations for patients and their families. “Communication between nurses and patients is very impor- tant, it is a nurse’s medium for patient preparation during hospi- talization, preparation for going home, or for home care.” (PN2) “We inform the patient when they should come back for treat- ment and check-ups, as well as what they need to do to prepare for that.” (PN5) Subtheme 3: caring attitude The caring attitude of nurses is related to the patients’ and fam- ilies’ satisfaction with receiving health support from nurses. The caring attitude of nurses is shown by the nurse’s smile, joking atti- tude, friendliness, humility, and responsibility in their work. “The more we can show an empathetic attitude and empathetic body gestures, both to patients and families, the more it can pro- vide a kind of support for the patient’s condition and the condition of the family who cares for them.” (PN2) “Not showing a face that is too serious, but smiling and joking, in my opinion, that’s one of the ways to get closer and more famil- iar with patients so that they are more enthusiastic.” (PN5) “All nurses are good and responsible, also friendly.” (PF1) “Very helpful and work with full responsibility.” (PF2) “Good nurses, friendly and always provide supportive advice.” (PP1) “Nurses who care with heart, and that is the most important.” (PP2) Subtheme 4: help with activities of daily living (ADL) Nurses help patients meet their daily living needs when there is no family or companion to rely on. The fulfillment of patients’ daily living needs by nurses includes assisting with feeding, bathing, and washing hair. “If no family is accompanying, we help with the patient’s needs, such as helping to feed.” (PN1) “That is typically what we do to help patients, such as bathing and washing their hair.” (PN2) Subtheme 5: realistic expectations Nurses do not set certain expectations for patients and families. This is important to prevent excessive hope. Nurses inform patients and families about the patient’s current condition and potential future outcomes, and they communicate all available treatment options designed to assist patients. “We communicate the truth about the patient’s condition and life expectancy so that the patient and family understand and do not expect anything more than the patient’s initial condition.” (PN1) “We tell patients and families what the maximum treatment and care is like, especially to terminal patients, so that patients and families do not have excessive expectations.” (PN5) Theme 4: health service policies This theme focuses on service aspects that can support the development of a palliative nursing care model. Subtheme 1: no code blue The variable status of palliative care patients renders the code blue policy inapplicable. Palliative care patients with deteriorating conditions continue to receive emergency treatment as per estab- lished protocols but are no longer assigned a code blue. “Starting this month, deteriorating palliative care patients are not given a code blue. They are still resuscitated in the room, but a code blue will not be called.” (PN3) Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13398] [page 103] “If the condition is bad, now the code blue is no longer used for palliative care patients.” (PN5) Subtheme 2: supportive therapy Supportive therapy is given not to cure the disease but to relieve symptoms and reduce suffering for the patient. “The therapy provided is typically maximal, which means that the only additional treatment available is supportive therapy. For example, painkillers are administered if there is pain.” (PN3) “Palliative care patients here usually receive supportive ther- apy such as medication to reduce pain and various symptoms so that they can carry out daily activities.” (PN5) Subtheme 3: entertainment Palliative care patient entertainment services are very impor- tant to maintain the psychological health of patients during treat- ment. Entertainment services can be provided in groups with singing, karaoke, and dancing activities. “To maintain the psychological health of our patients, we usu- ally provide entertainment media, we hold “sarasehan”. Sarasehan refers to a gathering of patients in the hall where they can participate in karaoke entertainment, singing, dancing, and counseling.” (PN1, PN2). Subtheme 4: availability of resources The constraints faced by palliative care nurses, who are responsible for patient monitoring, necessitate that other nursing professionals caring for palliative patients engage in self-directed learning. This development happens through socialization with palliative care nurses, participation in webinars, and direct consul- tation with palliative doctors. “Only one nurse has undergone palliative training. Though still limited, we benefit from socialization, participate in webinars, and have more direct consultations with palliative doctors.” (PN2, PN4). Subtheme 5: teamwork Good teamwork is related to the speed of handling palliative care patient cases. The main teamwork is between doctors and nurses. Palliative doctors dedicate ample time for communication and consultation with nurses whenever necessary, entrusting them to handle patients needing immediate treatment without waiting for a doctor’s presence for the patient’s benefit. All of this is effec- tively communicated through teamwork. “We can disturb all the doctors at any time. We contact them as if there are no working hour limits. Doctors also trust nurses and do not hesitate to involve them in important actions that are com- municated for their patients’ sake.” (PN5) “Palliative care patients usually re-enter the ER. Nurses typi- cally inform the palliative care nurse when another palliative care patient arrives in the ER. The ER nurse’s service operates as usual, responding only to complaints and not including any special serv- ices.” (PN5) Subtheme 6: chemotherapy services The availability of chemotherapy facilities for cancer patients is very helpful in improving their health status. Chemotherapy services have successfully reduced the tumor size and expedited the advanced stage of treatment necessary for surgical procedures. “My husband was treated here, and there has been a change. Now it has improved because there is chemotherapy.” (PF1) “Now the lump has not grown again, and my mother has undergone the fourth chemotherapy.” (PF2) “More or less six chemotherapies, then the doctor said she could have surgery. Yesterday, after consulting with the doctor, the results of the laboratory examination were good, and after the sixth chemotherapy surgery could be performed.” (PF3) Subtheme 7: health insurance BPJS (Social Security Agency on Health) is an Indonesian health insurance program that has supported many palliative care patients in their treatment plans. The existence of BPJS facilities is beneficial for patients and families in financing treatment. “This hospital accepts patients with BPJS insurance, so we are grateful that because we have BPJS insurance, we don’t have to pay for treatment costs.” (PP1) “Coincidentally, my mother uses BPJS, there is nothing to pay. This is very helpful, helpful.” (PF2) Theme 5: cultural influence This theme focuses on cultural aspects that are of concern in developing a palliative nursing care model. Subtheme 1: spiritual needs The availability of clergy in hospitals is needed for patients who need prayer support to gain better spiritual strength. “We prepare clergy and inform patients and families that if they are in critical condition and need clergy, we already have them available. We then contact the clergy to arrange prayer serv- ices for those patients.” (PN2) “Always ask for prayers from the clerics to be given strength and healing.” (PP2) Subtheme 2: fear of death Fear of death is a significant experience for patients and fami- lies that nurses need to understand. It takes time for patients and their families to process the situation and for families to prepare for the death of a loved one. “Most still tend to be afraid of dying. The family will do any- thing so that the patient can survive, even though they know that the patient is at the final station. There is a fear of being aban- doned and leaving the family.” (PN3) Subtheme 3: desire not to die at home Not wanting to die at home is a culture in this region. Dying at home is considered a failure for the family in caring for palliative care patients. “If possible, the patient is treated longer and dies in the hospi- tal. The patients should not die at home because if they die at home, the community usually thinks the family was unable to care for them.” (PN4) Subtheme 4: Internet use Using Google as a search engine is one way for patients and families to find answers and good guidance for what they need. Special issue Pathways of Change [page 104] [Healthcare in Low-resource Settings 2025;13(s1):13398] Unfortunately, misinterpreting information that does not align with the patient’s condition can be a challenge for nurses. “Especially now, patients’ families are playing around with Google, googling a little bit and saying that the family should still be alive, they should be treated in the ICU, and so on, based on what they read on Google.” (PN4) “With technology, we can search online to learn about the dis- ease and what chemotherapy is like.” (PF2) “Google is very helpful if I have questions.” (PF3) “I sometimes search on Google for the causes and prevention.” (PP1) Subtheme 5: alternative medicine The use of alternative medicine is related to delays in medical treatment, which results in worsening patient conditions. Patients tend to choose alternative medicine and shamans and ignore med- ical treatment. “Taking traditional medicine as people suggest, hopefully, you will recover.” (PP1) “Some patients are more inclined to alternative medicine, smart people, herbal concoctions, ignoring medical treatment. Then they don’t get good results, then they seek medical treatment and are already in a serious condition.” (PN5) Discussion The condition of palliative care patients is an important aspect that forms the basis for developing a nursing care model. Patients requiring palliative care must be properly identified, as this is nec- essary for receiving effective palliative care.14,15 There are still pal- liative care patients who have low levels of knowledge and have wrong information about palliative care, highlighting the need for better health education.16 The age of the patient is an important fac- tor to consider in palliative care; in comparison to younger patients, older patients are more accepting of their condition and expect less palliative care to prolong their lives.17 Moreover, palliative care patients often experience severe psy- chological issues and require effective support to enhance their comfort, psychological well-being, and resilience, ultimately improving their quality of life.18 Family support greatly improves the palliative care process, allowing patients to cope with their challenges more effectively. Family support encompasses various dimensions, including informational support, whereby the family is required to comprehend the patient’s health condition and offer guidance regarding health matters; instrumental support, which pertains to the family fulfilling the financial requirements associat- ed with the patient’s treatment process; and emotional support, which includes elements of self-esteem and companionship that contribute to the patient’s happiness and motivation.2 The active involvement of the family in caring for patients with respectful, clear, and culturally appropriate communication will provide emo- tional strength so that patients can undergo better treatment and care.18 However, it is important to consider that families may also face significant emotional challenges stemming from the impact of the disease on their relatives’ emotional well-being.19 Along with family support, nurses who have a positive attitude toward palliative care can influence quality services and improve patients’ quality of life.20 The role of nurses serves as a crucial starting point for the healthcare team to consider various factors, including culture.1,21 Nurses, as providers of palliative health serv- ices, play a fundamental role in understanding the cultural assump- tions that influence patients’ decision-making, fostering open com- munication with families, and identifying what best meets their expectations during their treatment.3 Additionally, nurses deliver- ing palliative care must recognize that instilling hope in patients should be grounded in realism to assist patients and families in accepting their circumstances and preparing for a dignified death.22 Therefore, improving the understanding and skills of nurses is very important to enhance the quality of palliative care services.6 Nurses who underwent palliative care training had significantly more positive attitudes toward palliative care than those who did not receive such training.20 Education about palliative care has proven effective in increasing nursing students’ knowledge, atti- tudes, comfort, and self-awareness regarding the importance of palliative care in health services. Palliative care education and practice should continue to evolve and be integrated into nursing schools to help nursing students understand early on that palliative care is a vital competency they must achieve.23 As patient advo- cates, nurses play a role in safeguarding information that should not be disclosed to others or anyone claiming to be the patient’s family without the patient’s consent.24 This study found that current hospital policies no longer announce code blue signs for palliative care patients, but medical services and care are still carried out. Code blue often comes from palliative units, where patients have long-term diseases. The main purpose of palliative patient care is to assist patients in living their lives and accepting death with dignity.25 A code blue situation in a hospital is a highly stressful event for everyone involved and pro- foundly impacts the emotional well-being of patients and their families. Regardless of the results, code blue can be traumatic for palliative care patients and their families if it occurs repeatedly after the worsening of the patient’s condition.26 Besides that, emer- gency services, as the main unit for handling code blue, are very busy, noisy, and not an optimal environment for palliative care patients. Consequently, hospital policies need to consider the spe- cial role of the emergency unit in managing palliative care.27 Another essential aspect of palliative care is entertainment. Music therapy or singing for palliative care patients can overcome emotional problems, improve social relationships, and improve patient comfort.28 The restricted availability of qualified human resources in the realm of health care specializing in palliative services necessitates robust advocacy directed toward policymakers to increase the number of skilled palliative care professionals within public health.29 Ownership of health insurance, such as BPJS, serves to safe- guard patients and their families against the adverse financial repercussions associated with medical care expenses. Furthermore, possessing health insurance ensures that patients receive equitable healthcare services.30 Affordable access and complete facilities available at health facilities will be able to increase public aware- ness to utilize health services as the main place to obtain treatment and services that meet expectations.31 Culture is a constellation of societal beliefs and behaviors that shape the patient’s identity as part of a community group. Unique cultural backgrounds are important to assess and accommodate properly because they can affect the disease process, the success of health care, and the patient’s ability to make decisions.32 Clergy leaders can influence patients and families to obtain spiritual peace according to their religion. Spiritual care has been widely proven to increase patient comfort and patient acceptance of illness in pal- liative care.33 Fear of death is common in palliative care patients, Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13398] [page 105] both young and elderly. However, it can be reduced with maximum comprehensive nursing in a special palliative care unit.34 Passing away at home is often deemed unexpected, as it is perceived as a failure of the family to provide adequate care for their relatives. Determining the place of death and who to accompany are impor- tant aspects that should be considered in the process of assessing culture-based palliative nursing care.35 Searching for information on the internet has had an impact on increasing anxiety in palliative care patients because they get inap- propriate information. The lack of optimal information from health service providers generally influences information-seeking behav- ior online.36 Therefore, nurses are expected to be able to develop pocketbooks or modules as a clearer and more precise medium for information and health education for patients and families in order to reduce anxiety due to limited access to information. The materi- al presented must also adopt a cultural approach, ensuring that patients and families feel respected in accordance with relevant cultural aspects.37 Alternative and complementary medicine includes various treatments, herbs, diets, and physical therapies typically not considered in conventional therapies. Alternative medicine is the patient’s choice, often disregarding medical treat- ment. Those using alternative medicine should be aware of poten- tially dangerous side effects, interactions with other therapeutic drugs, delays in the diagnosis process by doctors, and the possibil- ity of impacting timely medical treatment.38 In the coming years, palliative care should focus on communi- ty and family needs, emphasizing the external factors that enhance its effectiveness after hospital discharge. This includes acknowl- edging patient choices to pursue alternative therapies while not adhering to traditional medical practices. Community nurses and primary care providers play a crucial role in delivering ongoing home-based or community-centered palliative care to patients.8 A culturally safe, community-based care approach will contribute more positively to enhancements in comprehensive palliative care services.18 Clinical implications The findings of this study highlight the significant clinical effectiveness of nursing assessment, intervention, and implementa- tion of culture-based palliative care in hospitals. Key nursing assessments involve patient age, education level, knowledge level, psychological issues, economic status, health insurance coverage, use of alternative medicine, and the desire to die at home. Key components of nursing intervention and implementation include communication with patients and families, providing family sup- port, advocating for patients and families, educating patients and their families, maintaining a caring attitude, assisting patients with ADL, offering hope, avoiding code blue situations, delivering sup- portive therapy, facilitating entertainment, ensuring the availability of patient care resources, collaborating as a team, providing chemotherapy services, addressing spirituality, and developing internet-based information systems. This study has limitations, including the lack of religious or cultural figures and stakeholders as informants for obtaining serv- ice leadership recommendations. However, it could help researchers identify important factors to consider when developing a culture-based palliative nursing care model in hospitals. Engaging stakeholders as experts in evaluating the developed pal- liative nursing care model is a significant step for the future. Conclusions This study underscores significant experiences in palliative care, focusing on patient age, psychological factors, educational background, and knowledge acquisition. The support of family members, effective communication, assistance, and economic sta- tus are of paramount importance. Nurses assume a crucial role as advocates and educators, balancing care with realistic expecta- tions. Additionally, health facility policies regarding code blue pro- tocols, supportive therapies, recreational activities, human resour- ce allocation, teamwork, chemotherapy protocols, and insurance matters are essential components. Cultural considerations, such as the involvement of clergy, apprehension surrounding death, inter- net utilization, and preferences for alternative medicine, signifi- cantly impact the quality of care provided. 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