Knowledge and Public Perception of Palliative Care in Germany

Abstract

Background:

Literature reviews reveal poor knowledge and awareness of palliative care in the public. Health literacy deficits impact access to palliative care.

Objectives:

The aim of this manuscript is to explore the public perception of palliative care in Germany.

Design:

Triangulated qualitative research design: a snowball-spread online survey and a random pedestrian survey.

Setting/Subjects:

Citizens in Germany.

Results:

The pedestrian survey (n = 100) revealed 34% of the participants being not familiar with palliative care. The online survey (n = 994) 5.7% of participants reported to not know what palliative care was. The public's perception of palliative care is mainly medicine oriented, referring to inpatient care for the immediately dying; however, further significant misperceptions were scarce.

Conclusions:

The public perception shows an indistinct picture of palliative care, and some misconceptions about the objectives and areas of responsibility of the subject, meanwhile, palliative care is known to a majority of people. Understanding partly incomplete pictures of patients and relatives may help to react appropriately in staff–patient interactions and improve public relations.

Introduction

Palliative care as a medical discipline has a unique profile regarding goals, values and attitudes.^1,2 Research already led to fields of knowledge deemed relevant to be known by the public that are within the domains of the scope of palliative care, palliative care eligibility, differentiation between hospice and palliative care, timing of palliative care, as well as financing of palliative care.³ Conceptions of humanity and care and associated values and ethics are equally evident in internal language use,^4,5 in professional communication, and in public relations work of the discipline.⁶

People in the public have differing ideas about the objectives and scope of palliative care.

The public knowledge and awareness regarding palliative care is highly relevant in the context of health literacy, access to health services, and barriers to the delivery of palliative care. A 3-year communitywide dissemination of information on palliative care was evaluated by Akiyama et al. 2016 in Japan. The knowledge about opioids and sense of security among families and the general public increased.⁷ Descriptions of community knowledge on and attitudes toward palliative care are available for Australia,⁸ England,⁹ and Japan¹⁰ but not yet for Germany. The literature presents high rates of people without any or insufficient knowledge of palliative care (Japan: 63.1%,¹⁰ England: 79.9%⁹) and misperceptions (Australia: median of at least three misperceptions per person⁸). Internationally discussed is how the use of terms influences dissemination of palliative care attitudes.^11,12 This is vividly discussed in Germany as well.¹³ Patel and Lyons¹⁴ report on a review that investigated the knowledge, awareness, and perceptions of palliative care in the general public since 2003 and in different countries. Their findings show that most studies revealed poor knowledge and awareness of palliative care in the public.¹⁴ Latest research is on e-communication,^4,15 online palliative care and oncology patient education resources,¹⁶ podcasts,¹⁷ and web presentation of palliative care services in Germany.¹⁸

Objectives

The aim of this study was to explore the public perception of palliative care in Germany.

Design

We chose a triangulated qualitative research design to explore the public perception of palliative care. A constructivist approach was applied assuming that people construct their own reality by interpreting perceptions according to their perspectives, predominately influenced by their knowledge and experiences.

The public perception of palliative care was investigated using a snowball-spread online survey and random pedestrian survey. In statistics research, snowball sampling (or chain-referral sampling) is a nonprobability sampling technique where existing study subjects recruit future subjects from among their acquaintances. As the sample builds up, enough data are gathered to be useful for research.¹⁹

Qualitative content analysis adapted from Mayring²⁰ allows for systematic analysis and rule-guided interpretation and the assignments of text passages to categories can be evaluated quantitatively.

The qualitative study is reported according to Consolidated Criteria for Reporting Qualitative research (COREQ) reporting guidelines.²¹

Setting/Participants

Setting

The public is referred to as citizens with and without personal experiences in palliative care context.

Sampling

Eligible participants for the online or pedestrian survey were citizens, proficient speakers of Standard German, committing to participate via answering the pedestrian survey or the online survey. For the online survey, we used snowball sampling to recruit study participants. For the pedestrian survey, a random sample of people was selected. Only people with sufficient proficiency in the standard German language was interviewed to achieve greater accuracy in the interview questions. This was justified by the fact that the semantics of the term “palliative” should be determined as precisely as possible, and the language of competent speakers is better suited for semantic analysis.

Recruitment

Recruitment for the online survey took place spreading a link in different social media platforms, mailing lists, and press releases in August 2019, initiating a snowball system.

We interviewed randomly selected passers-by in four cities (Ulm, München, Berlin, and Freiburg) between August 2019 and January 2020 for the pedestrian survey.

Data collection

Online survey

An online survey was designed and applied to gain insights on the public state of knowledge on palliative care key values, tasks, and goals. The participants started the survey after initial information on the study, duration, and data protection, giving their consent by clicking the “start” button. First of all, a closed question assessed knowledge about palliative care (Do you know palliative care? Answering options: yes/no/not sure). Participants who self-proclaimed knowledge about palliative care were invited to answer questions on their previous experiences with palliative care (no experience, private experience, occupational experience, and private and occupational experience). A free text field enabled the participants to independently formulate their own answers on key values, goals, and tasks of palliative care. All participants received questions on sociodemographic data such as gender, age, and occupation. The online survey software Unipark Questback²² was used. Cookies ensured that participants could only take part once. The survey was performed anonymously.

Pedestrian survey

Two doctoral candidates conducted an interview training with special focus on recruitment of passers-by beforehand with a senior researcher. Participants and interviewers did not know each other before.

The semistructured pedestrian survey guide included an opening question on by-passers knowledge of palliative care. They gave verbal informed consent to participate and audio-recording. If the person had some ideas, she was asked to report her experiences and/or encouraged to report subjective associations of key values, goals, and tasks of palliative care. The guiding questions were based on the questions of the online survey to enable comparability of the results of both survey methods. Open questions were chosen to allow participants more freedom in their answers. Participants' age and occupation were assessed. The duration of the survey was scaled to be short, but it was possible for participants to elaborate their perspective as long as they wished.

Data processing and analysis

Data from the online survey were extracted from the survey software and transferred to Excel. The pedestrian interviews were audio-recorded and transcribed verbatim. Datasets from the online survey were checked for completeness and plausibility. Qualitative content analysis according to Mayring²⁰ was applied for analysis of open questions in both the online and the pedestrian survey. We used MAXQDA 2020, a computer-assisted qualitative and mixed-methods data software,¹¹ for qualitative analysis. After working through half the text material of the online survey and assigning codes, one researcher assured the plausibility of chosen codes according to the research question. As soon as coding was finished for all data sets, the assigned codes were structured to main categories and subcategories. The data of the online survey were analyzed first, and then the category system was applied to the data of the pedestrian survey. For the pedestrian survey, the category system was modified inductively where necessary.

To ensure inter-coder-reliability, a co-coding was performed independently by a second doctoral candidate. Any discrepancies were resolved via careful discussion and in consensus. A third (senior) researcher checked the accuracy of the category definitions and the correct match of the code assignments to the categories. Inaccuracies were reworked.

The study received approval from the local ethics committee (details will be added after review).

Results

From 1117 online survey participants, 1006 completed the questionnaire. Another 12 data sets were excluded due to missing entries on the question on palliative care. Out of the remaining 994, 57 (5.7%) participants reported to not know what palliative care was. Finally, 937 data sets were included in the content analysis. The largest proportion of the included study population was aged between 21 and 30 years. A total of 57.5% of participants were employees working in the areas of health care (39.2%), teaching (11%), or economy (10.6%) (Table 1).

Table 1.

Sociodemographic Characteristics of Participants of the Online and Pedestrian Surveys

	Online survey, Participants self-identified as familiar with palliative care (N = 937)	Online survey, Participants self-reporting to not know what palliative care is (N = 57)	Pedestrian survey, Participants self-identified as familiar with palliative care (N = 66)	Pedestrian survey, Participants self-reporting to not know what palliative care is (N = 34)
Average age, years	43.0	33.4	48.6	38.8
Gender, %
Female	74.9	52.6	51.5	28.3
Male	25.1	43.8	48.5	61.7
Divers	0	2.5	0.0	0.0
Training/occupational status, %
Pupils	0.5	0	0	11.8
Students	19.3	29.8	9.0	11.8
Employees	57.5	52.6	77.0	58.8
Retired	11.7	7.0	14.0	17.6
Self-employed	0	7.0	0	0
Not stated	11	3.6	0	0
Experiences with palliative care, %
Private	24.8	—	39.4	—
Job	25.2		7.6
Private and job	7.0		1.5

In total, 100 persons participated in the pedestrian survey (Table 1) out of which 43 reported to be not familiar with the term “palliative care.” The other 66 participants were aware of palliative care and felt able to define it according to their knowledge. Their responses were included in the data analysis. Seventy-seven percent of the participants were employed (most frequent occupations: health care 21%, engineering and technology 17%).

Those who were not familiar with palliative care and were younger on average. There was no significant gender-difference concerning the self-identified awareness of palliative care.

Content analysis of the online survey findings showed the main categories “general characteristics of palliative care,” “range of services and concepts,” “recipients' characteristics,” “societal and political relevance,” and “misconceptions.” We analyzed 937 data sets from the online survey (845 who stated to know palliative care and 92 who were not sure) that included 3562 units of meaning, and 66 data sets from the pedestrian survey (59 who stated to know palliative care and 7 who were not sure) that included 290 units of meanings. The percentage of participants in the online/pedestrian survey mentioned the respective aspect is shown in brackets. Table 2 outlines the code structure.

Table 2.

Code Structure of the Online Survey and the Pedestrian Survey Data Analysis

Main categories	Subcategories	Third level categories
General characteristics of palliative care	Tasks and objectives	Symptom relief
		Inclusion of relatives/family members
		Quality of life and well-being
		Availability of staff to inform and talk^a
	Time and place	Timing of the integration of palliative care during the care trajectory
	Time and place	Place of care
	Values and attitudes	Patient's dignity
	Values and attitudes	Patient's autonomy
	Benefits of palliative care in general	No third-level categories
Range of services and concepts	Services	Medical treatment
		Psychological care
		Nursing care
		Spiritual care^a
		Social work^a
		Support and accompaniment
	Concepts	Noncurative approach
		Multiprofessional and interdisciplinary approach^a
		Holistic approach^a
		Attitude toward shortening or prolonging life
Recipient's characteristics/illness	Incurability	No third-level categories
	Short prognosis (e.g., imminent death)
	Treatment options, status of illness
	Type of illness
Societal and political relevance	No subcategories	No third-level categories
Misconceptions	No subcategories	No third-level categories

Occurred solely in the online survey code structure.

General characteristics of palliative care

Symptom relief (60%/47%), maintenance and improvement of quality of life and well-being (28%/26%), and the inclusion of relatives/family members (13%/12%) are considered to be the most important tasks and goals of palliative care. “Increase in the quality of life at the end of life, more joy and togetherness for the patient as well as the relatives and friends.” (A655, personal and professional experience) “[…] I would spontaneously say that it has something to do with pain treatment, that is, pain therapy […]” (Munich 3). About 17% of the online survey participants solely mentioned pain relief.

Participants stated that palliative care mainly takes place at the end of life. Online survey participants (20%) and 24% of passers-by described palliative care as being a service exclusively for the dying. Participants located palliative care in the hospital setting, <2%/1.5% mentioned palliative care services in home care settings.

Palliative care was predominantly associated with the values of the patients' dignity (8%/24%) and respecting the patients' will and autonomy (4%/11%).

Range of services and concepts

Palliative care was often defined as a noncurative approach (11%/1.5%). “Medical treatment, which can no longer heal but relieves suffering.” (A615, personal experience); “Care of untreatable patients” (A638, personal experience). Few online survey participants (0.6%) got into the fact that palliative care might be applied simultaneously to curatively oriented therapy approaches. Palliative care was occasionally described as a holistic or multiprofessional approach in the online survey (9%). Medical treatment was the predominant description of the type of care (17%/8%); very few participants referred to other occupational groups such as psychology (6%/3%) and care (3%/6%). “A functioning pain therapy and pleasant treatment (social, psychological and physical) […].” (A357, no experience).

Recipients' characteristics

Recipients were characterized as patients with incurable illness (8%/14%) and very limited life time prognosis (e.g., imminent death) (5/3%). “Pain relief therapy for terminally ill people” (A554, personal experience). “People, who are terminally ill, […].” (A719, personal experience). “People, who will almost certainly die in the near future, […].” (A855, no experience). Few statements were made on the type of illness: “[…] in the last phase of life, especially for cancer patients or other seriously ill people” (A633, personal experience).

Societal and political relevance

The societal relevance of palliative care was mentioned by 13%/11% of participants. “I understand palliative care to mean the urgently needed empathic help for people with serious illnesses, the treatment of which is often associated with end-of-life care, something that has unfortunately been neglected in recent years. It is closely linked to the hospice movement […] and urgently needs to be promoted” (A219).

Misconceptions

In 1%/1% of the answers, palliative care was associated with euthanasia. Few answers (0.3%/6%) showed significant misperception of palliative care such as prenatal medicine or preventive medicine.

The comparison of online survey participants with experience of palliative care to those without showed that participants with professional experience draw a more comprehensive picture of palliative care, and participants with private palliative care experience more often referred on terminal care.

Discussion

Main findings

In the public, up to one-third might not know palliative care at all. The answers of those who have some knowledge show the image in the public of palliative care to be a mainly medicine-oriented (pain relief) inpatient care for the immediately dying who have no options left for (curative) treatment. This does not represent the core messages the public should have knowledge about such as the extent and boundaries of palliative care, criteria for determining eligibility for such care, the distinctions between hospice and palliative care, appropriate timing for initiating palliative care, and its financial aspects as outlined by Kozlov and Carpenter³ and integrated in their Palliative Care Knowledge Scale (PaCKS).²³ These are core messages that should be widely understood as shown in their study by rating of palliative care professionals. Palliative care as a discipline is not yet sufficient in adequately communicating its objectives. Experiences with palliative care led to a more comprehensive picture. The patient-centered and multidisciplinary approach was appreciated in the public. Significant misperceptions were scarce.

Strengths and limitations

The pedestrian and the online surveys were based on different sampling and data collection strategies.

Due to recruitment bias, pedestrian survey findings concerning the knowledge about palliative care might be more representative for the public than those of the online survey. The snowball approach resulted in more participants with a health care background and more participants with an academic background in the online survey. A higher level of knowledge about palliative care in that group was found in a Portuguese study as well²⁴ In our study, when comparing the employment sectors of our sample groups to the broader employed population in Germany, which numbers 45.5 million, notable differences emerge, indicating some restrictions of generalization.

The representation of health care professionals is significantly higher in our samples. The online survey group shows 39.2% working in health care, and the pedestrian sample has 21%, compared to only 10.8% in the general employed population. There is also a higher percentage of individuals working in teaching in our samples. The online survey indicates 11%, and the pedestrian sample shows a higher percentage, both exceeding the 2.1% observed in the general population. Conversely, fewer participants in our samples are employed in the economy sector. In the online survey, this figure is 10.6%, and it is lower in the pedestrian sample compared to a higher 29.5% in the general employed population. The representation in the engineering and technology sector is similar between the general population and our pedestrian sample, with 18.2% and 17%, respectively. Additionally, the pedestrian survey took place in university cities with a rather high level of education of the population on average. It is likely that findings might differ in more rural areas.

What this study adds with reference to existing international literature

To the best of our knowledge, this is the first study that explores the perception of palliative care in the general public in Germany. In line with the available literature, our results indicate that there is a majority in the public in Germany being aware of palliative care.¹⁴ Nevertheless, the number of people being unaware is high. Many associate palliative care with care for the immediate dying, similar to other countries examined in previous studies.^9,25,26 In our study, we could not reproduce the internationally described phenomenon that palliative care is seen as a form of health care only for cancer patients.^9,26 Bearing in mind limitations on representability, we can, nevertheless, confirm international study results on more knowledge with people aged 40+ in literature, in our study aged 30+. People who had at least some previous experience with palliative care had better knowlegde.¹⁴ There was no significant gender-difference on awareness or knowledge of palliative care in our study.

Appropriate communication and information are fundamental components of the palliative care approach. In the actual staff–patient interaction, the newly acquired knowledge makes it possible to better understand partly incomplete pictures of patients and relatives in relation to palliative care and to react appropriately to them. Nevertheless, we know from another study of our group, that in web presentations of palliative care facilities, they rely mainly on the Word Health Organization (WHO) definition, without informing about its comprehensive approach.¹⁸ A Japanese study indicates that a high exposure of information in the public via small media and lectures in the community is effective to enhance public awareness.⁷ Public education programs might be an approach as well, similar to campaigns to increase vaccination readiness.²⁷

A more comprehensive representation in media (interviews with staff members of different professional background, websites of palliative care institutions and associations)¹⁸ might improve the public perception. Laypeople with personal experience of palliative care in their private environment could be motivated to share their experiences in community-based meetings and local patient and family education programs. Younger people might be reached by information spread via current media features such as podcasts¹⁷ and social media. Effectiveness of these approaches or a combination of measures to improve public awareness should be measured with instruments such as PaCKS²³ with a representative study population to ensure their impact.

Conclusion

The public perception shows a minimally distinct picture of palliative care, and some misconceptions about the objectives and areas of responsibility of the subject; meanwhile, palliative care is known to a majority of people. Understanding those partly incomplete pictures of patients and relatives and awareness that the health professionals' own understanding might differ from the patients may help to react appropriately to them in staff–patient interactions and improve public relations. Sufficient knowledge of the approaches, values, and objectives of palliative care is likely to be an important factor related to palliative care (PC) service utilization. Lack of knowledge can lead to underuse of palliative care by patients, limit informed decisions based on communication, and discourage individuals from seeking patient-centered palliative care at the end of life.

Footnotes

Acknowledgments

This work was performed in partial fulfilment of the requirements for obtaining the degree “Dr. med. dent.” by Susanna Schweighart. We are very grateful that the doctoral candidate Magdalena Michels was partly supported with the qualitative data analysis. Miriam Baron (medical doctor candidate) contributed to the acquisition of data of the pedestrian survey. Many thanks to Natan Dykes for editing the manuscript in an earlier stage of the draft. We would like to thank all participants for their time and participation. Our sincere thanks goes to the German Association for Palliative Care (Deutsche Gesellschaft für Palliativmedizin e. V., abbrev. DGP) and our contact person Karin Dlubis-Mertens for her valuable input and the possibility to recruit participants at the venue. We are grateful Kevin Tolle for his support on translating the quotations into English.

Authors' Contributions

M.H. (female, nursing scientist, social worker, Dr. phil., Dr. rer. biol. hum.) substantially contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, drafted the manuscript. She contributed to the funding proposal. J.P. (male, linguist, Dr. phil.) substantially contributed to the conception of the work, and the interpretation of data, and critically revised the manuscript for important intellectual content. He raised funding. S.S. (female, dental medical doctor candidate) was responsible for performing the investigation on the public (pedestrian survey and online survey). She substantially contributed to the acquisition, analysis, and interpretation of data, and drafted parts of the manuscript together with M.H. M.H. (female, linguist, Prof. Dr.) substantially contributed to the conception of the work, and the interpretation of data, and critically revised the manuscript for important intellectual content. C.O. (male, medical doctor) substantially contributed to the conception of the work, and the interpretation of data, and critically revised the manuscript for important intellectual content.

Funding Information

The study was funded by several foundations of the University of Erlangen: Universitätsbund, Ilse and Dr. Alexander Mayer Foundation, Luise Prell Foundation.

Author Disclosure Statement

The authors declare that there is no conflict of interest.

References

IAHPC. IAHPC Global Project—Consensus Based Palliative Care Definition. 2019. Available from: https://hospicecare.com/what-we-do/projects/consensus-based-definition-of-palliative-care/definition[Last accessed: July 20, 2022].

Saunders

. The evolution of palliative care. J R Soc Med, 2001; 94(9):430–432; doi: 10.1177/014107680109400904

Kozlov

, Carpenter

. “What is Palliative Care?”: Variability in content of palliative care informational web pages. Am J Hosp Palliat Care, 2017; 34(3):241–247; doi: 10.1177/1049909115615566

Peters

, Heckel

, Habermann

, et al. Language in Motion—Time-Typical Vocabulary of Palliative Medicine. Zeitschrift für Palliativmedizin, 2019; 20(03):125–131; doi: 10.1055/a-0873-4234

Peters

Fachdiskurs, Fachsprache Und Zentrale Konzepte von Palliativmedizin Und Palliativversorgung Im 21. Jahrhundert. Eine Korpusbasierte Linguistische Diskursanalyse an Fachtexten Der Jahre 2000–2019. Friedrich-Alexander-Univeristät Erlangen-Nürnberg: Erlangen; 2021.

Peters

, Dykes

, Heckel

, et al. Presenting Palliative Care Units and Specialized Outpatient Palliative Care Teams on the Internet—a Corpus-Based Meta-Analysis of Websites. Zeitschrift für Palliativmedizin, 2022; 23(01):46–53; doi: 10.1055/a-1689-7524

Akiyama

, Hirai

, Takebayashi

, et al. The effects of community-wide dissemination of information on perceptions of palliative care, knowledge about opioids, and sense of security among cancer patients, their families, and the general public. Support Care Cancer, 2016; 24(1):347–356; doi: 10.1007/s00520-015-2788-4

Collins

, Brown

JEH

, Mills

, et al. The impact of public health palliative care interventions on health system outcomes: A systematic review. Palliat Med, 2021; 35(3):473–485; doi: 10.1177/0269216320981722

McIlfatrick

, Slater

, Beck

, et al. Examining public knowledge, attitudes and perceptions towards palliative care: A mixed method sequential study. BMC Palliat Care, 2021; 20(1):44; doi: 10.1186/s12904-021-00730-5

10.

Hirai

, Kudo

, Akiyama

, et al. Public awareness, knowledge of availability, and readiness for cancer palliative care services: A population-based survey across four regions in Japan. J Palliat Med, 2011; 14(8):918–922; doi: 10.1089/jpm.2010.0529

11.

Zambrano

, Centeno

, Larkin

, et al. Using the term “Palliative Care”: International survey of how palliative care researchers and academics perceive the term “Palliative Care.”. J Palliat Med, 2020; 23(2):184–191; doi: 10.1089/jpm.2019.0068

12.

Fishman

, Greenberg

, Bagga

, et al. Increasing information dissemination in cancer communication: Effects of using “Palliative,” “Supportive,” or “Hospice” care terminology. J Palliat Med, 2018; 21(6):820–824; doi: 10.1089/jpm.2017.0650

13.

Bollig

, Unger

, Pani

. Is there a difference between Palliative Care and Palliative Medicine?. Palliativmedizin, 2010; 11(06):304–313; doi: 10.1055/s-0030-1248613

14.

Patel

, Lyons

. Examining the knowledge, awareness, and perceptions of palliative care in the general public over time: A scoping literature review. Am J Hosp Palliat Care, 2020; 37(6):481–487; doi: 10.1177/1049909119885899

15.

Scott

, Hudson

, Charnley

, et al. Development of an eHealth information resource for family carers supporting a person receiving palliative care on the island of Ireland. BMC Palliat Care, 2019; 18(1):74; doi: 10.1186/s12904-019-0457-y

16.

Prabhu

, Crihalmeanu

, Hansberry

, et al. Online palliative care and oncology patient education resources through Google: Do they meet national health literacy recommendations?. Pract Radiat Oncol, 2017; 7(5):306–310; doi: 10.1016/j.prro.2017.01.013

17.

Nwosu

, Monnery

, Reid

, et al. Use of podcast technology to facilitate education, communication and dissemination in palliative care: The development of the AmiPal podcast. BMJ Support Palliat Care, 2017; 7(2):212–217; doi: 10.1136/bmjspcare-2016-001140

18.

Peters

, Dykes

, Heckel

, et al. Pulling Together? Potrayal of Competence, Patient-Accessibility and Language Differences in Websites of German Hospices, in- and Outpatient Palliative Care Services. SAGE Publications;, 2020; pp. 186–187; doi: 10.1177/0269216320958098

19.

Leighton

, Kardong-Edgren

, Schneidereith

, et al. Using social media and snowball sampling as an alternative recruitment strategy for research. Clin Simulat Nurs, 2021; 55:37–42; doi: 10.1016/j.ecns.2021.03.006

20.

Mayring

Qualitative Content Analysis: Theoretical Foundation, Basic Procedures and Software Solution. Klagenfurt; 2014.

21.

Tong

, Sainsbury

, Craig

. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Q Health Care, 2007; 19(6):349–357; doi: 10.1093/intqhc/mzm042

22.

Questback GmbH, UNIPARK. Unipark EFS Online Survey Software [Software]. 2021.

23.

Kozlov

, Carpenter

, Rodebaugh

. Development and validation of the Palliative Care Knowledge Scale (PaCKS). Pall Supp Care, 2017; 15(5):524–534; doi: 10.1017/S1478951516000997

24.

Dixe

MDA

, Santo

IDDO

, Lopes

, et al. Knowledge and Myths about Palliative Care among the General Public and Health Care Professionals in Portugal. IJERPH, 2020; 17(13):4630; doi: 10.3390/ijerph17134630

25.

Fliedner

, Zambrano

, Eychmueller

. Public perception of palliative care: a survey of the general population. Palliat Care, 2021; 15:263235242110175; doi: 10.1177/26323524211017546

26.

Claxton-Oldfield

, Claxton-Oldfield

, Rishchynski

. Understanding of the term “palliative care”: A Canadian survey. Am J Hosp Palliat Care, 2004; 21(2):105–110; doi: 10.1177/104990910402100207

27.

Wakefield

, Loken

, Hornik

. Use of mass media campaigns to change health behaviour. Lancet, 2010; 376(9748):1261–1271; doi: 10.1016/S0140-6736(10)60809-4