Ethical challenges and multidisciplinary approaches in end-of-life oncology care: Insights from the 2025 AIOM Ethics Days

Abstract

End-of-life care in oncology represents a complex and multidimensional challenge that requires ethical awareness, effective communication, and multidisciplinary collaboration. Drawing from the discussions and data presented during the 2025 AIOM Ethics Days, this paper highlights key aspects influencing the quality and humanity of end-of-life care. Significant gaps persist in clinicians’ knowledge and in the practical implementation of shared care planning, not solved by the dedicated Italian law approved in 2017 (n.219). Communication between oncologists and patients remains a critical factor in fostering informed decisions and emotional support. Awareness of prognosis and early integration of palliative care improve quality of life, yet these remain underutilized. Spiritual support and organizational innovation are increasingly recognized as essential components of comprehensive care. The findings highlight the importance of interprofessional dialogue, ethical reflection, and ongoing education to reduce overtreatment and professional distress. Fostering a culture of respect and shared responsibility is essential to uphold patients’ dignity throughout the end-of-life process.

Keywords

ethical issue in oncology end-of-life multidisciplinary teamwork

Introduction

The management of end-of-life care in oncology was the focus of the event promoted by the Italian Association of Medical Oncology (AIOM) held in Lecce on September 19–20, 2025 ( Figure 1 ). It represents a complex and delicate area of intersection among clinical needs, ethical aspects, psychological, cultural and spiritual dimensions, and normative challenges (Tables 1 and 2, Figure 2).^1,2 The starting point is a deep commitment to respect and listening—not only to patients and caregivers but also to the professionals involved—acknowledging the value of every decision and the limits of knowledge in every therapeutic journey; humility thus becomes the best stance in facing the uncertainties and difficulties of end-of-life care (EoLC).^3,4

Figure 1.

AIOM Ethics Days 2025 on End-of-Life Care

Table 1.

The essential aspects at the end of life: what oncologists need to know.

Aspects	Description	Main Data / Evidence
Law 219/2017	Premise for activating Shared Care Planning (SCP), to understand patients’ wishes regarding end-of-life.	30% of Italian clinicians report not knowing the law, 35% know it fairly well, 35% know it well.¹³
Physician–Patient Communication	A difficult and complex process; willingness to listen is a prerequisite for a healing relationship. It is necessary to learn to communicate and to share even the uncertainty of outcomes.	Fundamental at every stage of the care pathway to ensure informed choices, reduce anxiety, and plan end-of-life care.^21,22
Recognition and Respect for Human Dignity	Based on ethical principles of beneficence, autonomy, and justice.	Beneficence: appropriateness and proportionality. Autonomy: right to choose (to know or not to know), informed consent, Advance Directives, and SCP. Justice: effective use of resources, equitable access, fair consideration of interests, and non-discrimination.
Giving the Right Meaning to Words	“Words are never just words: they are acts that build human environments. They can connect or divide, serve truth or serve themselves. We must disarm words to disarm minds and disarm the Earth.”²²	Respect, humility, and listening; Hope vs. illusion; Caring for rather than taking charge of; Medical help to die rather than euthanasia; Assisted dying rather than assisted death; Quality of bereavement.
Con-sense (Shared Meaning)	Generating meaning together. A cornerstone of the healing relationship and shared treatment pathway.	Oncologists tend to overestimate what patients have understood: always verify comprehension of information given.²²
Shared Care Planning (SCP)	A dynamic, continuous, and shared process that allows patients to express their wishes after proper information, and to update them over time.	92% of clinicians consider it feasible in oncology patients, but only 36% actually apply it in clinical practice.¹³
Awareness of Prognosis	Promotes early access to palliative care, improves quality of care and the doctor–patient relationship, reduces depression, and ensures end-of-life consistent with patients’ wishes.	71% of clinicians report always or often informing patients of prognosis¹³; only 10% of patients are fully aware, 41% have partial awareness.²³
Recognizing the Role of the Team	Communication within the team ensures shared goals, full assessment, and formulation of the best care plan. The team is a strategic resource ensuring personalized, integrated care for patients and families.	56% of clinicians always share decisions within the team, 32% fairly often.¹³ Teamwork is possible when everyone’s dignity is recognized; requires sensitivity and active listening.
Responsibility	Ability to provide responses and support; requires communication skills, empathy, and relational awareness—treating each person with dignity, equity, and respect.	Applies to patients, families, and colleagues alike.
Fostering Relational Awareness	Contributing to each person’s journey toward awareness of their uniqueness and equal dignity.	Shift from guilt to responsibility.

Table 2.

The essential aspects at the end of life: For care beyond illness.

Aspects	Description	Main Data / Evidence
Palliative Care (PC)	Indicator of quality care; avoids therapeutic obstinacy and patient abandonment. The PC team should be involved early.	Globally, only 40% of patients needing PC at end-of-life receive it.⁵ 13.5% of Italian clinicians never activated PC; 42% activated it in 75–100% of cases, and 13.5% always.¹³
Spiritual Support	Search for meaning; spiritual suffering is associated with anxiety and depression.	Only 17% of patients feel spiritually supported. Need to recognize this need and strengthen services.¹⁴
Emerging Needs	Rethink organizational models to fit societal changes: aging population, frail elderly with comorbidities, people living alone, limited economic resources.	9 million people in Italy live alone (5 million are elderly); around 15% of the population, over one-third of households; in some cities exceeding 40%.²⁴
When the Oncologist Should Stop	Overtreatment is caused by psychological, cultural, and cognitive biases among patients, oncologists, and families. A setting where patients’ fears combine with those of caregivers and relatives. Anticancer treatments in the last month of life: Indicator of poor quality of care; delays access to PC, increases ER visits and inappropriate hospitalizations. Harmful for patients, staff, services, and economically.²⁵	Study of 78,446 patients: no benefit in overall survival, increased adverse events, reduced quality of life.²³ ESMO and ASCO guidelines on communication and end-of-life care.^26,27 10-40% of patients receive anticancer treatments in the last month of life.²¹ 26% of Italian clinicians say they “always or often” give oncological treatments, 34% “sometimes”, 26% rarely, and 14% never¹³. Need for systematic use of prognostic assessment tools.^21,28
Palliative Sedation	An ethically and clinically indicated therapy aimed at improving quality of life and death by controlling refractory symptoms causing intolerable suffering.	25–33% of cancer patients in palliative care require sedation.¹² 9% of Italian clinicians report using it rarely, 15% never, 17% occasionally, 30% quite often, 29% always.¹³
Proportionality of Care and Therapeutic De-escalation	Suspension of treatments that are no longer effective or appropriate. “Do I have permission to stop? Did I ask whether it was right to start?” The best therapy respects the goals of the care plan.	50.3% of clinicians consider hydration/nutrition as supportive care, 49.6% as medical treatment. Only 19.4% comply with patients’ requests to suspend life-sustaining treatment.¹³
Euthanasia / Medically Assisted Suicide	Requests often linked not to intolerable suffering but to a life perceived as intolerable. Essential to interpret the underlying need, ensure PC options were offered, and maintain relational understanding.	65% of clinicians are in favor, 50% under certain circumstances (unacceptable suffering, informed choice, short life expectancy). 90% of clinicians support a national law regulating end-of-life.²
Processing Bereavement	Final act of end-of-life assistance; influenced by the quality of the patient’s death.	Testimony of a young woman’s husband: speaking about death while healthy was a valuable opportunity, preventing it from catching them unprepared.¹³
Training of Healthcare Professionals	Strategic to ensure quality, ethically grounded care shared with patients and teams; reduces compassion fatigue and moral distress.	34% of clinicians feel poorly or not at all prepared to assist dying patients, 39% enough, 27% feel very confident.¹³ Associations play a key role in professional training and education.
Role of Associations	End-of-life oncology requires diverse skills and shared multi- and interdisciplinary pathways.	Need for common programs and shared procedures to ensure quality, appropriateness, and timeliness. Strategic role in institutional and legislative decisions.

Figure 2.

Current state of the art and key challenges in end-of-life oncology care in Italy.

Insights from the 2025 AIOM Ethics Days and national survey

The 2025 AIOM Ethics Days were preceded by a survey promoted by AIOM with the participation of the Italian Society of Palliative Care (SICP), Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI), Italian Society of Psycho-Oncology (SIPO), Italian Society of Surgical Oncology (SICO), and the Italian Association of Radiotherapy and Clinical Oncology (AIRO), addressing end-of-life issues, conducted online from April to July 2025, and joined by 562 professionals (89% of whom were physicians). In addition to presenting the survey data, the sessions in Lecce provided an opportunity for interdisciplinary discussion of these complex and highly debated topics, involving philosophers, bioethicists, sociologists, legal experts, psychologists, spiritual caregivers, oncologists, palliative care specialists, anesthesiologists, nurses, family members, patients, patient organizations, and caregivers. Tables 1 and 2 present the main emerging issues discussed at the conference and related evidence, drawn partly from the survey and partly from the existing literature.

International and national regulatory frameworks

Internationally, EoLC is regulated according to different legislations. An overview of the current situation can be drawn from the Nuffield Trust report of August 2025.⁵ Another recent international report by the OECD (Organization for Economic Co-operation and Development), operating in over 100 countries, aims to define better policies for better lives and identifies key issues in EoLC: 1) less than 40% of patients who need palliative care receive it; 2) care provided often does not align with patients’ wishes; 3) care quality is poor; 4) only about a quarter of patients establish advance care directives (ACDs); and 5) among elderly patients who die (50% in acute hospitals), only 10–25% receive adequate support for symptom relief and psychological support.⁶ The report also highlights the lack of adequate financial resources allocated to EoLC (in OECD countries, hospital expenditures account for between 32% and 67% of EoLC costs), as well as insufficient scientific research in this field, both clinically and organizationally. Fewer than 30% of participating countries have a national research program in EoLC. This remains the case despite the well-documented benefits of early palliative care integration⁷ and holistic end-of-life assistance (better quality of life, reduced costs due to decreased hospitalizations in acute care settings, reduced use of inappropriate drugs, and more appropriate care settings matching patient needs and wishes).⁶ Results from some studies show that racial and ethnic minoritized populations with lung cancer experience more intensive EoLC than the white population.⁸

In Italy, Law 219/2017 marked a fundamental legislative turning point, affirming the right to advance healthcare directives for all citizens and introducing the concept of Shared Care Planning (SCP) for patients with chronic and disabling illnesses.⁹ In this framework, SCP should be understood not merely as informed consent to a single medical act, but as a broader and dynamic process that also includes Advance Care Planning as described in international literature.¹⁰ Of note, this law does not address euthanasia or medically assisted suicide (MaS), but rather focuses on patient autonomy, decision-making processes, and the shared definition of care goals within the therapeutic relationship.⁹ In this light, the uniqueness of SCP should be emphasized, as it amplifies the voices of patients and their needs in all settings, throughout their care journey, valuing the uniqueness of the person. Moreover, SCP underscores the creation of a shared project within a caring relationship, between those seeking help and those offering it (the expression “Communication time is care time” perfectly applies to this setting). This clarification allows a more accurate ethical interpretation of shared decision-making processes and facilitates their correct correlation with the principles introduced by Law 219/2017.⁹ SCP requires a rethinking of innovative organizational models in health and social care services—flexible and responsive to the emerging challenges of a changing society. A distinct legal and ethical framework emerged with the Italian Constitutional Court ruling no. 242/2019, which addressed the issue of MaS by identifying specific and strictly defined conditions under which the punishment for assistance may be excluded, without constituting a comprehensive regulatory law. The ruling reaffirms the central role of access to palliative care and palliative sedation and has contributed to an ongoing public, ethical, and institutional debate regarding the need for a possible future legislative intervention on assisted dying in Italy.¹¹ Furthermore, patients must be informed about alternative solutions, especially access to palliative care and palliative sedation.^1,7,8,12

Despite this, knowledge of Law 219 remains limited among both citizens and healthcare professionals, and its systematic application in daily clinical practice is rare. Available evidence shows that 34% of clinicians report feeling poorly or not at all prepared to assist dying patients, 39% consider themselves sufficiently prepared, and only 27% feel very confident in managing these complex situations.¹³ These data highlight a relevant gap between the legal framework and everyday clinical practice, suggesting that legislation alone is insufficient to ensure appropriate EoLC.¹³ In this context, scientific and professional associations could play a key role in promoting education, training, and ethical support, fostering shared competencies and increasing clinicians’ confidence when facing EoLC and medical assistance in dying scenarios. Experiences from a few Italian regions (Tuscany and Emilia-Romagna), as well as the much longer tradition in Switzerland that were presented at the AIOM conference, demonstrate that addressing requests for assisted dying from a healthcare perspective is complex but mandatory. Even the relevant terminology is not always shared, and the distinction between euthanasia (direct action by a physician to induce death at the patient’s request by administering lethal drugs) and MaS (the act of intentionally ending one’s own life by self-administering lethal drugs) is not universally understood. Difficulty still remains in reaching consensus about word usage and meaning. One consistent concept, however, is that the request for assisted dying aims to accelerate a process experienced by the person as gravely distressing, motivated by lack of hope and the search for meaning in life. This reflects not only intolerable suffering, but also a life perceived as intolerable.⁵

The spiritual/psychological dimensions and the role of multidisciplinary teamwork

The spiritual, narrative, and psychological dimensions play a central role in EoLC, integrating with clinical and regulatory aspects to provide comprehensive support to patients, their families, and the entire care team.^3,7 Spirituality, intended as a search for meaning, provides hope and helps patients find significance in life despite suffering, bringing attention back to fundamental values and the mystery of existence.¹⁴ However, actual spiritual assistance remains scarce in oncology (ranging from 9% to 51% of patients), highlighting a significant gap between needs and organizational responses.¹⁵

Testimonies from hospices presented at the AIOM ethics conference further underscored the fundamental importance of multidisciplinary teamwork, empathic listening, and psychological support - including for families and professionals - in helping patients process their journeys, preventing isolation, and reducing moral distress linked to ethical dilemmas or organizational constraints.¹⁶ This distress can deeply affect healthcare workers, requiring targeted support strategies and lifelong training to ensure the well-being and cohesion of care teams, encourage open discussions, and normalize the topic of death. These elements are considered essential for fostering awareness, reducing uncertainty and emotional burdens, and promoting the dignity of individuals up to their final moments.^1,4,17

All this requires healthcare professionals willing to take on the challenge, developing listening, communication, and communication-relational skills, fostering respect and shared decision-making within the team.¹⁸ Sound moral judgment, the will to act beneficially, and the courage to stop when cancer treatments are no longer effective are equally crucial and necessary elements to prioritize dialogue, closeness, and palliative care while respecting and valuing persons.⁸ Within this context, bioethics becomes a key to fostering reflection on the meaning and implications of suffering for patients and healthcare providers, and is a useful tool for imbuing this experience with meaning.¹⁹

With regard to euthanasia, the percentage of Italian oncologists who declare themselves in favor has only slightly changed since 2007 (year of the previous AIOM survey).²⁰ Specifically, 14% of oncologist always declared themselves in favor, compared to 10.8% today; and “in favor in certain circumstances” 42% on 2007 versus 52.1% today.

Conclusions

The AIOM-promoted event on EoLC enabled an open and participatory interdisciplinary dialogue among the various scientific societies involved in patient care, highlighting the strong need for greater interaction among the diverse professionals for the benefit of patients, as well as to reduce the stress and care burden on healthcare professionals. All scientific societies involved must promote dialogue, discussion, training, support, and motivation among all stakeholders. It is also necessary to share a unified project among scientific societies to be more effective in institutional decision-making and to promote organizational models in social and health care more aligned with the emerging needs of a changing society. In this perspective, a crucial step forward could be the development of shared national pathways for EoLC, integrating hospital, territorial, and home-based services, with clearly defined roles and communication tools, to ensure continuity of care and equity of access across regions.

Footnotes

Declaration of conflicting interests

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

Funding

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

ORCID iDs

Lorenzo Belluomini

Massimo Di Maio

Vittorina Zagonel

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