What Trust Has to Do with Palliative Care Development – By Roman Sklotskiy, PACED

When we speak about trust here, we are not considering it in the abstract. We are speaking about its institutional and social forms. In palliative care, trust means recognising the government as responsible for palliative care; trusting health professionals to speak honestly and competently about suffering, prognosis and care options; trusting civil society organisations to advocate for patients and families; and trusting communities to make room for shared decision-making, care planning and serious conversations at the most vulnerable stage of life.

The question feels particularly timely. The 2026 Edelman Trust Barometer describes a world marked by grievance, polarisation and insularity — a growing reluctance to trust those who are different from us.

The Barometer tracks public trust in four major institutions — government, business, media and NGOs — and synthesises these assessments into a broader comparative picture of institutional trust across countries. Its central theme, Trust Amid Insularity, is strikingly relevant to health systems.

Among the findings that seem especially important for palliative care are the following:

To explore this, I consulted the 2025 regional Atlases of Palliative Care, prepared by the ATLANTES Global Observatory of Palliative Care at the University of Navarra in partnership with regional organisations, including the European Association for Palliative Care, the Asia Pacific Hospice Palliative Care Network, the African Palliative Care Association, and others. These atlases present palliative care development not as a single outcome but as a system of six interdependent components: empowerment of people and communities, health policy, research, essential medicines, education and training, and service provision. If this is the architecture of palliative care, trust may be one of its hidden structural conditions.

The atlases also use broader development indicators, including the Human Development Index, to understand national differences. That is useful, but it captures dimensions such as longevity, education and standard of living — variables that are relatively tangible and measurable.

Trust is different. It is socially embedded, harder to quantify, and less stable in meaning across contexts. That makes it more difficult to analyse, but not less important.

A brief note on sources. The Global Atlas of Palliative Care, published by WHPCA, with its second edition appearing in 2020, remains a foundational reference in the field. For this column, however, I draw primarily on the 2025 regional atlases prepared by ATLANTES and its regional partners. The main reason is practical rather than evaluative: these atlases are more recent and are built around the current WHO conceptual framework and actionable indicators for assessing palliative care development, making them particularly useful for an exploratory comparison such as this.

For an initial comparison, I chose one relatively visible and comparable indicator: the number of specialised palliative care services per 100,000 population. I then compared it with a comparative trust measure: the Trust Index from the 2026 Edelman Trust Barometer. Of the 28 countries included in Edelman, only Canada and Indonesia had to be excluded because the relevant comparative data were not available in the corresponding atlases. This comparison does not capture palliative care development in its entirety. It looks at one important, but still partial, dimension of it: specialised service density.

The relationship may also run in the other direction.

Good palliative care requires honesty, continuity, skilled communication, respect for dignity, and a visible commitment to relieving suffering. When delivered well, it can strengthen trust among patients and professionals, among families and institutions, and, more broadly, among citizens and the health system. In that sense, palliative care may not only depend on trust; it may also help produce it.

This does not mean trust is the only driver. Across the 2025 regional atlases, the broader picture is one of uneven development, shaped by wider structural conditions: economic capacity, health-system maturity, regulatory environments, workforce constraints, and regional disparities in access. Progress is real, but it remains highly uneven, with persistent gaps in service provision, education, and access to essential medicines.

Nor do the available trust datasets allow for a clean comparison across all countries where palliative care remains underdeveloped, including many where PACED works. The overlap between trust surveys and palliative care data is limited. But that does not make the question any less relevant. It simply means we should treat it as a serious analytical hypothesis, not as a finished causal claim.

If a simple service-based comparison does not yield a clear answer, the next step is not to abandon the question but to ask where trust may operate more meaningfully. There are at least four ways in which this may matter.

First, trust may shape whether palliative care becomes a recognised part of public policy rather than a marginal or charitable add-on. It is reasonable to ask whether low trust in government makes it harder to frame, fund and sustain palliative care as a normal function of the health system.

Second, trust may matter for community empowerment and the patient voice. For palliative care to work well, patients and families need more than services; they need to be heard, have access to information, and live in a culture where preferences can be discussed and respected. That kind of culture is difficult to build where trust is thin, public discourse is fractured, and people retreat into ever smaller circles of safety.

Third, trust may shape access to essential medicines, particularly opioids for pain relief. Income, regulation, procurement and service capacity obviously matter. But trust may matter too. Where trust in institutions, expertise and responsible regulation is weak, fear can fill the gap: fear of misuse, addiction, scrutiny, or saying the wrong thing. In such settings, pain relief can become trapped between stigma and control.

Fourth, trust may support the academic and professional legitimacy of palliative care. Research capacity, specialist education and professional recognition do not arise automatically. They depend on a broader environment in which expertise is valued and institutions are willing to invest in long-term capacity. Where trust in expertise is stronger, palliative care may find it easier to move from moral necessity to a recognised field of knowledge and practice.

There is another reason this matters.

The Edelman report uses an interesting phrase: ‘trust brokering’. It describes efforts to bridge gaps and build trust between groups that distrust one another. The phrase originates in a different context, but it resonates strongly with palliative care. In countries where palliative care is still developing, progress may depend not only on clinical champions and technical reform, but also on actors capable of translating between worlds: state and society, medicine and community, expert knowledge and public fear, policy language and lived experience.

This is particularly relevant in settings where palliative care is still evolving and where trust in institutions cannot be taken for granted. In such contexts, building palliative care is not only about creating services. It is also about building legitimacy: demonstrating that palliative care is not abandonment, not ‘less care’, and not only for the final hours of life, but a serious and humane response to suffering.