Background Home-based end-of-life palliative care presents unique ethical challenges that differ fundamentally from those in institutional settings. Healthcare professionals navigate the complex role of being both clinical experts and guests in patients’ domestic environments, operating in a context where professional authority is continuously negotiated rather than institutionally established. Research aim This study examines the ethical tensions healthcare professionals encounter in home-based end-of-life palliative care and explores the strategies they employ to balance and negotiate competing ethical values within patient-family relationships. Research design A qualitative study using thematic content analysis conducted through focus groups and semi-structured interviews. Participants and research context Thirty-three multidisciplinary healthcare professionals from Israeli home-based hospice care participated, all employed by a national organization specializing in home-based medical services. Data was collected through three profession-specific focus groups (physicians, nurses, social workers) and nine semi-structured interviews with organizational leaders. Ethical considerations The study was approved by the Institutional Review Board. All participants provided written informed consent, were assured confidentiality and anonymity, and informed of their right to withdraw without consequences. Findings Two interrelated themes were identified. “ From Guest to Clinician ” describes how professionals balance clinical authority with domestic sovereignty, manage involuntary exposure to private patient information, and develop “protective witnessing,” a deliberate ethical practice of selective attention preserving patient dignity. “ Distributed Responsibility in Multi-Stakeholder Care ” reveals the paradox of accountability without control: professionals bear clinical responsibility without institutional oversight while working alongside family members as untrained care partners with competing priorities. Conclusions Home-based palliative care places professionals at the intersection of clinical responsibility and domestic sovereignty, a position for which existing frameworks offer insufficient guidance. Addressing these structural and relational challenges requires both individual-level preparation, including training in ethical decision-making in low-control environments, and systemic policy reform.
Hochwald et al. (Sat,) studied this question.