{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T03:47:12Z","timestamp":1790221632383,"version":"4.1.0"},"reference-count":57,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,14]],"date-time":"2026-07-14T00:00:00Z","timestamp":1783987200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100019349","name":"Universidad T\u00e9cnica Particular de Loja","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100019349","id-type":"DOI","asserted-by":"crossref"}]},{"id":[{"id":"https:\/\/ror.org\/04dvbth24","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Palliative sedation is a key intervention to relieve refractory suffering at the end of life; however, its implementation depends on access to essential medications. This study aimed to evaluate the availability and access to palliative sedation medications and to identify associated barriers among physicians affiliated with the Ecuadorian Association of Palliative Care (ASECUP). A quantitative, cross-sectional study was conducted using a structured, validated questionnaire administered to 82 eligible ASECUP-affiliated physicians. Descriptive and bivariate analyses were performed to assess associations between medication availability and institutional variables. Midazolam was the most frequently used medication (82.0%); however, availability was inconsistent, with only 54.9% reporting constant access. The main barriers identified were regulatory restrictions (53.7%), distribution problems (36.6%), and the absence of clear access policies (41.5%). Administrative difficulties were also common: 40.2% of participants reported modifying clinical protocols due to medication shortages, and 48.8% observed adverse clinical consequences. Significant disparities were found according to the type of institution and level of care, as indicated by chi-square p-values (institution type: p = 0.002; level of care: p &lt; 0.001), with lower medication availability in public and primary care settings. These findings indicate that access to palliative sedation medications in Ecuador is limited by structural and systemic barriers rather than economic factors alone. Improving access requires system-level interventions, including stronger regulatory frameworks, optimized supply chains, and integration of palliative care across all levels of the health system. Ensuring continuous and equitable access to essential medications is essential to reduce preventable suffering and guarantee dignified end-of-life care.<\/jats:p>","DOI":"10.3390\/ijerph23070901","type":"journal-article","created":{"date-parts":[[2026,7,14]],"date-time":"2026-07-14T10:12:53Z","timestamp":1784023973000},"page":"901","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Availability and Access to Palliative Sedation Medications in Ecuador: A National Survey of Palliative Care Physicians"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4782-523X","authenticated-orcid":false,"given":"Patricia","family":"Bonilla-Sierra","sequence":"first","affiliation":[{"name":"Faculty of Health Sciences, Universidad T\u00e9cnica Particular de Loja (UTPL), Loja 110107, Ecuador"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luz Damaris","family":"Villalta-Tandazo","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, Universidad T\u00e9cnica Particular de Loja (UTPL), Loja 110107, Ecuador"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e883","DOI":"10.1016\/S2214-109X(19)30172-X","article-title":"The Escalating Global Burden of Serious Health-Related Suffering: Projections to 2060 by World Regions, Age Groups, and Health Conditions","volume":"7","author":"Sleeman","year":"2019","journal-title":"Lancet Glob. Health"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e017624","DOI":"10.1136\/bmjgh-2024-017624","article-title":"Confronting Global Inequities in Palliative Care","volume":"10","author":"Peeler","year":"2025","journal-title":"BMJ Glob. Health"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e138","DOI":"10.1017\/S1478951525100461","article-title":"Refractory Symptoms and End of Life Midazolam Use in Cancer Patients, a Single Center Experience","volume":"23","author":"Tolppanen","year":"2025","journal-title":"Palliat. Support. Care"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1177\/02692163231220225","article-title":"Revised European Association for Palliative Care (EAPC) Recommended Framework on Palliative Sedation: An International Delphi Study","volume":"38","author":"Surges","year":"2024","journal-title":"Palliat. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1093\/eurpub\/ckac153","article-title":"Regulations on Palliative Sedation: An International Survey across Eight European Countries","volume":"33","author":"Garralda","year":"2023","journal-title":"Eur. J. Public Health"},{"key":"ref_6","first-page":"e60698","article-title":"Challenges in Palliative Care in Latin America: A Narrative Review","volume":"16","author":"Pergolizzi","year":"2024","journal-title":"Cureus"},{"key":"ref_7","unstructured":"Tripodoro, V.A., Su\u00e1rez, D., B\u00e9jar, A.C., Montero, \u00c1., Ospina, P.R., Saca, J.M.L., Stoltenberg, M., Connor, S., Garralda, E., and Bastos, F. (2025). Palliative Care Atlas of the Americas 2025, Ediciones Universidad de Navarra (EUNSA)."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1089\/jpm.2022.0122","article-title":"Barriers of Access to Opioid Medicines within the Context of Palliative Care in Latin America: The Perception of Health Professionals","volume":"26","author":"Vahos","year":"2023","journal-title":"J. Palliat. Med."},{"key":"ref_9","unstructured":"(2026, June 27). INEC Estimaciones y Proyecciones de Poblaci\u00f3n. Available online: https:\/\/www.ecuadorencifras.gob.ec\/proyecciones-poblacionales\/."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2224859","DOI":"10.1080\/17441692.2023.2224859","article-title":"Access to Health Services for Chronic Disease Care during the COVID-19 Pandemic in Ecuador: A Qualitative Analysis Using a Social Determinants of Health Approach","volume":"18","author":"Rivadeneira","year":"2023","journal-title":"Glob. Public Health"},{"key":"ref_11","first-page":"101399","article-title":"Medicines Availability in Ecuador\u2019s Public System (2015\u20132024): A Policy Design Analysis of Financing, Public Procurement, and Governance","volume":"56","author":"Fontaine","year":"2026","journal-title":"Lancet Reg. Health Am."},{"key":"ref_12","unstructured":"Tripodoro, V.A., B\u00e9jar, A.C., Zapata, C., Su\u00e1rez, D., Montero, \u00c1., Garralda, E., and Centeno, C. (2025). Informe Sobre La Situaci\u00f3n de Los Cuidados Paliativos en Ecuador Seg\u00fan Los Indicadores de La OMS, ATLANTES Global Observatory of Palliative Care."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Rodr\u00edguez Quintana, T., D\u00e1valos-Batallas, V., Vargas-Mart\u00ednez, A.-M., L\u00f3pez, L., Bonilla-Sierra, P., Lomas-Campos, M.-M., and Leon-Larios, F. (2021). Implementation and Knowledge of the Clinical Practice Guide for Palliative Care in the Ecuadorian Primary Care Level. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph182111573"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Hidalgo-Andrade, P., Mascialino, G., Mi\u00f1o, D., Mendoza, M., and Marcillo, A.B. (2021). Knowledge of Palliative Care in Ecuador. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18094840"},{"key":"ref_15","unstructured":"Asamblea Nacional del Ecuador (2025). Ley Org\u00e1nica de Cuidados Paliativos, Tercer Suplemento No. 8."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Javanparast, S., Anaf, J., and Tieman, J. (2022). Equity Consideration in Palliative Care Policies, Programs, and Evaluation: An Analysis of Selected Federal and South Australian Documents. BMC Palliat. Care, 21.","DOI":"10.1186\/s12904-022-00997-2"},{"key":"ref_17","unstructured":"International Narcotics Control Board (2021). Report of the International Narcotics Control Board for 2020, United Nations."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.1016\/S0140-6736(17)32513-8","article-title":"Alleviating the Access Abyss in Palliative Care and Pain Relief\u2014An Imperative of Universal Health Coverage: The Lancet Commission Report","volume":"391","author":"Knaul","year":"2018","journal-title":"Lancet"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1644","DOI":"10.1016\/S0140-6736(16)00161-6","article-title":"Use of and Barriers to Access to Opioid Analgesics: A Worldwide, Regional, and National Study","volume":"387","author":"Berterame","year":"2016","journal-title":"Lancet"},{"key":"ref_20","unstructured":"(2026, February 13). Organizaci\u00f3n Panamericana de la Salud Cuidados Paliativo. Available online: https:\/\/www.paho.org\/es\/temas\/cuidados-paliativos."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Pozsgai, \u00c9., Garralda, E., Busa, C., Payne, S., Hasselaar, J., Mosoiu, D., Surges, S.M., Van der Elst, M., Mercadante, S., and Centeno, C. (2024). Report on Palliative Sedation Medication Usage: A Survey of Palliative Care Experts in Eight European Countries. BMC Palliat. Care, 23.","DOI":"10.1186\/s12904-024-01484-6"},{"key":"ref_22","first-page":"93","article-title":"Sedaci\u00f3n Paliativa","volume":"14","year":"2021","journal-title":"Rev. Cl\u00ednica Med. Fam."},{"key":"ref_23","unstructured":"Ben\u00edtez-Rosario, M.\u00c1., Alonso, A., and Gonz\u00e1lez, T. (2023). Protocolo de Tratamiento en Cuidados Paliativos, Medical Dosplus S.L.. [1st ed.]."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1177\/08258597241256874","article-title":"Continuous Sedation in Palliative Care in Portugal: A Prospective Multicentric Study","volume":"40","author":"Flores","year":"2025","journal-title":"J. Palliat. Care"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"219","DOI":"10.2217\/pmt-2023-0023","article-title":"Access to Cancer Pain Management in Ecuador from Health Workers\u2019 Perspective: A Qualitative Study","volume":"13","author":"Fleckner","year":"2023","journal-title":"Pain Manag."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"4283","DOI":"10.69639\/arandu.v12i1.855","article-title":"Barreras que limitan la atenci\u00f3n paliativa en pacientes de bajo nivel econ\u00f3mico: Una revisi\u00f3n sistem\u00e1tica","volume":"12","author":"Caizaluisa","year":"2025","journal-title":"Arandu UTIC"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"43","DOI":"10.37431\/conectividad.v5i4.213","article-title":"Limitaciones legales en los cuidados paliativos en Ecuador","volume":"5","year":"2024","journal-title":"Conectividad"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1016\/j.jpainsymman.2025.02.469","article-title":"Practice of Palliative Sedation in Patients Followed by a Palliative Home Care Team","volume":"69","author":"Mercadante","year":"2025","journal-title":"J. Pain Symptom Manag."},{"key":"ref_29","first-page":"e1011","article-title":"Disponibilidad y accesibilidad de los opioides para manejo del dolor y cuidado paliativo en Colombia: Estudio tipo encuesta","volume":"50","author":"Moyano","year":"2022","journal-title":"Colomb. J. Anestesiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"766","DOI":"10.1177\/02692163241270915","article-title":"Defining and Developing Primary Palliative Care as an Essential Element of Primary Health Care","volume":"38","author":"Munday","year":"2024","journal-title":"Palliat. Med."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Sluggett, J., Collier, L., Bartholomaeus, J., Inacio, M., Wesselingh, S., and Caughey, G. (2021). National Trends and Policy Impacts on Provision of Home Medicines Reviews and Residential Medication Management Reviews in Older Australians, 2009\u20132019. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18189898"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1398","DOI":"10.1089\/jpm.2018.0387","article-title":"Documento de Posici\u00f3n Oficial Sobre La Promoci\u00f3n Global de Cuidados Paliativos: Recomendaciones Del Grupo Internacional Asesor PAL-LIFE de La Academia Pontificia de La Vida, Ciudad Del Vaticano","volume":"21","author":"Centeno","year":"2018","journal-title":"J. Palliat. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"8","DOI":"10.47606\/ACVEN\/MV0255","article-title":"Barreras en el acceso a los cuidados paliativos: Perspectivas de pacientes y familias","volume":"7","author":"Paccha","year":"2025","journal-title":"M\u00e1s Vita"},{"key":"ref_34","unstructured":"Radbruch, L. (2023). Equity\u2014Can We Achieve Equal Access to Hospice and Palliative Care for All?, European Association for Palliative Care (EAPC)."},{"key":"ref_35","first-page":"2","article-title":"Salud p\u00fablica en Ecuador como factor de desarrollo social: Una revisi\u00f3n bibliogr\u00e1fica","volume":"6","year":"2023","journal-title":"Rev. Cient. Arbitr. Investig. Salud GESTAR"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/j.jpainsymman.2024.10.024","article-title":"Use of Essential Medicines for Pain Relief and Palliative Care: A Global Consensus Process","volume":"69","author":"Pastrana","year":"2025","journal-title":"J. Pain Symptom Manag."},{"key":"ref_37","first-page":"469580221133217","article-title":"Barriers to Access to Palliative Care in Colombia: A Social Mapping Approach Involving Stakeholder Participation","volume":"59","year":"2022","journal-title":"Inq. J. Health Care Organ. Provis. Financ."},{"key":"ref_38","first-page":"1","article-title":"Need, Demand, Supply in Health Care: Working Definitions, and Their Implications for Defining Access","volume":"18","author":"Mason","year":"2023","journal-title":"Health Econ. Policy Law"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1111\/1475-6773.13951","article-title":"Definition and Categorization of Rural and Assessment of Realized Access to Care","volume":"57","author":"Zahnd","year":"2022","journal-title":"Health Serv. Res."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/s43065-024-00104-0","article-title":"Measuring Post-Disaster Accessibility to Essential Goods and Services: Proximity, Availability, Adequacy, and Acceptability Dimensions","volume":"5","author":"Enderami","year":"2024","journal-title":"J. Infrastruct. Preserv. Resil."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"101334","DOI":"10.1016\/j.jth.2022.101334","article-title":"Exploring the Temporal Variations in Accessibility to Health Services for Older Adults: A Case Study in Greater London","volume":"24","author":"Zhang","year":"2022","journal-title":"J. Transp. Health"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e240209","DOI":"10.1001\/jamanetworkopen.2024.0209","article-title":"Accessibility of Opioid Treatment Programs Based on Conventional vs Perceived Travel Time Measures","volume":"7","author":"Kim","year":"2024","journal-title":"JAMA Netw. Open"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e69496","DOI":"10.2196\/69496","article-title":"Effects of Perceived Scarcity on Mental Health, Time and Risk Preferences, and Decision-Making During and After COVID-19 Lockdown: Quasi-Natural Experimental Study","volume":"11","author":"Zhu","year":"2025","journal-title":"JMIR Public Health Surveill."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"34655","DOI":"10.1038\/s41598-025-19736-7","article-title":"Effects of Scarcity on Women\u2019s Cognitive Ability to Manage Mental Health and Substance Use after Prison Release","volume":"15","author":"Johnson","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e09716","DOI":"10.1016\/j.heliyon.2022.e09716","article-title":"Factors Influencing Poor Medication Adherence amongst Patients with Chronic Disease in Low-and-Middle-Income Countries: A Systematic Scoping Review","volume":"8","author":"Chauke","year":"2022","journal-title":"Heliyon"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1016\/j.jpainsymman.2025.08.027","article-title":"Global Consensus-Based Essential and Expanded Packages for Palliative Care and Pain Relief for Adults and Children: A Delphi Study","volume":"70","author":"Pastrana","year":"2025","journal-title":"J. Pain Symptom Manag."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"692","DOI":"10.1093\/heapol\/czs108","article-title":"Access to Medicines from a Health System Perspective","volume":"28","author":"Bigdeli","year":"2013","journal-title":"Health Policy Plan."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"101867","DOI":"10.1016\/j.ejon.2020.101867","article-title":"Limited Access to Care for Persons with Breast Cancer in Africa: A Systematic Review","volume":"50","author":"Salisu","year":"2021","journal-title":"Eur. J. Oncol. Nurs."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/s12942-019-0172-1","article-title":"Urban and Rural Differences in Geographical Accessibility to Inpatient Palliative and End-of-Life (PEoLC) Facilities and Place of Death: A National Population-Based Study in England, UK","volume":"18","author":"Chukwusa","year":"2019","journal-title":"Int. J. Health Geogr."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Lin, H., Huang, Y., and Wang, Y. (2025). Facilitators and Barriers to Palliative Care Delivery in Rural China: A Qualitative Study of the Perceptions and Experiences of Rural Healthcare Professionals. BMC Palliat. Care, 24.","DOI":"10.1186\/s12904-025-01848-6"},{"key":"ref_51","first-page":"8","article-title":"Barreras y facilitadores para el acceso a cuidados paliativos en M\u00e9xico. Perspectiva de los trabajadores de la salud","volume":"48","year":"2025","journal-title":"Rev. Mex. Anestesiol."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Salikhanov, I., Katapodi, M.C., Kunirova, G., and Crape, B.L. (2023). Improving Palliative Care Outcomes in Remote and Rural Areas of LMICs through Family Caregivers: Lessons from Kazakhstan. Front. Public Health, 11.","DOI":"10.3389\/fpubh.2023.1186107"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Isangula, K.G. (2022). The Dangers of Being Old in Rural Tanzania: A Call for Interventions for Strengthening Palliative Care in Low-Income Communities. Front. Aging, 3.","DOI":"10.3389\/fragi.2022.888396"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"e1750","DOI":"10.1016\/S2214-109X(21)00408-3","article-title":"Palliative Care and Catastrophic Costs in Malawi after a Diagnosis of Advanced Cancer: A Prospective Cohort Study","volume":"9","author":"Bates","year":"2021","journal-title":"Lancet Glob. Health"},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Nwagbara, U.I., Ginindza, T.G., and Hlongwana, K.W. (2020). Lung Cancer Awareness and Palliative Care Interventions Implemented in Low-and Middle-Income Countries: A Scoping Review. BMC Public Health, 20.","DOI":"10.1186\/s12889-020-09561-0"},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Aregay, A., O\u2019Connor, M., Stow, J., Ayers, N., and Lee, S. (2023). Palliative Care in Ethiopia\u2019s Rural and Regional Health Care Settings: A Qualitative Study of Enabling Factors and Implementation Challenges. BMC Palliat. Care, 22.","DOI":"10.1186\/s12904-023-01283-5"},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Davalos-Batallas, V., Vargas-Mart\u00ednez, A.-M., Bonilla-Sierra, P., Leon-Larios, F., Lomas-Campos, M.-M., Vaca-Gallegos, S.-L., and De Diego-Cordero, R. (2020). Compassionate Engagement and Action in the Education for Health Care Professions: A Cross-Sectional Study at an Ecuadorian University. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17155425"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/7\/901\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T04:39:02Z","timestamp":1784176742000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/7\/901"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,14]]},"references-count":57,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["ijerph23070901"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23070901","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,14]]}}}