Palliative and end-of-life (EOL) care are central to oncology social work, yet structural racism hinders equitable care for patients of color. This impacts referrals, pain management, hospice use, and treatment aggressiveness. This article explores how racism functions as a structural barrier and offers evidence-based strategies for dismantling inequities.
What Does Structural Racism Look Like in Oncology and Palliative Care?
Multiple studies document that racial/ethnic minorities, particularly Black, Hispanic, and Indigenous patients, experience significant disparities in access to palliative care services, including late referrals, reduced hospice utilization, and lower rates of advance care planning (Elk et al., 2020). A 2024 scoping review confirmed that racial discrimination is among the primary contributors to inequitable access to palliative and EOL care worldwide (Sítima et al., 2024).
An antiracism framework explains how inequities are perpetuated, not only through interpersonal bias but also through segregation, resource allocation, and institutional policies (Umaretiya et al., 2022). Scholars argue that without naming racism explicitly, disparities in symptom control, pain management, and hospice enrollment remain unaddressed (Algu et al., 2024; Johnson, 2013; Rhodes et al., 2022). As Leandro et al. (2024) stress, Critical Race Theory offers a powerful lens to validate the prevalence of structural racism and to recognize the voices of marginalized patients.
Evidence shows consistent undertreatment of pain for racial minorities. In cancer and palliative settings specifically, Black, Hispanic, and Indigenous patients receive less adequate analgesia than White patients even when pain intensity is equivalent (Anderson et al., 2009). Contributing factors include provider stereotyping (e.g., believing patients of color have higher pain tolerance), fear of opioid misuse in marginalized communities, and inadequate clinical education on recognizing pain in non-White patients.
Minoritized patients are more likely to experience aggressive EOL cancer care in hospitals, versus supportive care in hospice (Dierfeldt et al., 2021; Namireddy et al., 2017; Nikzad et al., 2024; Jawed & Comer, 2024). This trend is often misaligned with patient values and may worsen family distress. Factors include delayed prognostic communication, mistrust, and clinician assumptions that aggressive treatment indicates higher-quality care for patients of color.
How Can Oncology Social Workers Address This?
Research indicates that decades of structural racism result in a power differential where patients feel that their cultural values are minimized, therefore mistrusting medical teams. Oncology social workers (OSWs) can mobilize care to shift from a mindset that “a family is mistrusting” toward an approach that earns a family’s trust (Daubman et al, 2025). First, it is important to assess language concordance and utilize interpreters when needed. Second, providers can ask patients if they would like a family member (or members) present during visits, recognizing that their support system may not be limited to the nuclear family. OSWs can also apply a narrative practice to explore sources of strength and values to learn families’ wishes at EOL (Ewy, 2025).
OSWs are uniquely positioned to advocate for equity through direct patient support, team collaboration, community outreach, and policy advocacy.
Strategic Goals & Action Steps:
- Anchor your caseloads in equity
Monitor race and ethnicity data in conjunction with pain management practices and palliative and hospice referral and utilization patterns to assess and address disparities in equitable palliative care.
- Push for standard audits
Advocate for equity reviews in palliative service utilization by race/ethnicity.
- Partner for education
Training with a racial equity lens empowers clinicians to recognize implicit bias in pain assessments and EOL planning (Nikzad et al, 2024). Provide training that promotes an antiracist and culturally sensitive practice. - Advocate clinically
Flag any patients delayed in pain control or palliative referral to providers and teams. Collaborate with teams to identify hospice options and equitable pain protocols that align with families’ cultural values. - Mobilize community engagement
Partner with community leaders to help build trust, create a shared language, and learn about patients’ barriers to accessible care. - Inform institutional policy decisions
Collaborate with administrators to embed equity metrics in referral/treatment metrics, track patient experience, and advocate for funding aimed at more equitable care. Advocate to legislators for reimbursement models that incentivize equity in palliative and EOL care.
Conclusion
Equitable cancer care demands that OSWs confront structural racism head-on. By leveraging patient insight, evidence-based advocacy, cross-sector collaboration, and community engagement, OSWs can drive tangible change. To operate at the top of our license, we must unmask and dismantle the systems that obstruct equitable care. Only then can we fulfill our ethical and professional responsibility to ensure dignified, culturally attuned EOL-care for every patient, regardless of their race or ethnicity.
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