An aging population in the Global North is associated with an increased prevalence of chronic diseases that will ultimately contribute to their death [1]. Due to the population’s increasing life span and resultant aging, it is essential to consider how effectively health care systems, especially palliative care services, respond to patients with chronic illnesses [2-4].

The World Health Organization states that palliative care aims to improve quality of life for those patients living with life-limiting diseases, by reducing pain and proactively managing and treating symptoms associated with their disease processes [5]. Historically, palliative care was limited to patients with cancer [6] and was described as care for individuals with a life-threatening disease [1]. With an aging population, palliative care systems evolved and are no longer limited to oncological or life-threatening diseases [7]. Palliative care currently includes patients with multiple morbidities [8] and individuals in need of quality-of-life–focused care due to frailty, advanced age [9], or disabling conditions [10,11]. Thus, palliative care services are justified based on individual patients’ needs rather than specific diagnostic codes. The target patient for palliative care is an individual with a “palliative cluster” of symptoms or factors, including a life-threatening or life-limiting, chronic, or terminal condition, necessitating multidimensional needs.

Past health care models focused on disease-directed care in which the recognition of the terminal nature of a patient’s condition occurs late, resulting in delayed hospice and end-of-life care [12]. However, the changes in managing chronic and life-limiting conditions to enhance the quality of life have resulted in a new model in which palliative care service is initiated at the time of diagnosis. In this model, the focus shifts toward symptom management rather than cure, and a transition to hospice care when a patient’s life expectancy is 6 months or less; during this time, the primary purpose of care is maximizing the patient’s quality of life [13].

A challenge for health care systems is how to provide integrated care for patients with increasingly complex chronic conditions [14]. Integrated care is a combination of multiple disciplines at different levels of care, focused on improving the quality of health care services [3]. It also facilitates connections and cooperation between funding sources, organizations, and clinical services, with the purpose of offering efficient and high-quality care. As a result, integrated palliative care (IPC) provides coordinated services of care [15].

For patients in Southern Minnesota, access to palliative and hospice care services can differ based on the type of insurance the patient has. For example, the national insurance for the older population, Medicare Part A, covers inpatient hospital stays, short-term stays at nursing facilities, and home care [16]. Reimbursement for palliative care is not standardized as it is for hospice care [17,18]. In contrast, the Spanish health care system provides universal access to all residents. Instituto Nacional de la Salud (the government’s public health organization) provides health care services to all communities in the country [19], and these services include palliative care for patients with chronic illnesses and terminal diseases.

In both countries, with aging populations, the main challenge for health care systems is to provide integrated care for patients with increasingly complex chronic conditions [14]. IPC is an approach to improve services for patients with chronic illnesses and terminal diseases.

The COVID-19 pandemic can be a distinguishing marker between the period considered “normal” and the pandemic era, which brought many changes to society and health care delivery [20,21]. The pandemic also impacted health care providers who were faced with ethical dilemmas such as determining resource allocation and the prioritization of patient care [22], as well as end-of-life care decisions [23]. Additional ethical concerns encountered by palliative care providers were autonomy in the patient and family decision-making processes [24], the discontinuation of treatments and therapies [23], and communicating with families and patients in a society that required social distancing and limiting factors such as face masks [22].

When taking care of patients with chronic conditions, integrative and complementary care is often experienced as beneficial [25]. The integrative health approach provides patients in need of palliative care with nonpharmacological strategies to manage pain and other nausea, depression, and anxiety symptoms [26]. Examples include aromatherapy, acupuncture, massage, homeopathic practices, and cultural practices [27]. In addition, palliative care in conjunction with complementary care can offer patients comfort during this phase of life [26].

One way to see how care is being delivered to people with complex chronic conditions is through the analysis of reality; therefore, this study aims to first describe the Southern Minnesota palliative care system in the United States and then compare it to the palliative care system in Spain. To be able to carry out the general objective of the study, the following specific objectives will be developed:

This study was initiated in August 2021, when the research team met and established its organization and the project goals. The Institutional Review Board application was submitted in April 2022, and further project planning has been undertaken during spring 2022. Results are pending ethical review and data collection, which will take place in spring and summer 2022, followed by data analysis in fall 2022. Dissemination of results and development of various study reports will be anticipated after data analysis is completed in 2023.

Anticipated results for this study are expected to be consistent with those found in the foundational study completed in Osona, Spain. In that study, major themes included a need for improved collaboration, continuity of care, and sustainable funding. Ethical dilemmas identified included the decision to continue nonbeneficial treatment, life-sustaining and life-prolonging therapies, and palliative sedation.

Anticipated outcomes for this study on IPC in Southern Minnesota will include suggestions to enhance patient care, improve organizational structures, and change policy, as indicated by the study findings. Understanding ethical dilemmas encountered by palliative care service providers and the complementary therapies used will identify new patient-centered care strategies.

There is currently an increased interest in IPC, an optimal approach to provide care for patients with chronic conditions and terminal illnesses [36]. However, the literature indicates that there is no agreement on the definition of IPC’s essential components, and thus, there is the need to define its integral elements [37,38]. Consequently, IPC implementation varies across settings, and understanding its application is complicated. Describing and comparing different IPC systems such as the ones in Southern Minnesota and Osona offers greater insights into the implementation of IPC systems in 2 different countries.

The COVID-19 pandemic offers an opportunity for reflection and a new interpretation of health issues, especially in the ethical domain [20], such as resource provision and care prioritization [22]. In addition, the pandemic has exposed unique health-related ethical dilemmas [39], resulting in more complex decision-making processes [23]. This study will reveal the ethical dilemmas Southern Minnesota palliative care providers have encountered during the COVID-19 pandemic and compare them to those confronted by health care professionals in Osona’s palliative care system.

In summary, further research on the implementation and evaluation of IPC systems is needed. Describing the essential elements, ethical dilemmas, and complementary therapies of the Southern Minnesota palliative care system will bring a greater understanding of their implementation within the IPC systems. Additionally, comparing 2 IPC systems that are similar in population and rural setting will provide a richer understanding of the impact of IPC systems on people with chronic illnesses. Study findings will contribute to enhanced patient care, organizational improvements, policy change, and a better understanding of the impact of different health care system models.