As Scotland faces a growing end-of-life care crisis, too many patients are left suffering, isolated, and without the support they desperately need if they wish to die at home.

The demand for home-based end-of-life care is increasing, with projections showing that two-thirds of people in Scotland may eventually die outside hospitals.

This is particularly relevant given the prevalence of geographic disparities that create inconsistent access to essential palliative care resources, leaving many people to face their final moments under suboptimal conditions. As such, there is a need for a seismic and systemic shift in how Scotland addresses end-of-life care delivery in rural settings across Scotland.

While there are many symptoms that need managing at end-of-life, pain is the single one that most people fear. To die in pain is most people’s concern, yet many patients suffer needlessly due to gaps in community healthcare support.

As such, it is important to note that effective pain/symptom management does not only improve patients’ quality of life, and alleviates their psychological distress, it leaves loved ones with a more positive experience of death and dying today.

Yet, families across the country continue to struggle to access necessary medications at critical times – most often out of hours when GP practices are closed. This is not what the public expect when facing death and underscores the need for consistent, around-the-clock access to medication and symptom management. This demands active research into models that ensure seamless, continuous pain/symptom management irrespective of location, or time of day.

In a country as developed as Scotland, it is unacceptable that a patient's comfort in their final days depends on their postcode. Specifically, wishing to die at home in rural settings brings with it a set of circumstances that are challenging to manage.

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Dr Sarah Holmes, medical palliative specialist at Marie Curie, has highlighted that some individuals are so concerned about the lack of end-of-life care provision where they live, that they move house to ensure good care is accessible.

We also know that those who live in more rural/remote rural settings can face fuel poverty for example, meaning that accessing treatment is even more challenging and that poverty and deprivation are associated with poorer experiences at end-of-life, as is the case for many of Scotland’s rural locations. This is not acceptable in the UK in the 21st century.

Lack of access to care outside regular hours is a significant issue, particularly in Scotland’s rural areas. What is required is not only the integration of end-of-life care services within the NHS, as it is often treated as an “add-on” service supported by charitable funding. But also, an approach that is innovative to ensure that out of hours rural needs are met without the delays that are currently experienced.

Waiting for 2 or 3 hours for pain relief is not an effective, nor compassionate service for those dying and their loved ones watching them suffer. The current, often limited approach can lead to emergency department attendance and admission to hospital. Both of which are not equipped to support those dying. Transforming current rural services through strategic investment would ensure that more people receive dignified support during their last days, regardless of their circumstances.

While this talk about improving end-of-life care delivery, particularly in rural settings, is important, we must be mindful that the key issues that require addressing are the need for 24/7 responses to pain/symptom management needs, which are primarily constrained by funding, given the current NHS climate, and enticing the appropriately qualified workforce who can think outside the box to support this delivery.

Out of hours cover is often poor even within urban areas, let alone further afield, resulting in delays in receiving appropriate support and treatment. This can force families to rely on emergency services to deliver timely symptom management, services that are already overstretched.

This is a call to action for policymakers to make dignified, accessible end-of-life care a priority for everyone — whether they live in bustling cities or remote rural areas. End-of-life needs are universal, and Scotland can’t afford to lag in providing compassionate care across all communities. More than just improving existing services, the time has come for innovative, 21st-century care models that meet modern needs rather than settling for outdated approaches or citing limited funding and staffing as obstacles.

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Despite promises in Scotland’s 2015 Strategic Framework for Action on Palliative and End-of-Life Care, which aimed to ensure “equitable, accessible” services, rural areas still face serious gaps. Challenges like limited resources, long distances to healthcare, and a shortage of healthcare workers in remote regions have made these promises hard to fulfil.

Research shows that home-based palliative care not only aligns with patients’ preferences but also saves significant costs by reducing hospital admissions and emergency visits. Investing in accessible, community-based end-of-life care would relieve pressure on hospitals while ensuring people experience compassionate, cost-effective care in their final days.

The deficiencies within Scotland’s end-of-life care system are not unsurprising. What is surprising, however, is that no one is exploring solutions beyond the standard hours of care to better prioritise the comfort and safety of patients and their families.

Through dedicated research, policy change, and a commitment to standardised care, Scotland can ensure that all individuals receive compassionate, quality end-of-life support. Partnerships between universities, healthcare institutions, and charitable organisations can drive data-driven improvements in NHS end-of-life care, ensuring that a 'good death' is accessible to all.

As a 'good death' should be the right of every individual, not a privilege determined by geography. It's time to close the gaps in care and guarantee this for all at the end of life.

Dr Sandra Lucas is a Senior Lecturer in Adult Nursing at the University of the West of Scotland, leveraging her extensive academic and clinical background to strengthen nursing education, particularly in palliative care. Formerly a Senior Palliative Care Clinical Educator in Australia, she led impactful programs in Victoria. Her research focuses on social prescribing in palliative care, cannabinoid therapy, and end-of-life policy, with recent contributions to Scotland’s Assisted Dying Bill underscoring her commitment to compassionate, evidence-based care practices.

Dr Rhona Winnington is a Senior Lecturer in Adult Nursing at the University of the West of Scotland, is a registered nurse and sociologist, with a particular interest in patient choice and accessibility to high quality end-of-life care within the context of institutional hierarchies. Dr Winnington has a clinical background in community palliative care nursing and is invested in using her knowledge and experience to improve end-of-life care. Her research focuses on supporting end-of-life care provision in rural settings, end-of-life policy, with a recent contribution to Scotland’s Assisted Dying Bill.