Background The Liverpool Care Pathway for the Dying Patient was introduced into parts of New Zealand in 2005. Unique ‘cultural goals’ were added, in recognition of the importance of the provision of culturally appropriate care.

Aims To assess the use of the cultural goals in practice and to investigate stakeholders' experiences and perspectives of how the cultural goals influence culturally appropriate end-of-life care.

Methods A mixed method study including, in this phase, two clinical audits, semi-structured interviews with 20 stakeholders, and a focus group with 20 Maori clinical staff. Interview data were analysed thematically, and audit data were analysed using descriptive statistics and content analysis.

Results Participants identified many factors that acted as constraints or enablers in the provision of culturally appropriate care. These factors operated at multiple levels, including at the individual level of clinicians and carers, at the organisational level, the health sector level, and across cultural groups within our society. Constraints included staff discomfort in talking about cultural needs and providing cultural care, the increasingly multicultural health workforce with divergent understandings of cultural needs during the end-of-life phase, differing palliative care service contracts, and structural features of organisations that impeded staff meeting patients' and families' cultural needs. Enablers, such as in-service education programmes, addressed some, but not all of these constraints. Enablers operated mostly at the level of individual clinicians and services. Ongoing support and funding for development of these initiatives was relatively unstable.

Conclusions Culturally appropriate care is a core priority to reduce health inequities related to access to palliative care. However the increasing complexity of the cultural landscapes of patients and families, clinicians and carers, services, the health sector and society mean that a sustainable, multilevel approach is required to address cultural needs.