The present study showed that: (i) the most appropriate structure of the QCQ-PC for use in patients with DM eligible for palliative care is with a single domain, called “quality of care”; and (ii) the number of items remained the same, i.e., 12 items. In contrast to the version by Barros et al. [20], the only Brazilian validation of the instrument for cancer patients, which has two domains: (i) communication with healthcare professionals; and (ii) care and assistance provided by healthcare professionals. We used the parallel analysis implemented in EFA to identify the domains of the QCQ-PC since it is considered a robust method by previous studies [30, 31] Parallel analysis compares real data to simulated data to identify dimensionality [31]. In addition, we used several fit indices to investigate the adequacy of the unidimensional structure.

Both versions are short forms, with the version in the present study featuring a simpler structure and score calculation, facilitating its use and interpretation, and reducing the chances of filling errors, which are common in longer instruments [20]. The population of the Brazilian version consisted of individuals with cancer receiving palliative care in a hospital setting [20], while the present sample consists of individuals diagnosed with DM receiving primary, secondary and tertiary care.

The original version has four domains: (i) adequate communication with healthcare professionals; (ii) discussion about the value of life and care goals; (iii) support and guidance for comprehensive care needs; and (iv) accessibility and sustainability of care. Moreover, it is emphasized that the instrument, besides being applied to a different population, is situated in a different cultural context [19]. The care received by most of our sample, in primary and secondary care services, resembles palliative care in some aspects, such as continuous and comprehensive follow-up, focus on improving quality of life and preventing complications, timely identification of health issues, and engagement of family members or caregivers.

In primary care policy, one of the principles is the centrality of care on the individual, built with their participation according to their needs, with the aim of achieving well-being, considering the social and family context in which they are inserted [32]. Similarly, in palliative care, the focus is on the interests and autonomy of the individuals and their support network, aiming to provide the highest possible well-being. Thus, efforts are made for timely diagnosis of health issues and avoiding unnecessary interventions [33].

As an instrument designed to assess the quality of palliative care, there is the FAMCARE scale, created to evaluate the quality of care offered to individuals with terminal cancer and their families. The entire sample of the validation process consisted of individuals and families receiving palliative care, thus it can also be used to assess the quality of this care approach [34].

Similarly to the version of the QCQ-PC identified in the present study, the FAMCARE scale is a short instrument containing 20 items with four response options: very satisfied, satisfied, dissatisfied, and very dissatisfied [34]. It is observed that there are no validated instruments in Brazil aimed at evaluating the quality of palliative care, especially from the users’ perspective. There are, however, instruments that assess the quality of care in other healthcare settings, also cross-culturally validated, such as the Patient Satisfaction with Mental Health Services Scale (SATIS-BR) [35].

The SATIS-BR was validated for Portuguese, aiming to assess the user’s perception of mental health services, and is composed of three domains: relationships with the team, the way users are treated by professionals, and satisfaction with the service’s physical conditions, consisting of 15 items [35]. Similar to the QCQ-PC version in the present study, the scale allows for an understanding of aspects of the service, as perceived by users that need improvement. Therefore, the present version of the QCQ-PC provides greater ease in evaluating the quality of services offered to individuals with DM eligible for palliative care, and due to its simplified structure, any entity involved in care can carry out its application.

This study has limitations that should be mentioned, such as not having a defined clinical approach to palliative care. However, we know that the nature of DM is complex, complicating the determination of when a patient can benefit from palliative care or when they are approaching the end of life, making the prognosis challenging. Furthermore, the culture of palliative care is deeply rooted in cancer patients. Therefore, physicians and other health professionals should learn more about the current indications and eligibility criteria for palliative care for chronic and progressive diseases.