Background <p>Mainland China’s end-of-life care system remained underdeveloped marked by underutilization of hospice care services. Physicians-initiated end-of-life communication is likely to result in immediate enrollment in hospice care. However, there is a lack of empirical evidence on how physicians in China undertake end-of-life communication in advanced cancer. This qualitative study aimed to explore physicians’ experiences on discussing end-of-life matters and facilitating hospice care transition within families of patients with advanced cancer.</p> Methods <p>A descriptive qualitative study was conducted. Using the purpose sampling, physicians were recruited from 8 hospitals in Shanghai, China. Physicians were eligible if they had experiences in treating patients with advanced cancer and were ineligible if they did not directly participate in end-of-life discussions with patients/families. Semi-structured interviews were conducted from August 2022 to February 2023. Qualitative data were analyzed by content analysis approach.</p> Results <p>Among 18 physicians, three major themes emerged regarding barriers to effective end-of-life communication at physician, family, and system levels: (1) Physician avoidance in disclosing terminal prognosis: Prognostic uncertainty, Skill deficiency, Emotional burden, Concerns about therapeutic hope, and Systematic avoidance; (2) Family priority in end-of-life decision-making: Complex family dynamics, Cultural stigma, and Unstructured family coping; (3) Systematic fragmentation in hospice care integration: Limited awareness and understanding, Ineffective referral mechanisms, and Insufficient leadership support.</p> Conclusion <p>End-of-life communication in Shanghai is hindered by physician challenges, cultural norms favoring family decisions, and systemic gaps. Targeted training for non-hospice physicians, balanced approaches to patient autonomy and family roles, and strengthened referral/reimbursement policies are needed to improve hospice transitions.</p>