An older person with advanced heart failure may be admitted repeatedly because of breathlessness. Someone living with dementia may gradually lose mobility, communication and the ability to eat independently. A person with metastatic cancer may still be receiving active treatment while pain, fatigue and anxiety increasingly shape everyday life. In each case, the question is no longer only what medicine can treat. It is also how the person can live as comfortably, safely and meaningfully as possible while serious illness progresses.
That question is becoming increasingly important for Saudi Arabia. As explored across the Saudi Arabia Aging, Long-Term Care & Community Support Knowledge Hub, demographic aging will increase the number of people living for longer with chronic illness, frailty, dementia and multiple conditions. Palliative care is therefore part of the Kingdom’s future aging infrastructure, not a specialist concern confined to cancer services or the final days of life.
Saudi health policy already provides important foundations. The Saudi Model of Care recognizes palliative care as one of its care systems, while Ministry of Health guidance describes palliative medicine as multidisciplinary support intended to relieve physical and psychological suffering, improve quality of life, preserve dignity and support families. Services may be delivered through hospitals, outpatient clinics, home healthcare, palliative-care units, hospices and virtual clinics.
The strategic challenge is turning those elements into a pathway that people can enter early enough, access equitably and move through without losing continuity when the setting of care changes.
Palliative care is broader than care in the final days
Palliative care is sometimes understood primarily as what happens when curative treatment stops. That interpretation is too narrow for an aging population.
A person can benefit from palliative care while continuing treatment for cancer, heart failure, chronic lung disease, renal failure or another serious condition. The purpose is not necessarily to replace disease-directed treatment. It is to address pain, breathlessness, fatigue, nausea, anxiety, psychological distress and other burdens while helping the person and family understand what matters as illness changes.
Saudi Ministry of Health guidance reflects this broader approach, including people with cancer, advanced neurological disorders, dementia, Parkinson’s disease, stroke, kidney or liver failure, chronic heart disease and advanced lung conditions among those who may receive palliative care.
This distinction will become more important as longevity increases. Many older people will not experience a single, clearly defined transition from treatment to dying. Their health may decline through recurrent episodes of deterioration and partial recovery. Heart failure, dementia, frailty and multimorbidity can follow uncertain trajectories in which it is difficult to predict exactly when a person has entered the final stage of life.
Good end-of-life and palliative interfaces therefore depend less on finding a perfect prognostic moment and more on recognizing increasing need.
Saudi Arabia has an important service base to build from
Palliative medicine in Saudi Arabia has developed through specialist services, particularly within referral hospitals, alongside expanding home, outpatient and virtual provision. Current Ministry of Health information describes 21 palliative-care units distributed across health clusters, alongside provision in selected primary healthcare centers and private hospitals.
The significance lies not simply in the number of units. A geographically distributed specialist base creates the potential for palliative expertise to support wider health-cluster pathways rather than remain concentrated within individual tertiary institutions.
The Health Sector Transformation Program strengthens that opportunity because its broader direction emphasizes access, quality, prevention, digital transformation and keeping people healthy inside and outside hospital walls. Palliative care fits this direction even though its purpose is different from prevention. It asks how the system can support people effectively when serious illness can no longer be understood only through cure or recovery.
For the next phase of development, several dimensions matter together:
- identifying palliative need earlier;
- extending specialist expertise beyond hospital units;
- supporting care at home where appropriate and desired;
- strengthening symptom management and medicines access;
- supporting families without assuming they can provide unlimited unpaid care;
- maintaining continuity when people move between services.
These are operational questions as much as clinical ones.
Earlier identification changes what palliative care can achieve
The timing of referral shapes the value of palliative care. If a specialist team becomes involved only during the final hours or days, it may still improve comfort, but much of the wider opportunity has been lost.
Earlier involvement allows time to understand symptoms, establish relationships, discuss goals, support family members and anticipate likely changes. It can also reduce the repeated cycle in which every deterioration automatically leads to emergency attendance and hospitalization because no alternative response has been established.
This does not mean applying rigid prognostic thresholds. For many chronic conditions, prognosis is uncertain. A more useful operational approach is to identify patterns suggesting increasing palliative need: repeated admissions, progressive functional decline, worsening symptom burden, increasing dependence, significant frailty or a growing mismatch between treatment burden and likely benefit.
The central question becomes: would this person benefit from an additional layer of supportive care alongside existing treatment?
That approach is particularly relevant to older people with multimorbidity. Their needs may not fit a single disease pathway, and the point at which quality of life begins to outweigh further treatment intensity may differ substantially between individuals.
Scenario: repeated heart-failure admissions reveal an unmet palliative need
A 79-year-old man in Riyadh has advanced heart failure, diabetes and chronic kidney disease. During one year he is admitted several times with breathlessness and fluid overload. Each admission is clinically managed appropriately. Medicines are adjusted, symptoms improve and he returns home.
Yet the pattern continues. His daughter reports that he is exhausted after each hospitalization and increasingly frightened when his breathing worsens. He wants treatment that may help him, but he also wants to spend less time in hospital.
A palliative-care review does not mean withdrawing cardiology input. Instead, the team assesses symptom burden, explains what changes the family should expect and works with the treating clinicians to clarify which problems can be managed at home and which require hospital escalation.
The plan addresses breathlessness, medication, anxiety and emergency contacts. The family understands what to do when symptoms worsen. Home-based follow-up is arranged where available, while cardiology remains involved in disease-specific treatment.
The governance significance appears when the cluster examines repeated patterns rather than isolated admissions. If people with advanced heart failure are repeatedly admitted near the end of life without access to supportive planning, the issue may indicate a pathway gap rather than a series of unavoidable individual events.
This is where palliative care intersects with avoidable utilization governance: not by treating hospitalization as inherently undesirable, but by asking whether every admission is consistent with the person’s needs and available alternatives.
Choice of setting needs real service capacity behind it
Saudi Ministry of Health guidance identifies several possible settings for palliative care, including hospital-based services, outpatient clinics, home healthcare, palliative units, hospices and virtual clinics. It also describes care planning with the patient and family and options that may include returning home with medication and home palliative follow-up, receiving follow-up through primary healthcare or using hospice provision.
This reflects an important person-centered principle: where someone receives care matters.
But choice is meaningful only when practical capacity exists. A person may prefer home care, yet that preference cannot safely be honored if symptoms cannot be controlled, medicines cannot be accessed promptly or relatives are expected to provide complex care without adequate support.
Similarly, hospital care should not automatically be treated as a failure. Some people need inpatient symptom control, specialist interventions or levels of support that cannot safely be delivered at home.
The stronger model offers a continuum rather than an ideological preference for one location. The setting should follow need, safety, available support and the person’s wishes as far as these can reasonably be reconciled.
Home-based palliative care can connect treatment with everyday life
Home healthcare is particularly important because the home reveals needs that may be invisible in hospital. Clinicians can see whether medicines are manageable, whether equipment is suitable, whether mobility is declining and whether family members understand the plan.
For older people, this can help avoid unnecessary travel when specialist assessment can safely be provided at home or remotely. It can also make care feel less institutional at a time when familiarity, privacy and family presence may matter deeply.
The wider relevance connects with home- and community-based services: strong community care is not simply hospital care delivered at another address. It requires its own workforce, logistics, escalation routes and governance.
Organizations examining whether community services have the operational maturity to manage changing risk can use the Positive Risk Enablement Planner to structure decisions around independence, preference and proportionate risk. It is not a Saudi clinical or legal instrument, but its underlying approach is relevant where leaders need to balance safety with the person’s preferred place and pattern of care.
Families are partners in care, but should not become the hidden infrastructure
Family involvement is central to care in Saudi Arabia, including during serious illness and the end of life. Relatives often provide emotional support, help with decision-making, organize appointments, collect medication and assist with personal care.
The importance of family is reinforced by Saudi social expectations and by the legal framework for older persons, which recognizes family responsibilities alongside state protections and services. Yet strong palliative care should not translate that cultural value into an assumption that families can absorb any level of care indefinitely.
The burden can become substantial. A relative may be awake repeatedly overnight managing breathlessness, pain or confusion while also trying to maintain employment and other family responsibilities. Women may carry a disproportionate share of everyday care. Families may also feel unable to say that they are struggling because caring for an older relative is understood as a moral duty.
Professionals therefore need to assess caregiver capacity explicitly. Questions should include who is actually providing care, what they understand, whether they can manage medication and equipment, what happens overnight and whether respite or additional professional input is needed.
This is the important distinction within family care and caregiver burden. Respecting family roles means supporting them, not using them as a substitute for service capacity.
Scenario: honoring a preference for home without exhausting the family
An older woman with advanced cancer wishes to remain in her family home in Jeddah for as long as possible. Her two adult daughters strongly support this preference and initially say that they can manage everything themselves.
As symptoms progress, the reality changes. Their mother needs increasing assistance with movement, toileting and medication. One daughter begins sleeping beside her because pain frequently worsens overnight. The other reduces her working hours to help during the day.
A weak interpretation of family-centered care would treat their commitment as evidence that formal support is unnecessary. A stronger palliative assessment recognizes that family willingness and family capacity are different questions.
The care plan therefore includes regular clinical review, anticipatory symptom management, clear contact routes and training on medicines and signs of deterioration. Equipment and practical support are considered according to available services. The family is encouraged to report exhaustion or anxiety without feeling that doing so means abandoning their mother.
Her preference to remain at home continues to guide care, but it is not treated as an absolute instruction regardless of circumstances. If symptoms become unmanageable or the family can no longer provide safe support, inpatient palliative care remains an available option.
The outcome is not simply whether death eventually occurs at home. Quality also lies in whether the person remains comfortable, the family understands what is happening and care decisions remain responsive as circumstances change.
Multidisciplinary care is essential because suffering is multidimensional
Palliative medicine cannot be reduced to pain control. Physical symptoms matter enormously, but serious illness may also create psychological distress, family conflict, nutritional problems, loss of mobility, uncertainty about treatment and anxiety about what comes next.
Current Saudi Ministry of Health guidance describes multidisciplinary teams that may involve physicians, nurses, physiotherapists, occupational therapists, health educators, social workers, clinical nutritionists, pharmacists, psychologists and family members.
This breadth is important. A patient with advanced neurological disease may need help with swallowing, mobility and communication as much as pain relief. Someone with advanced cancer may need psychological support alongside symptom management. A family caring for a person with dementia may need practical advice on agitation and eating rather than another diagnostic investigation.
Multidisciplinary working also prevents one profession from carrying questions it is not equipped to resolve. Good palliative care depends upon clear role boundaries, shared plans and communication between teams.
The workforce challenge is therefore not only expanding the number of palliative specialists. It is building basic palliative competence across wider services while preserving specialist capacity for complex symptoms and difficult decision-making.
Primary healthcare can help move palliative care upstream
If palliative care remains concentrated in specialist hospitals, access will tend to occur late. Primary healthcare has an important role because it often provides the longest-running relationship with people living with chronic disease.
Primary-care teams can recognize progressive deterioration, review symptom burden and identify when specialist palliative advice may add value. They can also continue supporting patients who have returned home after hospital treatment.
This aligns with broader primary care and care coordination. The objective is not to turn every primary-care physician into a palliative specialist. It is to ensure that serious-illness needs do not remain invisible until a crisis forces hospital admission.
Virtual consultation may strengthen this model by allowing specialist palliative teams to advise professionals and patients outside major referral centers. Used well, this can extend expertise without requiring every locality to replicate the same specialist infrastructure.
But responsibility still needs to be clear. A virtual opinion does not create continuity if nobody is accountable for implementing the advice, monitoring symptoms and responding when the person deteriorates.
Medicine management becomes especially important near the end of life
As disease progresses, the purpose of medication may change. Treatments started years earlier to reduce long-term cardiovascular or metabolic risk may become less valuable when life expectancy is limited or the burden of taking them outweighs likely benefit.
At the same time, medicines for pain, breathlessness, nausea, anxiety or other symptoms may become increasingly important.
This requires careful clinical review rather than automatic continuation or withdrawal. Deprescribing should be individualized, considering prognosis, treatment goals, adverse effects and patient preference. Communication is particularly important because stopping a longstanding medicine may be misunderstood by families as “giving up.”
Pharmacists can contribute significantly by identifying interactions, reducing duplication and helping families understand complex regimens. Clear medication reconciliation becomes especially important after hospitalization or when several specialist teams remain involved.
The wider connection with medication management and polypharmacy is therefore central to safe palliative care in an aging population.
Dementia requires a different palliative lens
Dementia presents particular challenges because decline can be prolonged and prognosis uncertain. The person may gradually lose the ability to communicate pain, understand treatment decisions or express preferences clearly.
Palliative needs may nevertheless be substantial. Advanced dementia can involve swallowing difficulties, recurrent infections, immobility, distress, weight loss and increasing dependence.
The care challenge is to avoid treating each complication in isolation without considering the overall trajectory. A recurrent infection may technically be treatable while the broader question remains whether repeated hospitalization supports the person’s goals and quality of life.
Where preferences were discussed earlier, those conversations can help guide later care. Where they were not, families and professionals may have to interpret what is most consistent with the person’s known values, clinical situation and legal framework.
This is one reason palliative care should not depend entirely on a short predicted time to death. People living with dementia may benefit from supportive approaches long before clinicians can identify a final stage with certainty.
Choice and dignity require better communication, not only more services
Palliative care involves difficult conversations. People and families may need to understand that illness is progressing, that treatments have diminishing benefit or that future deterioration is likely.
The quality of these conversations matters. Technical information delivered without sensitivity can increase distress, while avoidance can leave families unprepared for predictable changes.
Saudi care also operates within cultural and religious contexts that shape attitudes toward illness, treatment, family responsibility and death. Clinicians need cultural competence without making assumptions that every Saudi family holds identical views.
Some patients will want detailed information and direct involvement. Others may prefer substantial family participation. The person’s own wishes should remain central where they can be established.
Consent, privacy and family involvement therefore need careful navigation. Family-centered care should not automatically mean family-controlled care.
The fundamental principle is dignity: people should be involved in decisions about their care to the extent they wish and are able, and communication should be understandable, compassionate and proportionate to their circumstances.
Scenario: a family requests continued treatment while the patient prioritizes comfort
A 68-year-old man with advanced metastatic disease has undergone several lines of treatment. His oncologist explains that further intervention is unlikely to produce meaningful benefit and may cause substantial side effects. The patient tells the palliative team that his priority is now pain control and spending time at home.
Some relatives struggle with this decision. They believe every possible treatment should continue and worry that changing the plan means abandoning hope.
The clinical task is not to dismiss the family’s concern. The team explains the expected benefits and burdens of further treatment, distinguishes active symptom care from therapeutic abandonment and confirms the patient’s own preferences.
His plan remains clinically active: analgesia is optimized, home follow-up arranged and clear escalation routes established. The goal has changed from extending treatment at almost any burden to maximizing comfort and time in the setting he prefers.
The scenario illustrates why rights, consent and decision-making remain relevant even within cultures where family relationships are particularly significant.
Good palliative care does not force an artificial choice between respect for family and respect for the patient. It creates enough communication, time and clinical clarity to hold both responsibilities appropriately.
Governance must follow the whole palliative pathway
It is relatively easy to measure the activity of a specialist palliative unit: referrals, consultations, beds occupied and episodes completed. It is harder, but more important, to govern whether the population who needs palliative care actually receives it.
Health clusters increasingly have the structural potential to examine these wider questions across hospitals, primary healthcare, home services and virtual care.
Leaders need visibility of patterns such as late referrals, repeated emergency attendance, uneven regional access, uncontrolled symptoms, delayed home support and differences between disease groups. If palliative care remains overwhelmingly associated with cancer while people with heart failure, dementia or advanced neurological conditions enter much later, that variation warrants examination.
The Governance Maturity Assessment can help organizations considering similar pathways test accountability, escalation and decision rights. It does not determine Saudi palliative-care standards, but it can help distinguish the existence of services from effective governance of the pathway connecting them.
Measurement should reflect quality of life as well as clinical activity
Palliative care creates a measurement challenge because traditional health-system indicators often emphasize cure, survival and utilization. Those measures remain important, but they do not capture the full purpose of palliative medicine.
A stronger evidence framework needs to ask whether symptoms are controlled, whether care preferences are understood, whether transitions are coordinated and whether families feel adequately supported.
Useful measures may include:
- time from identification of palliative need to specialist or appropriate supportive input;
- pain and symptom outcomes;
- emergency attendance and hospitalization in advanced illness, interpreted alongside clinical need;
- availability and timeliness of home follow-up;
- documented patient preferences and care-plan accessibility;
- family and patient experience;
- variation in access by diagnosis, region and setting.
These indicators should not become crude targets. A high hospital-admission rate near the end of life is not automatically evidence of poor care, because some admissions are clinically necessary and consistent with patient preference. Similarly, death at home should not become a universal quality target when some people prefer or require inpatient care.
The principle is alignment: does the care delivered reflect the person’s needs, preferences and clinical circumstances?
Organizations developing similar evidence frameworks can use the Quality Dashboard Builder to structure pathway, quality and outcome measures rather than relying solely on activity counts.
Geographic equity will become a strategic test
Saudi Arabia’s geography makes palliative access unevenness an important risk. Major referral hospitals can sustain specialist multidisciplinary teams more readily than smaller or remote communities.
The objective should not necessarily be identical infrastructure in every locality. It should be equitable access to appropriate expertise and support.
Health clusters can combine different resources: specialist units, primary healthcare, home-health teams, virtual consultation and referral pathways. The operational question is whether these arrangements allow someone outside a major city to receive timely symptom management without repeatedly traveling long distances.
Virtual care can help, particularly for clinical review and specialist advice, but it cannot replace hands-on nursing, equipment, medicine delivery or family support when those are needed locally.
Digital access may also vary. Older people with sensory impairment, cognitive decline or limited confidence using technology may need family assistance or non-digital alternatives.
Equity therefore needs to be measured through effective access rather than merely the existence of a national service offer.
Scenario: specialist expertise reaches a remote community without removing local responsibility
An older man with advanced chronic lung disease lives outside a major urban center. Traveling to a tertiary hospital has become increasingly difficult because he becomes breathless during the journey.
Local clinicians can manage routine elements of his care but need specialist support as symptoms become more complex. Rather than requiring repeated travel, a virtual palliative consultation is arranged with a specialist team within the wider health-cluster network.
The specialist reviews symptoms and medication with the local clinician, patient and family. Recommendations are incorporated into the local care plan, while criteria for hospital transfer remain explicit.
This is effective only because the virtual consultation is connected to practical capability. Local professionals remain responsible for follow-up, the family knows whom to contact and arrangements exist for physical escalation when necessary.
If the technology merely provides advice that local services cannot implement, it has moved information rather than care.
That distinction matters for technology-enabled care. Digital reach can reduce geographic barriers, but only when workforce, medicines, equipment and escalation systems remain available around the patient.
Funding models need to support care across settings
Palliative care can cross multiple parts of the health system: specialist hospitals, primary healthcare, home healthcare, pharmacy, rehabilitation, virtual services and sometimes social support.
Fragmented financing can make these interfaces harder if individual organizations are rewarded mainly for activity within their own setting. Saudi health transformation, including the longer-term development of strategic purchasing and population accountability, creates the possibility of aligning resources around pathways rather than isolated episodes.
The economic argument should nevertheless remain careful. Palliative care is sometimes promoted primarily because it may reduce hospital costs. Avoiding unnecessary hospitalization can create value, but cost reduction is not its defining purpose.
A person may require intensive and expensive palliative support because that is clinically appropriate. The value lies in providing the right care rather than simply the cheapest setting.
Population-based approaches should therefore consider both resource use and patient outcomes. If better home support reduces repeated emergency attendance while improving comfort and family experience, the case for investment becomes much stronger than a simple cost-saving calculation.
Palliative care also crosses the health and social-support boundary
Advanced illness often creates needs that are not purely medical. People may require help with washing, mobility, nutrition, equipment, transport, family support or safe living arrangements.
This means that long-term palliative development cannot be understood exclusively through Ministry of Health structures. The Ministry of Human Resources and Social Development has responsibilities relating to older-person welfare, social care and implementation of the Older Persons’ Rights and Care Law and its regulations.
Saudi Arabia’s legal framework emphasizes older people’s dignity, protection from abuse and neglect and their right to appropriate care, while also recognizing significant family responsibilities.
The interface becomes particularly important when an older person has both intensive healthcare needs and substantial everyday dependency. Health services may manage symptoms while relatives are left to organize almost every element of daily support.
This is where coordination across health and social care becomes strategically important. The future of palliative care will depend partly on whether medical and social-support systems can see the same person rather than dividing needs according to institutional boundaries.
Quality improvement should focus on recurrent pathway failures
Not every problem requires national policy change. Many improvements will come from learning systematically from local experience.
If a family repeatedly calls emergency services because it does not know whom to contact overnight, the problem may lie in communication or service coverage. If people referred for home palliative care wait too long for the first visit, capacity and triage may need review. If pain medication is repeatedly unavailable when people leave hospital, pharmacy and discharge processes may need redesign.
The most useful governance question is what happens when the same problem occurs repeatedly.
Organizations can use the Quality Improvement Action Plan Builder to translate recurring pathway issues into defined actions, ownership, evidence and review. It is a general improvement tool rather than a Saudi palliative-care standard, but the discipline of closing improvement loops is directly relevant.
Learning should also include patient and family experience. Some of the most important failures may never appear as serious incidents: poor explanation, fragmented communication, uncertainty about whom to call or a family feeling unsupported during a difficult final period.
The next workforce challenge is spreading palliative competence
Specialist palliative physicians and nurses will remain essential, particularly for complex symptom control and difficult clinical decisions. Yet demographic aging means specialist teams alone cannot carry the entire future workload.
Generalist professionals across hospitals, primary healthcare, emergency departments, home care and long-term support will increasingly need basic palliative competence.
This includes recognizing deteriorating illness, communicating sensitively, managing common symptoms, knowing when specialist referral is required and understanding how to support families.
Workforce planning should therefore consider tiers of competence rather than treating palliative medicine as an isolated specialty. Specialist teams can provide consultation, education and supervision while other professionals deliver appropriate components of care closer to the person.
This also strengthens resilience. A system dependent entirely on a small number of specialists will struggle as demand rises and geographic coverage expands.
International learning lies in integrating palliative care before systems become overwhelmed
Saudi Arabia is not alone in facing this challenge. Many countries developed health systems around acute treatment and only later had to build palliative pathways for aging populations with complex chronic disease.
Institutional models vary substantially. Some systems have extensive hospice sectors; others rely more on hospitals, primary care or community nursing. These structures cannot simply be copied into Saudi Arabia because financing, family roles, regulation, geography and cultural expectations differ.
The transferable lesson lies elsewhere.
Palliative care works best when it is treated as an integrated function of the health and care system rather than a final specialist destination. Early identification, generalist competence, accessible specialist advice, home support, medicines, communication and clear escalation pathways matter regardless of institutional model.
Saudi Arabia has the opportunity to develop these elements while its wider health transformation is still reshaping provider structures, digital systems and population accountability. That timing matters. Palliative care can be built into emerging pathways rather than added later as a separate service around them.
From service expansion to genuine choice
The next phase of Saudi palliative care will therefore be defined less by whether services exist and more by whether people can use them in ways that reflect their needs.
Choice requires information. It requires the person and family to understand the illness and likely trajectory. It requires sufficient services for options such as home care to be realistic. It requires professionals to recognize palliative need before crisis dominates the pathway.
It also requires governance capable of seeing variation. A national policy intention may be strong while access differs materially between regions, diagnoses or hospitals. Those differences need to become visible so that workforce and service capacity can respond.
As Saudi Arabia’s older population grows, the value of palliative care will increasingly be judged through ordinary human outcomes: pain controlled, breathlessness relieved, fewer frightening transitions, families better prepared and people able to spend more time in settings where they feel secure.
Conclusion
Saudi Arabia already has significant foundations for palliative care: specialist units across health clusters, multidisciplinary practice, home-health provision, virtual access and national recognition of palliative care within the wider Model of Care. Demographic aging now raises the level of ambition required.
The central challenge is moving from availability to continuity. People with advanced cancer, heart disease, organ failure, neurological conditions, dementia and multimorbidity need access before the final crisis, with specialist expertise connected to primary healthcare, hospitals, home services and family support. Their care should respond to symptoms and function while respecting dignity, privacy, cultural context and individual preference.
For families, stronger palliative care should mean partnership rather than unsupported responsibility. For health clusters, it means governing population access and outcomes rather than counting specialist episodes alone. For the wider system, it means recognizing that social support, workforce capability, medicines, digital infrastructure and funding arrangements all influence whether meaningful choice can actually be delivered.
The strongest future direction is therefore not simply more palliative-care beds. It is a connected pathway in which comfort, communication and quality of life remain active healthcare objectives alongside treatment. As Saudi Arabia builds a health system for longer lives, the way it supports people through serious illness and the end of life will become one of the clearest tests of person-centered transformation.