Objective To explore the barriers encountered during the downward referral process for palliative care within medical al-liances and to provide a reference for improving the continuity and accessibility of palliative care services. Methods A descriptive qualitative study was conducted.Purposive sampling was used to recruit 15 healthcare professionals involved in palliative care provision and referral coordination from three healthcare institutions within the Peking Union Medical College Hospital medical alliance.Semi-structured interviews were conducted, and the data were analyzed using thematic analysis. Results A total of 4 themes and 12 subthemes were identified:patient and family level: insufficient understanding of palliative care concepts and referral processes, limited trust in primary healthcare institutions, and disagreements among family members regarding care decisions; tertiary hospital level: inadequate awareness of palliative care concepts among healthcare professionals, insufficient communication skills, and excessive clinical workload; primary healthcare institution level:insufficient allocation of service resources, need for improvement in healthcare professionals′ palliative care competencies, and inadequate demonstration of service advantages; system and mechanism level:insufficient sustainability of medical alliance collaboration, ineffective transfer of care information, and inadequate ser-vice compensation mechanisms. Conclusion Downward referral for palliative care within medical alliances is influenced by multiple factors at different levels.Future efforts should focus on enhancing public awareness of palliative care, improving healthcare professionals′ competencies and communication skills, optimizing primary healthcare resources and service capacity, strengthening collaboration and information-sharing mechanisms within medical alliances, and establishing effective incentive systems to improve referral continuity and the quality of palliative care services.