This article is part of a series on end-of-life care in China, one of the world’s fastest-aging nations.

China is staring down a massive shortage of hospice services. The country’s over-60 population is nearing 300 million, or some 21% of the total population, and approximately 2.29 million Chinese die of cancer every year. The medical expenses associated with serious illnesses like cancer treatment can cause families to go bankrupt, while terminally ill patients interested in end-of-life care often have no options beyond expensive and scarce hospital beds.

One alternative is hospice care. Originating with Cicely Saunders, who founded St Christopher’s Hospice in the United Kingdom in 1967, the hospice care movement arose in response to modern medical technology. Although modern medicine plays a significant role in maintaining physical health and prolonging life, it can also prolong the suffering of terminally ill individuals. Hospices represent an attempt to address this problem by offering an alternative to curative care.

Chinese experts first took note of the idea in the late 1980s. In 1988, Tianjin Medical College established the Hospice Care Research Center, making it the first special research institute for hospice care on the Chinese mainland. But little progress was made until the last decade. In 2016, hospice care appeared in a major national health policy planning document for the first time. The following year, the National Health Commission issued guidelines for hospices, and the number of medical and health institutions in China with hospice care departments increased from 276 in 2018 to 4,249 by the end of 2022.

Yet these departments are often afterthoughts within hospitals and ignored by patients. Attitudes toward hospice care vary between countries and cultures, and studies have found that societies that advocate individualism have a higher acceptance of hospice services than collectivist societies like those found in much of East Asia.

Nevertheless, countries such as Japan, South Korea, and Singapore have developed their hospice facilities thanks to strong promotion and investment. So it’s worth asking why Chinese have been far more wary of the practice than their neighbors.

The first issue is financial. There are still only a few thousand hospice care institutions in China, most of which are embedded in hospitals. However, due to the fact that many hospice services are not currently included in the country’s medical insurance system, all of the existing hospice care institutions I surveyed face difficulties funding their work. Doctors joke that anyone who specializes in hospice care will go broke. Medical institutions prioritize curative treatment when allocating resources, while limiting the number of beds and the manpower they invest into their hospice units or else treating it as a luxury service for wealthy patients.

Bed turnover rate, average length of stay, mortality rate, and other similar metrics are important parts of China’s hospital evaluation system — all of which complicate the provision of hospice services. Reserving wards for hospice care means a decrease in revenue, while the need for family companionship means hospice wards are difficult to fit into crowded public hospitals.

There are also cultural factors. Many institutions encounter skepticism and reluctance from patients and their families when attempting to promote hospice care services, at least at first. Patients and their families believe that opting for a hospice means giving up on their loved ones. At a community center I visited, when healthcare workers recommended hospice care to families, they might face verbal abuse. Questions like how to broach the topic, with whom, and how to hold family meetings are all issues that require a soft touch. If family members are concealing a condition from the patient — a not uncommon practice in China — it is even more difficult to have these conversations.

But if the development of hospice care in China has been slow, professionals have come up with some creative solutions. Many hospitals that offer hospice care choose to integrate it into relevant departments of oncology, geriatrics, and rehabilitation, for instance. One hospice care department at a hospital my team and I surveyed initially only admitted critically ill patients, but later began to work on cancer rehabilitation. The medical staff there said that this allowed them to feel like they could still do something for the patients, and it also better met the expectations of the patients’ families. Given the cultural taboos surrounding death in China, as well as the ethics of filial piety, such vague and mixed practices make it easier for patients and their families to choose and receive hospice care.

Obviously, in order to truly promote hospice care in China, these ad hoc practices will need to be standardized. However, due to China’s vast geography, it is still necessary to consider the social realities and cultural practices of different regions. For example, in rural areas, hospice care should first focus on strengthening medical interventions such as pain relief, rather than aromatherapy, psychotherapy, and other practices increasingly popular elsewhere in the world.

Perhaps more pressingly, there is a need to discuss how to incorporate hospice care into the medical insurance system. At the same time, more concrete support policies should be given to medical and care institutions, such as enhancing resource allocation and financial support, expanding channels for funding hospice care like public donations, and changing assessment and evaluation indicators to better motivate professionals to take up hospice care.

Translator: Matt Turner; editor: Cai Yiwen.

(Header image: Lane Oatey/BJI/VCG)