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

In China, there is a common saying: “May the five blessings descend upon this home,” meaning longevity, wealth, health, virtue, and a “good death.” The last usually refers to dying from natural causes after a long life, with minimal suffering — for Chinese people, a good ending to one’s life is considered an important blessing.

But after decades of rapid social development, how do Chinese people now view death? And what do they consider to be a “good death”? I became interested in these questions when I began conducting research into patients with cancer in 2014, and so decided to launch a study on end-of-life care in 2017 to better understand how Chinese people hoped to die.

The results were rather surprising. Even though China has experienced drastic social and economic change, people’s notions about death remain traditional in many ways. When surveyed, most people mentioned that a good death would involve dying in bed of old age, dying at home of natural causes, or dying in one’s sleep. Ideally, they hope they can move about as normal, take care of themselves, and not experience much physical pain.

Meanwhile, an unexpected or sudden death, such as one caused by a traffic accident, suicide, homicide, or medical malpractice, is considered a “violent death.” Death from a sudden illness, such as a brain bleed or heart attack, is also considered inauspicious, whereby the soul of the deceased will be unable to find peace and can even bring misfortune to the living.

All of this is consistent with traditional Chinese ideas of a good death. For example, the good death in the five blessings also emphasizes dying from natural causes rather than an accident or foul play. People are often envious of those who die at an old age of natural causes because they had enough time to prepare and get their affairs in order.

When these conditions are met, the funeral can even be treated as a xi sang, or “happy funeral.” In these cases, family members will not be especially sad, the deceased will be laid out in a coffin for three to five days, and a large banquet will be organized for family and friends.

The presence of family and friends at the end of one’s life is another important feature of a good death among those surveyed. Most Chinese people do not have clear religious beliefs that can help them come to terms with death; therefore, loved ones are expected to help people face death calmly. Visit a hospital in China and you will find many older people near the end of their lives surrounded by family members taking turns to accompany them. In some parts of the country, local customs require those terminally ill to return to their home, while the entire family rotates to watch them around the clock until they die. If no family member is around at the time of death, it is considered a lonely and pathetic death.

However, with modern medical technology becoming more widespread, end-of-life care in China has started to become more centralized in medical institutions and handled by medical professionals. Long-term older patients in hospitals or nursing homes are vulnerable to becoming isolated from the family and social relationships that are crucial for a good death. Older people confined to institutions gradually reduce their former social activities, social relationships begin to fracture, and fewer and fewer people come to visit them, possibly ending up in a state of being forgotten. 

At the same time, the increasing intervention of medical technology at the end-of-life stage means that many Chinese families now pay large sums of money for life-prolonging treatment for their loved ones, often a manifestation of filial piety, which ironically can lead to patients suffering more physical pain.

Many interviewees, which also include healthcare professionals, expressed deep worries about patients becoming isolated in intensive care. One patient who had been in an ICU recalled being intubated, kept alive by various machines, and unable to leave her bed or have her family visit: “Hell must look like the ICU.”

There seems to be a surprising contradiction between Chinese people’s desire for a good death and the development of modern medical technology. However, the Chinese conception of a good death also does not seem fully compatible with the hospice care that has emerged in the West in the last few decades, which prioritizes individual rights. The interviewees barely mentioned values like personal choice and the autonomy of the dying person. On the contrary, the family still plays an important role in what Chinese people today define as a good death: death without regrets often means having lived a “complete” family life, and the feeling of being a burden to one’s family may increase the suffering of the person dying. However, the company and care of family members can also reduce anxiety and loneliness.

The absence of discussion about individual autonomy suggests that the cultural core behind the concept of a good death in China is still Confucianism. Rather than prioritize the autonomy of the dying person, Confucianism emphasizes the social and moral dimensions of death, such as the relationships between the dying person and their family, clan, ethnic group, and even society at large. The focus is on integrating an individual’s life into a larger community to generate meaning that transcends the life of the individual.

But whatever the culture, when we discuss something as important as death, it is more important to see people for who they are and what they truly want. With the continued development of medical technology, there will be more and more ways to put off death as long as possible, along with an increased obsession with doing “whatever it takes” when it comes to treatment, especially among family members. However, death is not just a medical technicality or a family matter. How someone enters the final stages of their life is perhaps the most important decision they can make for themselves. Therefore, their wishes and values should be respected as much as possible. 

Translator: David Ball; editors: Cai Yiwen and Vincent Chow.

(Header image: VCG)