A t the age of 66, Zhang Mengdie (alias), a former nurse who had devoted her entire career to helping others recover, was diagnosed with lung cancer. After five years of undergoing multiple rounds of chemotherapy and taking heavy medication, she was dying in an intensive care unit, her body plugged into banks of machines through a maze of plastic tubes, her blood connected to bags of fluids, and her muted senses constantly stimulated by bright lights and loud alarms.

Tormented by the relentless pain, Zhang began searching online for information about euthanasia—the practice of medically assisted dying, which remains illegal in China and most parts of the world. And it was during this search that she stumbled upon an unfamiliar field called hospice care.

Following careful consultations with Guo Yanru, a hospice care specialist at the Seventh Affiliated Hospital of Sun Yat-sen University in Shenzhen, Guangdong Province, Zhang and her family decided to pursue a new treatment plan focused on pain management—rather than extending life.

Between hope and submission, intensive medical intervention and a complete refusal of treatment, Zhang opted to go down a third path—to die with peace and dignity.

Cure sometimes, comfort always 

Even for a seasoned doctor like Guo, accepting the reality of mortality has not been an easy journey.

When Guo, fresh out of medical school, started her first job as an anaesthesiologist at the People's Hospital in Cangzhou, a small city in the northern province of Hebei, she firmly believed in the noble ability of doctors to save lives.

However, that faith soon began to falter, as she constantly had to deal with surgical cases that were way past the point of rescue.

"Every day was a roller coaster ride between the excitement of nailing a successful surgery and the frustration of failing to save a life," Guo told Beijing Review.

After transferring to the hospital's pain management center in 2010, she was exposed to a range of advanced cancers and other terminal diseases. Death was often inevitable and the countless losses she witnessed busted her old belief in the cure-based philosophies of medicine, which tend to regard death as something that can be fought against and resisted rather than as a natural part of life to be accepted and managed with compassion.

It was at that time that Guo first came across the concept of hospice care.

Hospice care, also known as palliative care, is premised on the idea that there is a difference between the quality of life and its length. Originating with Cicely Saunders, who founded St. Christopher's Hospice in the United Kingdom in 1967, the hospice care movement arose as a response to the many limitations of modern medicine.

With the continuous rise of new cures, better surgical techniques and evermore targeted therapies, medical advances have profoundly transformed the way people live but have done little to address the question of how they should die. For terminally ill patients, modern curative care can sometimes make dying more painful by artificially stretching out life and thereby sustaining their suffering.

Unlike traditional medical care, which tends to prioritize cure, hospice care focuses on comfort, addressing the wishes of the patient and their family, and easing distress as life draws to a close.

This approach offered Guo, who was searching for a new sense of purpose in medicine, a new perspective on aging and death.

"It was like slowly pushing a door open. You've always been on one side of the medical science. After you come to the other side, you discover that death is just a natural part of life and an integral part of medicine," she said.

High time for hospice For China, the opening of that door is an ongoing process spanning almost four decades.

The idea of hospice care first landed in China in the late 1980s. In 1987, the country's first hospice facility, Songtang Care Hospital, opened in Beijing. Equipped with a gym, a piano and a "nostalgia room" filled with old items from the 80s, Songtang focused less on medical treatment than on making patients feel connected and emotionally supported.

The following years saw hospital authorities from all over China visit the facility to observe how it operated. However, despite Songtang's national fame, little progress was made in spreading the model. On the contrary, Songtang had to move seven times due to complaints from residents of nearby neighborhoods, who felt that a hospital full of dying people brought bad luck to them.

Few cultures like to talk about death, and in China, the subject has long been an unbreakable taboo. "Mentioning death is considered so unlucky that patients are often reluctant to discuss the subject with their doctors and families, which often leads to uninformed decisions on end-of-life arrangements," Liu Yin, head of the hospice care clinic at Beijing Royal Integrative Medicine Hospital, told Lifeweek magazine.

Despite this deep-seated fear, death remains an increasingly jarring presence in the country, which struggles with a rapidly aging population.

Statistics from the Ministry of Civil Affairs show that as of late 2023, China's population aged 60 and above had approached 300 million, making up some 21 percent of the national headcount. By 2050, this figure is projected to reach roughly 500 million.

In 2015, the central authorities launched the Healthy China Initiative, outlining public health goals. Among them was the goal of integrating palliative care into the country's medical system.

The following year, the first batch of pilot hospice programs was introduced in cities including Beijing, Shanghai, Changchun in Jilin Province, Luoyang in Henan Province and Deyang in Sichuan Province. Since then, the number of hospice facilities across the country had grown from 276 in 2018 to over 4,000 by the end of 2023. While many of these institutions, located in hospitals or community clinics, are concentrated in larger cities, some have begun to spread into smaller urban areas.

Guo was a direct participant in this growing trend. In 2019, she led a team of colleagues and volunteers in founding a palliative care department in her hospital—the first of its kind in Cangzhou. On top of the standard facilities, the department also contains a meditation room, which allows for quiet contemplation and just "spacing out," as well as a "spa," where patients can peacefully finish the last stretch of their lives.

Over four years, the department has helped more than 2,000 terminally ill patients navigate peaceful end-of-life transition. Like its many counterparts in big cities, this small facility, tucked away in a small northern town, has become a vital link in the country's sprawling hospice care network.

The way forward

However, on a broader scale, hospice care in China remains in its early stages, as a combination of

cultural, social and economic factors continues to hinder its growth.

Besides the many taboos surrounding death, the ethics of filial piety also teach that the young should care for the elderly and that opting to forego active treatment means giving up on their loved ones.

The industry also faces a shortage of professional talent, as hospice care is yet to be incorporated into the country's medical education pathway. Some universities offer optional courses on palliative care, but the field is still not recognized as a standalone college major, Guo observed. In July, she relocated from Cangzhou to Shenzhen.

What's more, due to most hospice services currently not yet being included in the country's medical insurance system, many hospice institutions face difficulties funding their work.

"It is very hard to put a price on the human dimension of hospice services. The prices covered often do not show how much effort goes into it," Lu Guijun, head of the Department of Pain Management at Beijing Tsinghua Changgung Hospital, told Yicai, a Chinese business and financial media outlet.

The industry still needs to be more standardized in many ways. However, China's vast geography means that absolute standardization is unrealistic. While psychotherapy currently thrives in Shanghai's hospice scene, in rural areas, health facilities should perhaps focus less on spiritual healing and more on providing affordable pain management.

"For a long time to come, China will be in the process of setting up a general support system for hospice care. Meanwhile, it is necessary to consider the unique social realities of different regions," Guo concluded.

(Print edition title: To die a dreamed death) 

Copyedited by Elsbeth van Paridon

Comments to pengjiawei@cicgamericas.com