Hong Kong tries to give the elderly more care when they face death

Ng Yu-fung’s father was at his deathbed at Nam Long Hospital, a specialist hospital for cancer patients. “What makes me regret is that I was afraid of my father's death when he was near the end of his life,” Ng recalled. His father’s last moments of life inspired him to become a volunteer in hospice care. Today, Ng is president of the Hong Kong Hospice Social Workers Association.

The association’s goal is to enhance a patient’s quality of life before the end, focusing on pain management, spiritual care, and palliative care.

Hong Kong ranked 20th among 80 countries in the 2023 in quality of death according to a white paper published by the Economist Intelligence Unit. In 2015, Hong Kong ranked 22nd among 40 countries.

The Index scores countries across four categories: basic end-of-life healthcare environment; availability are; cost and quality of care.

End-of-life care involves palliative care and hospice care, thus the progress of hospice care in Hong Kong contributed greatly to the rise in rankings.

Dr. Fowie Ng, vice president of the Hong Kong College of Health Service Executives said that the progress of hospice care in Hong Kong is caused by many factors, including the city’s medical and social services.

“The Hospital Authority has set up a ward specifically to treat end-of-life patients. It used to be the responsibility of the Bradbury Hospice Centre, but now it has expanded to many hospitals setting up these ward services on hospice care,” Dr. Ng said.

Chan Mok-kwong, president of the Hong Kong Hospice Society said that not only has the government paid more attention to the development of hospice care in recent years, but the support groups who promote education and improve hospice care services have also made a lot of effort.

“If the patients have financial difficulties, we will help them apply for subsidies, and the fees will be relatively reduced or even waived,” Chan added.

Hospice care is not only about caring for the patient but also about caring for the psychology of the patient’s family members.

“We will have a dedicated nurse to follow up every case. The final step in handling a case is for nurses to help the family members of the deceased manage their emotions until they are restored to normal,” said Chan.

Ng created Relic Transformation, a new way to help with grief counselling for family members. It involves making pillows from the clothes of deceased relatives.

“The tradition in Hong Kong is to throw away all the clothes of the deceased to avoid missing the person. We hope to provide another direction to make people rethink the meaning of relics to the living,” said Ng. 

“We will add elements of psychotherapy, combined with verbal guidance, and invite the family member to pick up the pillow and hug it,” he said.

The 2021 Hong Kong government census shows that the proportion of elderly people aged 65 or above reached 20.5%, and this proportion will continue to rise. 

In 2000, Taiwan introduced Hospice and Palliative Care Regulations, providing a legal basis for medical autonomy for terminally ill patients and implementing hospice services.

In 2015, Taiwan passed the  Patient Autonomy Rights Act to establish the legal basis for  Advance Directive in relation to Medical Treatment (AD), enabling terminally ill patients to make their own decisions on whether to receive life-sustaining treatments.

But in Hong Kong, there is no legislation on hospice care.

 “When I visited the elderly homes, people there were very afraid of ‘Daughter from California syndrome’. That means usually their children don't care their parents’s life, but when the parents  are sick, they will fly back and disregard their wishes to give first aid,” Ng said, “This does not allow the patients to get the respect they deserve before they die, and the patient's rights need to be protected by law.”

In addition, the hospice care system in Hong Kong has yet to take shape, and there is a lack of government resource input.

 “The number of hospitals providing hospice care services is small, and there is a shortage of relevant professionals,” Chan said.  

Overall, the government has not shaped a social atmosphere to know about hospice care. “I think one of the most important things is whether seniors and their families are aware of hospice care,” Ng said. 

He added that people often have a misconception about hospice care, thinking that by choosing such a service they are giving up on saving the patient's life, but in reality, it's a different kind of medical treatment.

There was a lack of attention to the grief counselling aspect of the patient's family in hospice care as well.

“Their friends and relatives may not understand or even criticise them when they express their grief, as if the right to grieve is taken away,” Ng said.

“Hong Kong culture believes that patients should be in the hospital when they are dying, and if a patient is sick or being treated at home, it will affect the feng shui of that house,” Ng said.

 Ng added that it is difficult to provide good hospice care for the terminally ill at home because of the cramped living environment in Hong Kong.  

Even though it is legal to die at home under the current law, these two factors prevent many patients from choosing to die at home according to their own wishes.

 However, the fact that elderly people do not have the option of passing away at home does not mean that they will be sent to hospice care centres, and most of them will be sent to elderly homes only.

 “It is hard for elderly homes to provide hospice care because the training of the staff and the equipment aren't set up for such services,” Chan said.

Last November, the Legislative Council introduced the Advance Directives for Life-Sustaining Treatment Bill. This provides a legal framework for advance directives on medical treatment and orders not to perform cardiopulmonary resuscitation (CPR), as well as legal protection for health care and rescue workers in enforcing these two documents.

 The Society for the Promotion of Hospice Care, one of the major hospice care organizations in Hong Kong, aims to provide training at residential care homes for the elderly to teach staff how to provide hospice care services. The group also offers guidance to operators on how to optimize their facilities so that the elderly can receive better care.

In addition, the association provides medical personnel to the homes to provide medical treatment to the patients, issue legal death certificates when the patients die, and provide support to take the patients' bodies to the funeral halls.

 Hong Kong Hospice Social Workers’ Association is also promoting life and death education, and encouraging more people to join the ranks of social workers in hospice care.

 “I am now trying to publish my own life and death picture book. I hope it will be the first life and death picture book in Hong Kong,” said Ng.   

Ng said that some large insurance companies are now covering palliative care.

He hopes that the Hospital Authority can provide more relevant services and  promote them to the public.  

Chan said  that the government should not only pay more attention to hospice care in terms of a legal framework, but also provide more resources, such as beds, healthcare workers, medical training and so on.

“Various organizations as well as the government should work together to promote Hong Kong's success in this area,” Ng said.