Barriers in palliative care in current mainland China

Palliative medicine and hospices have been developing rapidly since 1960s in the west after Cicely Saunders set up this completely new subject. After 4 decades, palliative care is now well established and delivered in developed countries like UK and Australia. [1] But palliative care is developing relative slowly in developing countries. In china, it is still a quite new subject in medicine and not many people know it or recognize it as a specialty.[2]

Palliative care is introduced into China in 1991, with the milestone of official introduction of WHO three-step analgesic protocol Since then, trainings have been carried out by the government and organizations also called “hospices”(the same as in the west) have been set up all over the country by a charity foundation. .[3] It seems palliative care is developing on the right way in China, as what published literatures have been telling the outer world, however, many barriers do exist in palliative care in current China.

1. Misconception about palliative care

Although more and more training programs are held in China since palliative care was introduced into China in early 1990s, health professionals’ understanding about this new specialty remains quite limited and sometimes even wrong.[4] However, few surveys has been carried out and none literatures has been found on this topic.

The International Work Group on Death, Dying, and Bereavement visited China in 1992, and explained palliative care as “Lin Zhong Guan Huai”–“care for a person approaching death, i.e. terminal care.[5] This may be the reason why heath professionals in majority part of China believe that only dying patients need palliative care, which leads to the fact that patients come to hospice or palliative wards usually have very short life expectancies and palliative specialists could do little to help them. On the other hand, patients and families also consider hospice or palliative wards as places to wait to die, so they are unwilling to go for palliative care because it makes them desperate. Till now, not many people understand that palliative care can be helpful for patients just diagnosed with cancer and that it also plays an important role in some non-malignant diseases.[6]

2. Lack of knowledge and skills

In some surveys concerning heath professionals’ self-evaluation about their knowledge and skills in palliative medicine, a majority of participants showed unfavorable confidence and expressed their need for more trainings.[2,7] Clinicians are more skilled in dealing with common symptoms such as pain, but feel incompetent in dealing with less common ones like depression and anorexia. Apart from medical skills, communication is also a big problem. Let along communication with specific tasks such as truth telling, decision making, or breaking bad news, general communication skills of average physicians are very poor as a result of “the illness-centred” medical education. Nowadays, some medical schools are trying to teach students to treatment patients like persons, not carriers of illnesses and the communication skills in some health care professionals seem improved.

Although many physicians expressed their need of further training and there have been trainings and workshops in palliative care, and a number of participants have been reported to take part in such activities [4], it is not known what improvement in their skills and knowledge about palliative medicine was made or how much they brought back to their clinical practice. No formal test was performed after each training to measure their gains. No literatures can be found talking about effects of training in palliative care in China.

3. Wrong aim of delivering care &Lack of professionalism

In current China, hospitals’ incomes mainly depend on the money they charge from patients. The government’s budget for hospitals is small and has been reducing, while patients’ individual expense on health went up.[8] So health care providers in hospitals have to earn money to live on, which means the aim of delivering any care is mainly money making. However, according to a survey carried out in 2004, most doctors’ income was quite low, and their satisfaction of job and professional life was also scored low. Income was the main concern of most doctors in the survey.[9] Under such condition, health care providers have to seek other ways to make money to survive, which is a big distraction to their professional life and also a breakage in professionalism, such as accepting gifts for favors, or over-prescribing and over-treating for profit.

In palliative care, no resuscitation before death and limited roles of antibiotics or monitors should be common sense in physicians. But because of the reasons above, doctors have to prescribe as much medicines as possible, do resuscitation, place patients on monitors …… do anything that can be charged for, although they know very well they shouldn’t do these according to palliative textbooks. When it comes to psychological care or bereavement care that can’t be charged for under current medical system, nobody is willing to waste time on it. The aim of making money also prevents physicians in other specialty from referring their patients to palliative care, because they would like as many patients as possible to prescribe medicines to.

These barriers are quite complicated and with historical reasons. The current status of palliative care in China can not be changed by individuals or in a short time. It needs the government’s effort as well all the physicians’ to improve palliative care. And the medical system also needs to be changed to “patient-centred” so that doctors will practice to provide health, not to make money.

1. David Clark. From margins to centre: a review of the history of palliative care in cancer. The Lancet Oncology, Volume 8, Issue 5, May 2007, Pages 430-438
2. Xin Shelley Wang, Li Jun Di, Cielito C. Reyes-Gibby, Hong Guo, Shu Jun Liu and Charles S. Cleeland. End-of-life care in urban areas of China: A survey of 60 oncology clinicians. Journal of Pain and Symptom Management, Volume 27, Issue 2, February 2004, Pages 125-132
3. Xin Shelley Wang, Tong-du Li, Shi-ying Yu, Wei-ping Gu and Guang-wei Xu. China: Status of Pain and Palliative Care. Journal of Pain and Symptom Management, Volume 24, Issue 2, August 2002, Pages 177-179
4. Hong Zhang, Gu Wei-ping, David E. Joranson and Charles Cleeland. People’s Republic of China: Status of cancer pain and palliative care. Journal of Pain and Symptom Management, Volume 12, Issue 2, August 1996, Pages 124-126
5. Derek Kerr. Lin zhong guan huai: terminal care in china. American Journal of Hospice and Palliative Medicine, 1993 10(4), Pages 18-26.
6. M.S. Arolker and M.J. Johnson. Palliative care in non-malignant disease. Medicine, Volume 36, Issue 2, February 2008, Pages 96-99
7. Sosars V, Tan J. Worldwide hospice& palliative care: focus on East Asia. American journal of hospice& palliative care. 2000 17(6), Pages 372-3.
8. Tian Wei, Zhang Lulu, Ou Chongyang, et al. An analysis on present situation and development of medical delivery system in China. Journal of Medical Colleges of PLA. 2007 22(30, Pages 185-190.
9. Meng-Kin Lim, Hui Yang, Tuohong Zhang, Zijun Zhou, Wen Feng and Yude Chen. China’s evolving health care market: how doctors feel and what they think. Health Policy, Volume 69, Issue 3, September 2004, Pages 329-337

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