End of Life Care in Asia

Societal attitudes towards end-of-life care must evolve in tandem with rise in ageing populations and chronic illnesses.

Healthcare discussions often focus on improving quality of life, yet the idea of a ‘quality death’ remains largely overlooked, especially in Asia. In the coming years, demand for palliative care is expected to rise sharply, driven by ageing populations, increasing rates of chronic illness, shrinking family units and the decline of traditional extended family structures that once supported end-of-life (EOL) care.

Each year, more than 100 million people worldwide could benefit from hospice and palliative care, including patients, families, and caregivers who need support, yet fewer than 8% of those who need it actually receive it, according to the Worldwide Palliative Care Alliance.

Few nations, including developed, high-income nations, incorporate palliative care strategies into their overall healthcare policy. In a 2021 study by the Lien Centre for Palliative Care at Duke-NUS Medical School, the United Kingdom (UK) topped the world in quality of death, despite having existing challenges in their healthcare system. The same study ranks Taiwan third while Australia is tied at fourth place with the Republic of Korea and Costa Rica. 

In Southeast Asia, palliative care continues to face significant challenges ranging from limited awareness among the public and healthcare professionals and late referrals, to deep-seated cultural beliefs around death and dying.

These factors, coupled with shortage of trained healthcare professionals, often lead to services being unevenly distributed across urban regions and not adequately funded, further underscoring the challenges of integrating palliative services into mainstream healthcare systems.

Challenges in Malaysia and Singapore

The two countries differ significantly in terms of the awareness and capacity of palliative care services.

Awareness about palliative care and hospices in Malaysia is low, with it being largely considered as a last resort when the family or caregiver has ‘given up hope’. A needs assessment found that of 56,000 Malaysians per year who require palliative care, only about 8.3% have their needs met.

In Singapore, although general awareness is relatively higher, substantial misconceptions and low death literacy persist, with only 53% being aware of, and 48% receptive to, palliative care.

"Death is still a highly taboo topic for the older generation here particularly within the Chinese community, although things may be changing with the younger generations who are more open to having these discussions with their families. More public discourse in the media and crucial conversations on EOL issues by healthcare professionals can help to advance awareness and benefits of palliative care in Singapore,” says Tan Boon Heon, PhD, Chief Executive Officer (CEO) of HCA Hospice (HCA) in Singapore

Tan Boon Heon, PhD, Chief Executive Officer (CEO) of HCA Hospice (HCA) in Singapore

A survey by the Lien Foundation Singapore found that 77% of respondents said they wished to die at home, but only 27% of deaths occurred at home. Dying in their preferred place has been linked to more dignity and better quality of death for patients, and better bereavement outcomes for families with the potential impact of reducing the intensity of grief.

"Although earlier referrals can help patients achieve their wish to die at home or under hospice care, rather than in hospital, patients are often referred late, sometimes in their final weeks of life. This means we are unable to engage meaningfully with them, limiting our ability to comprehensively manage symptoms, prepare the family and/ or caregiver, and ensure the patient dies at their preferred place of death," Tan shares.

Dr Ednin Hamzah, CEO of Hospis Malaysia

CEO of Hospis Malaysia, Dr Ednin Hamzah, echoes the sentiment, "Many of our patients are referred to us with only a few days left to live. Sadly, about 30% of all our patients under our care die within a week, 50% survive for about a month, and only a small percentage survive beyond that.”

As the largest community palliative care organisation in Malaysia, Hospis Malaysia provides holistic, evidence-based palliative care to 1,000 to 1,500 patients yearly, or approximately 400 to 450 patients at any one time.

“People often do not have a good understanding of what a hospice is or what services it offers. In the United States, the terms ‘hospice’ and ‘palliative care’ refer to different things, but to us in Malaysia, they are one and the same. Our services extend to all patients with life-limiting illnesses, such as cancers, rare diseases, neurological diseases, organ failure, etc.," Dr Ednin says.

In the last 10 years, he has observed a reduction in patient referrals to community-based providers in tandem with more hospitals developing their own palliative care units.

He opines, “As a community palliative care provider, we are more cognisant of the patient’s daily needs outside of the hospital setting, such as how the patient is coping at home, the impact the illness has on family members and caregivers, as well as the social, psychological and emotional aspects of care. We're able to have a panoramic view of the situation, which you do not often see in a hospital setting where interaction with family members is limited."

In Singapore, palliative care and hospices are still mainly associated with late-stage cancer care. “In the past, about 80% of our patients were stage 4 patients or patients with metastatic cancer. But over the years we are seeing more patients with other diseases as well, and now cancer patients make up about 70% of our patients,” says Tan.

Ramping Up Palliative Care

Malaysia faces a huge disparity in terms of access to hospice and palliative care services, with human resource being the most pressing challenge. In efforts to address the manpower shortages in palliative care, Malaysia’s Ministry of Health has spearheaded the National Palliative Care Policy and Strategic Plan 2019 to 2030 which encourages palliative care modules to be incorporated in public and private medical schools' syllabi to raise the profile of palliative care as a medical sub-specialty.

The observance of annual events such as Palliative Care Awareness Month (PCAM) in April and World Hospice and Palliative Care Day on 11 October are crucial in raising awareness about EOL care. In addition, ongoing campaigns such as Speak Up! by Hospis Malaysia are aimed to encourage patients and families to discuss quality of life and illness, and reduce misconceptions about palliative care.

Dr Ednin shares, “One of our efforts is mobilising ‘compassionate communities’. We work with neighbourhoods to identify a representative or representatives who can be their point of contact in the event that someone is critically ill. This person can mobilise neighbours to provide basic caregiving skills to the patient in their area, such as transport, cooking meals, dropping in for regular visits, and so on. We create a basic support system within the community and help to mete out the burden of care. We saw this being applied successfully during the pandemic and hope to apply it to EOL care in some way.”

In 2023, Singapore’s Ministry of Health (MOH) launched the National Strategy for Palliative Care, outlining measures to enhance access, quality, awareness and affordability of EOL services. In line with this effort, HCA Hospice, Singapore’s largest home hospice provider and a registered charity, expanded its service capacity by 50% in 2025, and is now caring for around 1,200 adult patients.

“Although awareness around palliative care has risen over the years, there is still room for growth. Our biggest challenge is the manpower crunch, because more doctors and nurses must be trained in palliative care if we want to upscale our capacity. We must attract the right people, train them and keep them interested,” says Tan.

Closer collaboration between hospitals and community-based providers is also critical in achieving MOH’s aspirations of providing access to palliative care to 3 in 4 Singapore residents and adequate support to more than 4 in 5 caregivers. 

“These days, there is a lot of emphasis and awareness on healthy ageing and enhancing quality of life in Singapore. But we also need to acknowledge that people will eventually die — perhaps not at 85 but at 100 — it is inevitable. So, we need to normalise discussions on dying well and quality of death,” says Tan.

Focusing on Quality of Death

While hospice services in Malaysia and Singapore are at different stages of maturity, they share common themes of opportunity, challenge and urgency.

High-income models such as Australia's show how a comprehensive national strategy, monitoring and system integration can contribute to high-quality outcomes.

In Australia, patients receive palliative care on the basis of need, not prognosis. A needs assessment tool for palliative care (NAT-PC) is used by practitioners within the healthcare system and in non-specialist palliative care settings to assess the needs of the patient, and to provide a prompt for referral to a specialised palliative care service when required.

While Australia has largely succeeded in providing access to palliative care services to most of its population, despite the country's diverse geography and population, similar challenges remain, including inadequate funding, workforce shortages and inequitable access, particularly for people living in rural areas and underserved populations.

To successfully bridge the current gaps, what remains critical is normalising conversations around death and dying, so that dying well becomes recognised as an integral part of living well.