「生前」好走 x 「死後」走好：香港如何走好下一步｜Saying Goodbye x Good Goodbye: Hong Kong’s Next Steps in Life and Death
「死亡」還未發生時，總以為距離自己好遙遠，直到真的發生在身邊，才忽然開始思考「要選擇以何種方式死亡」。吉人吉事透過共四篇文章，詳細闡述了走好人生最後一程的關鍵要素以及逝者如何安個好「家」，亦有解讀全球範圍內的成功案例 [1] [3]。不同於前幾篇詳細展開數據及案例，本篇是最終篇，將用開放性的角度探討香港下一步可以做些什麼。
「教育」當頭，「政策」跟後
在香港，往往是先立法，後教育。香港缺乏公眾教育，不只體現在民眾對「醫療服務」的不知情，亦體現在民眾對「死亡」的逃避。其實香港已經領先亞洲，早於二十世紀末引進了「紓緩治療」概念，並於一九八二年開創了第一家公立醫院體系下的寧養中心，旨在為末期病人提供全人照顧，隨後港府陸續通過「紓緩治療服務策略」、「預設照顧計劃指引」等條例，旨在讓臨終患者「好走」；而在香港近九成的逝者選擇火葬服務時，曾因骨灰龕場輪候時間長達四年，極度供不應求，政府暫停開放龕場長達三年，並陸續推出「身後事安排專題網站」、「綠色殯葬中央登記名冊」等文件，旨在讓公眾了解殯葬服務，推廣環保「綠色殯葬」，同時減輕殯葬用地供應壓力，讓逝者「走好」。
截止最新數據統計，仍有超過八成沒聽過「預設醫療指示」及「紓緩治療」，香港市民對紓緩治療服務的了解和認識仍十分有限。除此之外，在香港僅有兩成逝者知曉並選擇「綠色殯葬」服務，「綠色殯葬」並沒有普遍被公眾所了解並接受，亦有許多人不願意談論與「死亡」有關的話題。香港於二零一五年的臨終質素全球排行中，表現最差的指標亦是「公眾參與」，與大多數未發展國家同名[2]。
「生死教育」常規化，方得深入人心
台灣與香港唯一不同的是軟硬件措施的進場順序：台灣的教育深入人心，專家學者共同推動，社會有了共識，才立法辦事；而在香港，先立法，再想盡辦法推廣到社會，告知民眾政府提供的服務。在台灣，即使是殯葬行業，都要求從業人員考取專業牌照，不止如此，台灣已領先香港，將「生死教育」納入中小學常規課程，甚至專門設置大學學位課程，亦消除醫護人員對「紓緩治療」方向的偏見，促使培育更多「紓緩治療」專業的醫護人員，效果顯著 [3]。
而香港的生死教育仍然主要依賴非牟利組織等志願團體的努力，這就是為什麼香港也像台灣一樣地去舉辦活動，很努力推廣「綠色殯葬」及「紓緩治療」，卻並未有顯著成效的主要原因。教育是最快也是最有效的方式，如若沒有常規教育作為基礎，怎能期待幾次展覽或講座就能改變人們內心對「死亡」的看法？如若沒有社會共識，更別說期待市民能主動地預先登記殯葬意願。對此，香港可以學習台灣的經驗，嘗試讓「生死教育」進校園，消除對「死亡」話題的偏見。
但除了學校，「教育」還可以發生在很多「場所」，例如「社區中心」、「文化基地」、「鄰里咖啡館」、「書店」甚至還有「墓地」等等，系列二的「死後」走好也提到了：一個好的「場所」是可以促使對話的發生，讓教育在空間中發揮更大的作用。日本東京已成功讓「青山靈園」成為市中心內深受公眾歡迎的公園，為何香港不行 [1]？
香港大多數居民居住於城市四分之一的土地上，人均公共空間只有不足三平方米，也難怪居民反對「墓園」出現在市區，除了心有芥蒂外，亦會擔心佔用公共空間。如若「生死教育」能逐漸消除公眾對「逝者之家」的偏見，讓逝者「走好」，亦能像美國那樣在墓園賞景、野餐甚至看露天電影 [1]，這樣的空間何嘗不是一種最好的「生死教育」。
香港亦有一些社會團體及獨立書店陸續舉辦「死亡咖啡館」活動，鼓勵市民積極談生死 [1]，如果能像英國那樣，讓這樣類似的活動發生在更多場所，例如音樂廳、藝術館、美術館、文化中心等，吸引更多人參與，並效仿台灣，不限制形式，將談論死亡發展成更多樣的形式，例如劇本殺，闖關遊戲等等，是否能涉及更多的群體，達到更好的效果？
「五全」照顧，分佈走
有研究顯示，紓緩治療的目標是「五全」：「全人」除了照顧病人身體以外，亦須顧及心理；「全家」不止照顧病人，還需顧及家人；「全程」確保病患有不同專科醫生合作照顧並為家人提供哀傷輔導；「全隊」指除了醫生外還需有臨床心理學家、物理治療師、社工等跨專業團隊提供服務；「全社區」旨在死亡不止發生在醫院，社區有足夠的資源支持病人在熟悉的環境中離世 [4]。而香港資源最多的是在港島，九龍新界雖有資源，但各醫院資源調配還不成熟，資源最少的則是新界西，須要特別關注。
香港的醫院框架大概分為急症醫院和復康醫院，紓緩治療服務大多數在復康醫院內提供。而紓緩治療的框架分三個層級：第一層級是醫院，第二層級是社區的安養院及護老院，第三層級是家宅安養。在香港，醫院提供的紓緩病床很有限，且某些輪候時間很長，而專門提供紓緩治療的機構又分佈不均，社區層級也僅有少數患者在港島區被支援，至於第三層級是幾乎沒有。在「生前」好走中有針對英國及台灣案例的詳細說明 [3]，香港亦可效仿，但要一步步來，需先將資源投入更多至第二層級奠定基礎，例如在鄰里長者中心、日間護理中心、安老院、綜合家庭服務中心等等，為紓緩治療服務培養更多專業的護理人員，並給各中心配備專業的護理設備，其次需與各聯網內醫院密切合作，讓市民在社區內也可安心接受「五全」的紓緩治療照顧。
「家宅」安養，路仍長
至於最後一個層級，也是最困難的。要滿足「家宅」安養並讓臨終患者走的舒適，須要滿足幾個條件：第一點也是最重要的，即是上述提到的具備充足且專業的居家護理人員，並與全科醫生緊密配合，讓患者及家人安心在家療養；第二點是加強公眾教育，消除公眾對「紓緩治療」即是「放棄治療」的誤解；第三點是確保家中有足夠舒適的環境讓患者「好走」。前兩點也是此系列討論的重點，也已經比對展示了香港的困境及如何借鑒成功做法。至於第三點，目前僅有二零二三的一份研究報告顯示近三成人願意在「家宅」離世，尚無數據支持的仍有很多要素，例如：願意在家離世的人中，滿意家中環境的有多少，如若給他們提供更舒適的環境，仍然願意在家嗎，等等。
在香港，大多數普通家庭的「家宅」面積都不大，甚至某些家庭還擠了好幾代人，因此很難確定是否適合臨終患者。另外，在「紓緩治療環境評估要素」中，其中一個指標是充分接觸自然空間的機會，而在香港市區，大部分馬路上連樹都沒有，從房間望出去是一座又一座高樓，很多住宅附近也沒有足夠的綠地空間，光是這個指標，香港的傳統「家宅」就很難滿足紓緩治療的標準。但問題是，仍要尊重病人意願，或許某些病人並不是很在乎住宿品質，只希望能在家中離世，這樣的比例又有多少？
這樣來看，臨終病人的需求是否從一開始就要被考慮到「住宅設計」、「建築設計」、「城市設計」甚至是整個「城市規劃系統」中，才能從源頭改善臨終病人的處境，讓病人「好走」，逝者「走好」。
註:
[1] 具體案例解讀請見「死後」走好 GUTS:CASE 篇
[2] 具體指標解讀請見「生前」好走 GUTS:BASICS 篇
[3] 具體案例信息請見「生前」好走 GUTS:CASE 篇
[4] 總結於陳曉蕾《香港好走》系列圖書：《怎照顧》,《有選擇》,《死在香港見棺材》
For many, death feels like a distant concept—something abstract and far away. But when it touches our lives, we are forced to confront it head-on and ask difficult questions: How do I want to live my final days? How do I want to be remembered?
In earlier articles of this series, we explored the key elements of a dignified end-of-life journey and how to create a comforting "home" for the departed, while reviewing successful global practices [1] [3]. This final piece shifts focus to Hong Kong’s next steps, exploring how the city can improve its approach to life, death, and everything in between.
“Policy First, Education Later” - The Gap in Hong Kong’s Approach
Hong Kong often prioritises legislation over education, introducing policies and services to tackle urgent issues while leaving public awareness trailing behind. This gap is especially evident in areas like end-of-life care and funeral planning.
The city is no stranger to innovation in palliative care. In the early 1980s, Hong Kong introduced its first hospice service, aiming to provide holistic care for terminally ill patients. Over the years, the government has implemented strategies such as the “Palliative Care Services Framework” and “Guidelines on Advance Care Planning” to ensure that patients can pass away with dignity.
Efforts have also been made to address the challenges of post-death arrangements. In Hong Kong, nearly 90% of the deceased choose cremation services. Due to a waiting time of up to four years for columbarium niches, there has been extreme demand. The government suspended the opening of columbarium facilities for three years and introduced initiatives such as an "After-death Arrangements Website" and a "Green Burial Central Register". These measures aim to inform the public about funeral services, promote environmentally friendly "green burials," and alleviate the pressure on burial land supply, ensuring that the deceased can "rest in peace."
Despite these efforts, public awareness remains low. Over 80% of Hong Kong residents have never heard of "advance directives" or "palliative care," and fewer than 20% of the deceased have chosen green burial options. Death remains a taboo subject, with many reluctant to discuss their end-of-life preferences. In the 2015 global ranking for end-of-life care quality, Hong Kong’s poorest-performing metric was "public engagement," on par with many underdeveloped nations [2].
Learning From Taiwan: Why Education Matters
Taiwan offers a compelling example of how education can lead to meaningful change. Unlike Hong Kong’s legislation-first approach, Taiwan builds public awareness before introducing policies, ensuring a supportive foundation for change.
In Taiwan, death education has been integrated into primary and secondary school curriculums. University programs offer specialised degrees in palliative care, and even funeral industry workers are required to obtain professional licenses. Healthcare professionals are trained to approach death with compassion, eliminating biases against palliative care and fostering a skilled workforce [3].
In contrast, Hong Kong’s death-related education depends heavily on the efforts of NGOs and volunteer groups. While these organisations work tirelessly to promote green burials and palliative care, their reach is limited. Without systematic, widespread education, it is unrealistic to expect a few campaigns or exhibitions to shift deeply rooted societal attitudes toward death. Hong Kong could benefit from following Taiwan’s lead by embedding death education into schools, normalising conversations about mortality from an early age. But education does not have to stop at the classroom. Community spaces—such as libraries, cultural centers, cafés, and even cemeteries—can serve as venues for discussions about life and death.
In Tokyo, for example, Aoyama Cemetery has been transformed into a popular public park. Could Hong Kong adopt a similar approach? [1] With most residents living on just a quarter of Hong Kong’s land and public space per capita at less than three square meters, the idea may seem far-fetched—not just due to cultural taboos but also concerns over land use. But with the right education and outreach, cemeteries could become multifunctional spaces where people reflect, gather, and embrace the cycles of life and death [1].
Some Hong Kong organisations and independent bookstores have previously hosted "Death Cafés" events encouraging open conversations about mortality [1]. If such events could expand to venues like concert halls, art galleries, and cultural centers, they might attract broader audiences. Taking a cue from Taiwan, Hong Kong could also embrace more creative approaches, such as escape rooms or role-playing games centered on death, to engage different demographics and normalise the topic.
Rethinking Palliative Care: The "Five Wholes" (「五全」照顧)
Research highlights the importance of the "Five Wholes" in palliative care [4]:
Whole Person (「全人」): Addressing not just physical needs but also emotional and psychological well-being.
Whole Family (「全家」): Supporting both patients and their loved ones.
Whole Journey (「全程」): Ensuring seamless collaboration among specialists and providing grief counseling for loved ones.
Whole Team (「全隊」): Involving multidisciplinary professionals, including doctors, psychologists, social workers, and therapists.
Whole Community (「全社區」): Providing resources that allow patients to pass away in familiar surroundings outside of hospitals.
Hong Kong’s current infrastructure struggles to meet these standards. Palliative care services are concentrated in rehabilitation hospitals, with limited availability in community settings. Resources are unevenly distributed, with Hong Kong Island far better equipped than areas like the New Territories West.
Hong Kong’s healthcare system is divided into acute care hospitals and rehabilitation hospitals, with most palliative care services concentrated in the latter. The framework for palliative care operates across three levels: the first is hospital-based care, the second is care provided at community facilities such as nursing homes and care centers, and the third is home-based care.
Currently, the availability of palliative care beds in hospitals is limited, with long wait times at some facilities. Additionally, specialised palliative care institutions are unevenly distributed, with most resources concentrated on Hong Kong Island. Community-level support is minimal, benefiting only a small number of patients, while home-based care is virtually non-existent.
Drawing inspiration from successful practices in countries like the UK and Taiwan, as discussed in the first part of this series [3], Hong Kong could adopt a step-by-step approach to improvement. The immediate priority should be strengthening the second level of care by investing more resources in facilities like neighborhood elderly centers, day care centers, nursing homes, and integrated family service centers. This includes training more specialised caregivers, equipping these centers with proper medical tools, and fostering close collaboration between hospitals and community networks. With these efforts, Hong Kong residents could access comprehensive "Five Wholes" palliative care within their communities, ensuring a more dignified end-of-life experience.
The Challenges of Dying at Home
For many, the ideal place to spend their final days is at home. However, making this a reality in Hong Kong is no small feat.
Three key conditions must be met:
Skilled care: Home-care professionals need to work closely with family doctors to ensure patients are cared for properly.
Public awareness: Misconceptions about palliative care—such as the belief that it means "giving up"—must be addressed through education.
Suitable environments: Homes must be equipped to provide patients with comfort and dignity.
While surveys suggest that nearly 30% of Hong Kong residents would prefer to die at home, many practical questions remain unanswered: How many of these individuals feel their current living conditions are adequate for end-of-life care? Would they still choose to die at home if offered better alternatives?
Hong Kong’s small living spaces pose significant challenges. Many families share cramped apartments across multiple generations, making it difficult to provide the privacy and comfort required for a dignified death. Additionally, one criterion for palliative care is access to natural surroundings. Yet, in urban Hong Kong, greenery is scarce, and most views consist of concrete high-rises, making it difficult for traditional homes to meet the standards required for palliative care. Nonetheless, it remains essential to honor patient desires. For some, dying at home in familiar surroundings is preferred, regardless of other factors. The question is, what proportion of patients hold this view? Furthermore, would patients alter their choices given access to a more agreeable alternative?
Moving Forward: A City That Cares
By prioritising education, strengthening community-level care, and rethinking urban spaces, Hong Kong can create a society where both life and death are treated with dignity. Death is not merely an end but a reflection of how we live—and how we prepare for it says much about the values of a society. It's time for Hong Kong to take the next step forward.
Remarks:
[1] For details, see article 4 - A “Good Goodbye” GUTS:CASE
[2] For details, see article 1 - “Saying Goodbye” GUTS:BASICS
[3] For details, see article 2 - “Saying Goodbye” GUTS:CASE
[4] Summarised from the book series 《香港好走》by Leila Chan :《怎照顧》,《有選擇》,《死在香港見棺材》
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