「生前」好走：有好好說再見嗎？｜"Saying Goodbye": Did We Say a Proper Goodbye?
在香港，平均每日死一百一十六人，不足十三分鐘便有一人去世，「死亡」是一個大部分人不願意提及，但又一定會在未來的某個時刻面對的境況。試問自己：死亡突然到來的那一刻，是否會手足無措？只記得照傳統跟著做，把喪事辦好，或許因為很倉促甚至都沒時間表達悲傷，然而儀式結束後，情緒撲面而來。香港每年超過四萬人死亡，其中因而抑鬱的親友約有兩成[1]。從被告知重症，走完殯葬儀式，見證親友離世，臨終這最後一程對病人和家人都影響頗大，如若處理不好，留下的遺憾和內疚可能會許久都無法了結。死亡如此令人措手不及，若有選擇，回到生前，一定都想好好善終，減少逝者及親友的遺憾，走好人生最後一程。「死亡」是個複雜且沈重的議題，本團隊將基於香港的政策體系，民眾偏好及空間規劃，分兩個系列進行剖析：「生前」好走和「死後」走好。
全球視野：各國如何詮釋「Palliative Care」？
提到「生前」好走，最重要的莫過於全方位照顧患者的處境，儘量減輕其身心靈的痛苦，提供如意的生活質素。這裡不得不提到一個概念「Palliative Care」，世界衛生組織在二零零二年給出定義，病人確診致命或是不可逆轉之疾病，且一些積極治療已經不起作用甚至會導致更大傷害時，患者有權接受「Palliative Care」以保持生活質素。至於中文解釋，各地區有不同說法：台灣稱作「安寧療護」或「安寧照顧」；內地稱作「姑息治療」，也會偶爾使用「緩和治療」或是「寧養照顧」；香港則有更多不同的稱謂，九零年代的「善終服務」（Hospice Care）、「紓緩治療」到李嘉誠基金會資助時用的「寧養服務」和「寧養中心」，今年賽馬會贊助時用的是「安寧在家」、「安寧頌」或是「安好居家寧養服務」等等。但無論名稱為何，本質都旨在整體提高病患的死亡品質，那香港在這方面進展如何呢？
香港於一九九八年成為亞洲第一個承認紓緩治療專科資格的地區。然而，據二零一五年的《經濟學人》「死亡品質指數」（Quality of Death Index）研究報告顯示，香港在八十個國家中排名第二十二位，落後於許多亞洲主要發達國家，例如台灣，新加坡，日本和韓國，其中台灣今年大幅超越香港，領先亞洲第一，排名全球第六。全球都在積極應對人口老化和出生率下降所造成的問題，各地區都愈來愈重視臨終患者的死亡品質，香港發生什麼事？
臨終關懷的挑戰：香港如何突破質素瓶頸？多方參與才能改變現狀！
香港在「二零一五全球死亡品質指數」研究報告中表現較差的有三，其一是「紓緩治療與醫療環境」，報告指出香港在「整體醫療支出、基於研究評估政策可用性，以及提供紓緩治療服務的能力」方面得分相對較低，僅得五十點四分，甚至低於中等收入國家巴拿馬和低收入國家蒙古國，得分最高的英國有八十五分，亞洲排名第一的台灣有八十分，而其中香港可以提供紓緩治療能力的估算值更低至百分之七[2]。換言之，香港去年離世的五萬七千人中，僅有能力向其中四千人提供紓緩治療服務。除了醫管局以外，還有食物及衛生局、勞工及福利局、社會福利署和一些民間團體都在提供不同類型的紓緩治療服務，但是並沒有政策令各部門合作，服務非常零碎[3]。因應「好走」倡議，兩千年醫管局轄下的醫院大約有三百張紓緩治療病床，截止二零一五年到二零一八年底，也僅有十六家公立醫院共提供約三百六十張病床，據最新數據顯示，明愛醫院已有四十張病床，較十年前僅多出十張，而一些醫院撥出來的「療養病床」還要排期好一段時間，反觀台灣的人口是香港的兩倍，但已有五十二家醫院提供「安寧病房」，約有七百張紓緩治療病床，再次說明香港提供紓緩治療服務的能力相當有限。
其二是「公眾參與」，香港僅得三十二點五分，甚至不合格，並與大多數未發展國家同名。二零一五的研究報告指出在香港「很少可以從政府網站和社區機構中獲得有關紓緩治療的資訊，公眾對於紓緩治療服務的了解和認識有限，且社區很少提供有關紓緩治療的培訓」[2]。其後，香港政府大力推動醫管局發布《紓緩治療服務策略》，並於二零一九年通過「預設照顧計劃指引」，旨在告知病人有權預先決定臨終意願，推廣紓緩治療服務。然而，據二零二三年最新數據「香港安寧照顧服務社區調查」[4]，及「香港臨終關懷定性研究」報告顯示[5]，有近八成的市民沒聽說過預設醫療指示，大多數人仍然不認識紓緩治療服務，而近九成的受訪者表示如果患有絕症，寧願接受紓緩治療服務也不願意痛苦地延長生命。
其三是「人力資源」，香港得分六十二點一分排名第二十，勉強合格，但也遠低於排名第九的台灣。報告指出香港「較缺乏受過紓緩治療專業訓練的專家、醫療專業人士和護理人員，無法確保提供高品質的紓緩治療服務」[2]，醫護界普遍對紓緩治療認識不深，甚至存有誤解。儘管公立醫院很有意願去成立紓緩治療團隊，但始終人手不夠，選擇專攻紓緩治療方向的醫護人員並不多。香港的十六家公立醫院都已有專門的紓緩病房，甚至有公立的白普理寧養中心是專門為晚期病人而設的療養院，且等候時間一般不超過兩週[3]，這些地點提供的服務包括住院紓緩服務、門診紓緩治療、家居紓緩治療、紓緩醫學診症組，及日間舒緩治療等，服務內容多樣，並由跨專業的團隊提供，包括紓緩治療專家、護士、臨床心理學家、醫務社工、物理治療師、職業治療師、營養師、其他專職醫療人員、靈性工作者和義工。截止二零一五年數據統計，一千位內科醫生裡，只有二十六人選擇紓緩治療科，全港在公營紓緩治療病房工作的護士一共也僅有兩百人[3]，截止二零一九年也僅有約四十名醫生選擇紓緩治療科及共三百名護士，而同年台灣已有八百名專科醫師投入紓緩治療。而部分紓緩治療的專家及醫護人員對醫院提供的服務並不熟悉，導致並不能給患者提供正確的資訊。可見，並不是香港沒提供紓緩治療服務的選項，而是很少有專業的醫護人員和義工，民眾獲得正確且有效的資訊也非常有限。
十年後，香港醫療服務系統恐瀕臨「崩潰」，臨終患者又該如何「好走」？
全球各地區每年死亡人數持續上升，香港也不例外。據統計，二零一四年香港死亡人數接近四萬六千人，二零二四年香港死亡人數接近五萬七千人，政府預計十年後將增加至六萬九千人，二零四六年甚至將高達九萬兩千人[1]。香港目前的死亡人數中，有超過九成是在公立醫院去世，然而針對紓緩治療服務的基礎設施和人力資源都遠不敷需，若繼續如此，香港的醫療服務系統將面臨前所未有的壓力，而對臨終病人的護理服務質量也遠遠無法達到預期。除此之外，亦有研究表明香港人也希望「回到社區，在熟悉的環境下接受護理，走完人生最後一程」，且有專家表示「我們必須加強非住院及外展服務，鼓勵紓緩治療人員與其他醫療專業人員緊密合作，並切實支援社區的非醫療照顧者，以達『持續護理』的整體目標，為末期或晚期病人提供更具自主性和令人明確心安的服務」[3]。
全球排名最高的英國每年約有五十萬人死亡，「少過六成死在醫院，兩成人在護理院，近兩成人在家裡離世，百分之四在養老院裡[3]」，截止二零一三年，仍有超過一半的死亡發生在醫院外，在家離世的比例更上升至近三成 [6]。而亞洲排名第一的台灣每年約有十六萬人死亡，市民仍然視在家離世是傳統文化，大多數人都比較支持，因而有近四成人是在家離世，甚至與死在醫院的人數相近。下一篇的吉人吉事將詳細解讀英國和台灣是怎麼做到緩解醫療系統壓力？在紓緩治療服務和人力資源上跟香港的差別是怎樣？而在城市空間規劃上，他們又是如何支持市民在社區以至於家中離世？如何在「生前」好走？
註:
[1] 數據來自政府開放數據平台「死亡統計」以及陳曉蕾《香港好走》系列圖書
[2] 根據據二零一五年的《經濟學人》（the Intelligence Unit of the Economist）「死亡品質指數」（Quality of Death Index）：紓緩治療能力的估算值（Capacity of deliver palliative care services）= <接受病人並在家庭和醫療設施中提供服務> / <特定年份的死亡人數>
[3] 部分數據源於陳曉蕾《香港好走》系列圖書：《怎照顧》,《有選擇》,《死在香港見棺材》
[4] 香港賽馬會慈善信託基金撥款近5.2億港元，於2016年策劃及開展推行為期十年的「賽馬會安寧頌」計劃，聯合香港大學社會科學學院及社會行政學系展開調查
[6] 數據來源於GOV.UK，Official Statistics，Palliative and end of life care profiles January 2025 update: statistical commentary
In Hong Kong, an average of 116 people pass away each day—roughly one death every 13 minutes. Despite its inevitability, “death” remains a topic that many avoid discussing. Yet, when the moment arrives, how prepared are we to face it? For most, the focus quickly shifts to following traditional funeral arrangements, often leaving little time to process emotions or grief. It’s only after the ceremonies are over that the weight of loss truly sets in.
Each year, over 40,000 people die in Hong Kong, and studies show that nearly 20% of their relatives and friends experience depression as a result [1]. From the moment someone is diagnosed with a terminal illness to the completion of funeral rituals, the journey of death profoundly affects both the individual and their loved ones. Without proper preparation or support, the experience can leave behind lasting feelings of regret and guilt.
Death is rarely predictable, and when it comes suddenly, it can feel overwhelming. If given the choice, many would prefer to plan for a dignified end—one that minimises regret for themselves and their families. This concept of "dying well" is not just about the final moments but also about ensuring that the process of saying goodbye is meaningful and respectful.
Death is a complex and deeply emotional topic, yet it is one that deserves careful consideration. To better understand this issue, our team will explore it through the lens of Hong Kong’s policies, cultural preferences, and spatial planning. We will approach the discussion in two parts: “Saying Goodbye” and “Good Goodbye”.
A Global Perspective: How Do Regions Interpret "Palliative Care"?
When it comes to ensuring a "good life before death," one of the most critical aspects is providing comprehensive care that alleviates physical, emotional, and spiritual suffering while maintaining a meaningful quality of life. This is where the concept of "palliative care" comes into play. Defined by the World Health Organization (WHO) in 2002, palliative care refers to the care that patients with life-threatening or irreversible illnesses have the right to receive when aggressive treatments are no longer effective or may even cause harm. The goal is to preserve their quality of life.
The terminology for “palliative care” varies across different Chinese-speaking regions. In Taiwan, it is known as “安寧療護” or “安寧照顧” (peaceful care). In mainland China, the terms “姑息治療”, “緩和治療” (alleviative treatment) and “寧養照顧” (serene care) are used. In Hong Kong, the names have evolved over time. In the 1990s, it was known as “善終服務” (hospice care) and “紓緩治療” (relief care). Later, under the sponsorship of the Li Ka Shing Foundation, it was introduced as “寧養服務” and “寧養中心” (serence care). More recently, with the funding from the Hong Kong Jockey Club, terms like “安寧在家”, “安寧頌” , and “安好居家寧養服務” (peace-at-home care) have emerged. Regardless of the terminologies, the core purpose remains: to improve the overall quality of life for patients during their final stages. But how is Hong Kong faring in this area?
In 1998, Hong Kong became the first region in Asia to officially recognise palliative care as a medical specialty. However, according to the 2015 “Quality of Death Index” report by The Economist, Hong Kong ranked 22nd out of 80 regions, trailing behind many developed Asian regions such as Taiwan, Singapore, Japan, and South Korea. Notably, Taiwan has surged ahead, now ranking 1st in Asia and 6th globally. As societies worldwide face the dual challenges of ageing populations and declining birth rates, there is an increasing emphasis on improving the quality of death for terminally ill patients. So, what is holding Hong Kong back?
Challenges in End-of-Life Care: How Can Hong Kong Break Through Its Bottleneck?
The "2015 Global Quality of Death Index" revealed significant shortcomings in Hong Kong's end-of-life care system, highlighting three critical areas of concern: infrastructure, public engagement, and human resources. These gaps underscore the urgent need for reform to address the challenges faced by terminally ill patients and their families.
1. Limited Palliative Care Infrastructure and Capacity
One of Hong Kong’s weakest areas was its palliative care infrastructure, scoring just 50.4 out of 100 points. This was lower than Panama, a middle-income country, and Mongolia, a low-income country. In comparison, the UK, ranked first globally, scored 85 points, while Taiwan, the top performer in Asia, scored 80 points.
A critical issue is Hong Kong’s limited capacity to provide palliative care. Estimates show that only 7% of those who need palliative services can access them [2]. With 57,000 deaths recorded in Hong Kong last year, this means only about 4,000 patients received proper palliative care. In 2000, public hospitals under the Hospital Authority (HA) had approximately 300 palliative care beds. By the end of 2018, this number had increased to only 360 beds across 16 public hospitals. For instance, Caritas Medical Centre currently offers 40 palliative care beds, just 10 more than a decade ago. Meanwhile, some patients must wait significant periods for palliative care facilities in hospitals. In contrast, Taiwan, with a population twice the size of Hong Kong, has 52 hospitals offering palliative care wards with around 700 beds—far surpassing Hong Kong’s capacity.
2. Low Public Awareness and Engagement
Another major concern is the lack of public engagement, where Hong Kong scored only 32.5 points, a failing grade comparable to many developing countries. The 2015 report highlighted the limited availability of information on palliative care from government and community organisation websites. Public understanding of palliative care was minimal, and opportunities for related community training were scarce [2]. In response, the Hong Kong government promoted the HA's “Strategic Service Framework for Palliative Care” and introduced the “Guidelines of Advance Care Planning” in 2019. These initiatives aimed to empower patients to make decisions about their end-of-life care and raise awareness of palliative services.
However, recent studies from the "Public Survey on End-of-Life Care in Hong Kong" [4] and the "Qualitative Study on End-of-Life Experience in Hong Kong" [5] conducted in 2023 revealed that nearly 80% of respondents were unaware of the guidelines, and most people remained unfamiliar with palliative care services.Despite this, nearly 90% of those surveyed said they would prefer palliative care over prolonging life with painful treatments if diagnosed with a terminal illness.
3. Lack of Trained Professionals
The third major issue is the shortage of trained professionals in palliative care. Hong Kong scored 62.1 points in this category, ranking 20th globally—barely passing, but still far behind Taiwan, which ranked 9th. The report noted a shortage of trained professionals in palliative care, including medical specialists, nurses, and allied healthcare workers. This lack of expertise limits the quality and availability of services [2].
Despite the willingness of public hospitals to establish palliative care teams, staffing shortages remain a significant challenge. In 2015, only 26 out of every 1,000 internal medicine doctors in Hong Kong specialised in palliative care, and there were just 200 nurses working in public palliative care wards [3]. By 2019, the numbers had risen slightly to around 40 doctors and 300 nurses. In stark contrast, Taiwan already had 800 certified palliative care physicians in the same year.
Currently, all 16 public hospitals in Hong Kong have specialised palliative care wards. Institutions such as the Bradbury Hospice provide specialised care for terminally ill patients, with wait times typically under two weeks [3]. These facilities offer a wide range of services, including inpatient care, outpatient consultations, home-based care, and day services. A multidisciplinary team composed of palliative care specialists, nurses, clinical psychologists, social workers, physiotherapists, occupational therapists, dietitians, spiritual workers, and volunteers delivers these services.
However, the limited number of trained professionals hinders the system. Many healthcare workers and volunteers lack proper training, and some are unaware of the full range of services available. This creates barriers to providing accurate information and quality care to patients.
Will Hong Kong's Healthcare System Collapse in 10 Years?
As global death rates rise year by year, and Hong Kong is no exception. In 2014, nearly 46,000 people passed away. By 2024, that figure is projected to reach 57,000, and by 2034, it is expected to climb to 69,000. By 2046, annual deaths could soar to 92,000 [1]. With more than 90% of deaths in Hong Kong currently occurring in public hospitals, the strain on the city’s healthcare system is already immense. If this trend continues, Hong Kong’s medical services face the risk of unprecedented pressure, and the quality of care for terminal patients will likely fall short of expectations.
There is also growing evidence that many Hong Kong residents prefer to spend their final moments in familiar surroundings, such as their own homes or communities, instead of in hospitals. Experts have emphasised the need to bolster home-based and outreach services. As one specialist put it: "We must strengthen non-hospital and outreach services, encourage greater collaboration between palliative care providers and other healthcare professionals, and provide meaningful support to non-medical caregivers in the community. By doing so, we can achieve the goal of 'continuity of care,' offering more autonomy and peace of mind to patients in their final stages of life." [3].
The UK, ranked first globally in palliative care, sees around 500,000 deaths annually. Less than 60% of these occur in hospitals—20% take place in care homes, another 20% at home, and 4% in nursing homes [3]. As of 2013, more than half of all deaths in the UK occurred outside of hospitals, with nearly 30% of people passing away at home—a growing trend [6]. Similarly, in Taiwan, about 160,000 people pass away annually. In line with traditional cultural values, many Taiwanese people prefer to die at home. As a result, nearly 40% of deaths occur at home, a figure that is almost equal to the number of hospital deaths.
What Can Hong Kong Learn?
The next article in this series will take a closer look at how the UK and Taiwan have managed to ease the burden on their healthcare systems. We will explore how their approaches to palliative care services and human resources differ from Hong Kong’s, and how their urban planning initiatives support residents who wish to die at home or in their communities.
Remarks:
[1] Data from the government’s open data platform “Death Statistics” and the book series 《香港好走》by Leila Chan
[2] According to the 2015 Economist Intelligence Unit’s “Quality of Death Index”: Estimated capacity for palliative care = <number of patients served at home and medical facilities> / <number of deaths in a specific year>
[3] Some data sourced from the book series 《香港好走》by Leila Chan ：《怎照顧》,《有選擇》,《死在香港見棺材》
[4] Supported by nearly HK$520 million from The Hong Kong Jockey Club Charities Trust, the ten-year “Jockey Club End-of-Life Community Care Project” was launched in 2016 in collaboration with the Faculty of Social Sciences and the Department of Social Work and Social Administration at The University of Hong Kong
[5]Knox, Michelle. "Design-related impacts on end-of-life experience: a brief report of findings from an exploratory qualitative study." American Journal of Hospice and Palliative Medicine® 40.7 (2023): 753-760.
[6]Data from GOV.UK, Official Statistics, Palliative and end of life care profiles January 2025 update: statistical commentary
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