Cancer has been the leading cause of death in Taiwan since 1982. More than 40,000 patients die of cancer each year and the number is increasing; however, the quality of life of these terminally ill cancer patients is often neglected. Many patients die after tremendous suffering. With advances in medical technology, both Taiwan and the West have followed a similar path leading to improved palliative medicine and hospice care. The hospice movement started in 1983, and the first hospice was set up in 1990 at Mackay Memorial Hospital in Northern Taiwan (1), a Christian-based hospital. Many hospices were set up thereafter, mainly in private hospitals owned or sponsored by religious institutions. In 1995, the National Taiwan University Hospital (NTUH) launched the first public ward devoted to providing palliative and hospice care and aiming to integrate service with teaching and research and increase public awareness of palliative care (2).

The 2015 Quality of Death index, as rated by the Economist Intelligence Unit, ranked Taiwan first among Asian countries and sixth in the world (3). This ranking is based on five categories; palliative and health care environment, human resources, affordability of care, quality of care and community engagement. The availability of palliative services has steadily grown in recent years, with hospice home care programs increasing by more than 50% since 2004 to reach 77 programs in 2015, and hospital-based palliative care teams increasing from 8 to 112 over the same period. There are 51 institutes having inpatient palliative care units at present. In terms of human resources, we now have about 759 specialists in palliative medicine, the majority of which are family physicians. In addition to this increase in palliative care teams, other medical specialists in related fields, such as nephrology or geriatric medicine, are receiving training in palliative care and now incorporate it into their treatment plans. Palliative care services are also affordable: Taiwan’s National Health Insurance (NHI) system plays a key role in the provision of palliative care, by determining insurance coverage and the level of reimbursement for specific services for both cancer and non-cancer patients, and reimbursement levels have increased for both home visits and hospital-based care, providing more incentive for institutions to offer palliative care. The quality of palliative care in Taiwan has always been a focus of attention, with a particular effort being made to improve the quality of a patient’s final days. Major advances have been made in recent years: For example, 50% of terminally ill cancer patients were accurately aware of their prognosis by 2012 (4). The use of aggressive medical treatments for cancer patients aware of their prognosis in the last month of life, such as CPR and intubation, also declined over this period. In addition, research concluded that physician-assessed autonomy is an important factor allowing for a good death, and is highly correlated with age, level of consciousness and quality of dying at the end of life in advanced cancer patients in Taiwan (5). Community engagement, in particular to help the patient and family achieve a good death at home, has been progressing, due to the cultural propensity to die at home (6).

In this review article, we highlight three particular areas that might have contributed to the success of hospice palliative care in Taiwan, in addition to the efforts mentioned above; the laws and regulations, spiritual care and research network. Finally, we discuss the future challenges and prospects for Taiwanese encounters.

1. Laws and regulations of hospice palliative care in Taiwan

The passing of the “Natural Death Act” in 2000 set the example and established a landmark for patient autonomy in Asia; it guarantees the patient’s right to request that medical staff do not resuscitate (DNR) them and to reject other futile medical treatments at the end of their life, thus reflecting the importance of palliative care from the policy perspective. The Natural Death Act provides medical personnel with a legal basis to make medical decisions in accordance with the living will of patients. Despite the several amendments that have been made to the law over the years, a previous study demonstrated that the enactment of the Natural Death Act in Taiwan has contributed to improving the quality of end-of-life care (7).

In 2015, Taiwan passed another pioneering law entitled the “Patient Autonomy Act”. This law states that the patient may decline medical treatment according to his/her own will. This applies not only to terminally ill cancer patients, but also to those who are irreversibly comatose, vegetative, suffering from terminal dementia, or are experiencing intractable symptoms and suffering. Advance directive and advance care planning consultations are advised for every patient wishing to apply this law. The Patient Autonomy Act will come into force in 2018.

2. Spiritual care for the terminally ill in Taiwan

More than 70% of Taiwanese are Buddhists. Taiwanese indigenous spiritual care was launched in 1995 after the Hospice and Palliative Care Unit of the National Taiwan University Hospital was founded (8). This unit received research grants to study the possibility of applying Buddha dharma in terminal care, resulting in the launch of the training program for Clinical Buddhist Chaplains (CBC) in 2000. This unit is renowned as a center of excellence for training in spiritual care. Buddhists concentrate on the four establishments of mindfulness regarding the body, feelings, states of mind, and phenomena, or focus on the life structure of the body, mind, and wisdom. Qualified CBCs are required to successfully complete a training program consisting of lectures as well as bedside practicum before applying Buddhist practices to end- of-life care. According to the Four Noble Truths, clinical diagnosis and treatments, when considering the sickness as spiritual suffering, can be determined by categorizing it into its physical, psychological, family, social and spiritual aspects; the goal of care is planned according to the ‘Four Dwellings in Mindfulness’; the effects of the practice of Buddhist methods are carefully evaluated and recorded. The training programs that a professional CBC has to complete are divided into four stages: a basic three-month clinical training program on hospice wards, continuing education program and advance study, teaching skills training program and a faculty development program. There are now 35 qualified CBCs working in 39 units across the 13 areas of Taiwan. In palliative care units, trained CBCs resolve patients’ spiritual sufferings, promote their spiritual status and reduce their fear of death. These practices help patients to transcend the worldly dharma, discover their ‘inner’ power, improve their quality of dying and achieve a good death. CBCs provide both the family members and medical teams with life education, transform obstacles into practical assistance and reduce grief.

3. Taiwan research network and cross-cultural collaboration

Inspired by Dr. Stein Kaasa of the European Palliative Care Research Centre, the Taiwan Academy of Hospice Palliative Medicine established its own research network in Taiwan in 2011. By collecting data simultaneously in different medical centers and through hi-tech methods, we believe it is the most efficient, influential and up-do-date way to carry out research in palliative medicine in the 21st century.

The academy functions as the soul of the network. The secretariat is responsible for funding and supervising the progress of the project. The academic division conducts the research in every detail, including setting the direction of the research, recruiting the participating hospitals, monitoring data collection in each hospital, and assigning people for data analysis, writing and final authorization.

Since achieving a good death is one of the ultimate goals in palliative care, the first multicentre study we conducted was to find out what affects the quality of dying of terminally ill cancer patients in Taiwan. As a previous study showed that patient autonomy is one of the factors, we wanted to further examine what affects patient autonomy. By using the validated ‘Good Death Scale’ we had previously developed, we measured the associated correlates that affect quality of dying and patient autonomy. Four medical centers participated in the study and the team held monthly teleconference discussions (5).

Recently, we have been collaborating with Dr. Tatsuya Morita, an internationally renowned scholar in palliative medicine from Japan, focusing on the subjects of physician- perceived good death and patient autonomy. For this purpose, a survey was designed and distributed by the Japanese team, and physicians from Korea, Japan and Taiwan answered the questionnaire via computer. The study is the first example of a cross-cultural research network in Asia (6,9). A Japan- Korea-Taiwan research network has now been established and provides the collaboration required for the East-Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED) cohort. Recently, the School of Public Health of National Taiwan University and Kyoto University signed a mutual collaboration contract to conduct research in the fields of long term care, end of life care and advance care planning.

4. Future prospects and challenges

Despite the many advances that have been made in the past 20 years, Taiwan is still facing a number of challenges, such as the development of an infrastructure for home care; namely, how to persuade patients and family to return home and prepare for a good death without worrying about a lack of backup support. There is a high readmission rate after discharge from hospital for the terminally ill (10). In addition, the advocacy of advance directive and advance care planning would have to be a focus of attention, since truth telling is culturally regarded as taboo in Taiwanese society.

With the consensus from the government and society to make it a priority, hospice and palliative medicine in Taiwan has been growing steadily. From the policy perspective, The Natural Death Act and the Patient Autonomy Act have guaranteed terminally ill patients the right to decline futile treatment and die with dignity. Financially, hospice and palliative medicine comes under the coverage of the National Health Insurance and the level of reimbursement has been increased, in order to give more incentive to the hospitals. Internationally, we have initiated a research network with Japan, Korea and Kyoto University to share our research outcomes. There is a long and winding road ahead, but much progress has already been made and we anticipate achieving even greater success in the future.