DEATH, DYING and B E R E A V E M E N T A Hong Kong Chinese Experience

Edited by Cecilia La i Wan Cha n an d Amy Yin Ma n Cho w

* if c * # £ H R *f c H O N G KON G U N I V E R S I T Y PRES S

Hong Kong University Press 14/F Hing Wai Centr e 7 Tin Wan Pray a Roa d Aberdeen Hong Kon g

© Hong Kon g Universit y Press 200 6

ISBN 962 20 9 787 1

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Photograph o n cove r courtesy of Mr Timothy H. Y. Chan

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Hong Kon g University Press is honoured tha t Xu Bing, whose ar t explore s the comple x theme s o f languag e acros s cultures , ha s written th e Press' s name i n hi s Squar e Wor d Calligraphy . Thi s signal s ou r commitmen t t o cross-cultural thinkin g an d th e distinctiv e natur e o f our English-languag e books publishe d i n China .

"At firs t glance , Squar e Wor d Calligraph y appear s t o b e nothin g mor e unusual tha n Chines e characters , bu t i n fac t i t i s a new way of renderin g English word s i n th e forma t o f a squar e s o the y resembl e Chines e characters. Chines e viewer s expec t t o b e abl e t o rea d Squar e wor d Calligraphy but cannot. Western viewers, however are surprised t o find the y can rea d it . Delight erupt s when meanin g i s unexpectedly revealed. "

— Britta Erickson, The Art ofXu Bing

Contents

Foreword Robert A. NEIMEYER i x

Foreword Che Hung LEONG x i

Foreword Vivian Taam WONG xii i

Preface x v

Contr ibutors xii i

Chapter 1 In t roduct io n 1 Amy Yin Man CHOW and Cecilia Lai Wan CHAN

PART ONE DEAT H

Chapter 2 O u r Memoria l Quilt : Recollection s o f Observation s 1 5 from Clinica l Practic e o n Death , Dyin g an d Bereavemen t Cecilia Lai Wan CHAN and Amy Yin Man CHOW

Chapter 3 A Persona l Journey: T h e Physician , th e Researcher , 3 1 the Relative , an d th e Patien t Yvonne Yi Wood MAK

Chapter 4 "Lettin g Go " an d "Holdin g On" : Grievin g an d 6 5 Traditional Deat h Ritual s i n H o n g Kon g Peter Ka Hing CHEUNG, Cecilia Lai Wan CHAN, Wai FU, Yawen LI and Grace Yee Kam Pau CHEUNG

Chapter 5 Makin g Peac e wit h th e Unknown : A Reflectio n 8 7 on Daois t Funerar y Liturg y Chi Tim LAI

vi Contents

Chapter 6 Deat h fro m th e Buddhis t View : Knowin g th e Unknow n 9 3 JINGYIN

Chapter 7 Autops y i n Chinese : A Forensi c Pathologist ' s Vie w 10 5 Philip Swan Lip BEH

Chapter 8 Deat h Metaphor s i n Chines e 11 7 Wing Shan CHEUNG and Samuel Mun Yin HO

Chapter 9 Wha t I s Goo d Death : Bridgin g th e Ga p betwee n 12 7 Research an d Interventio n Wallace Chi Ho CHAN, Heung Sang TSE and Timothy Hang Yee CHAN

PART TWO DYIN G

Chapter 1 0 Impac t o f Palliativ e Medicin e o n th e Qualit y o f Lif e 13 9 of th e Dyin g Michael Mau Kong SHAM, Kin Sang CHAN, Doris Man Wah TSE and Raymond See Kit LO

Chapter 1 1 Dying : T h e Las t Mont h 15 1 Raymond See Kit LO

Chapter 1 2 Euthanasi a an d Forgoin g Life-sustainin g Treatmen t 16 9 in th e Chines e Contex t Chun Yan TSE and Samantha Mei Che PANG

Chapter 1 3 Communi t y Palliativ e Car e i n H o n g Kon g 18 3 Faith Chun Fong LIU

Chapter 1 4 T h e Rol e o f Chines e Medicin e i n Cance r Palliativ e Car e 19 5 Siu Man NG

Chapter 1 5 Providin g End-of-Lif e Care : Enhancin g Effectivenes s 20 9 and Resilienc e Peter Wing Ho LEE and Tracy Tak Ching KWAN

Chapter 1 6 Car e fo r Chines e Familie s wit h Patient s Facin g Impend in g 22 5 Death: Nurses ' Perspective s Amy Yin Man CHOW, Jess ShukFun LO, Wendy Wai Yin LI and Carmen Yuek Yan LAI

Chapter 1 7 Walkin g a Tightrope : T h e Los s an d Grie f o f Parent s 24 1 with a Chil d Sufferin g fro m Cance r i n Shangha i Vivian Wei Qun LOU and Cecilia Lai Wan CHAN

Contents vii

PART THREE BEREAVEMEN T

Ghapter 1 8 Bereavemen t Car e i n H o n g Kong : Past , Presen t 25 3 and Futur e Amy Yin Man CHOW and Cecilia Lai Wan CHAN

Chapter 1 9 W h e n Eas t Meet s West : Th e Implicatio n fo r 26 1 Bereavement Counsellin g Brenda Wing Sze KOO, Agnes Fong TIN, Elaine Wai Kwan KOO and Sze-man LEE

Chapter 2 0 T h e Us e o f Structure d Therapeut i c Bereavemen t Group s 27 3 Agnes Fong TIN, Elaine Wai Kwan KOO and Sze-man LEE

Chapter 2 1 T h e Us e o f Volunteers i n Bereavemen t Car e 28 5 Eddie Ho Chuen CHAN

Chapter 2 2 T h e Da y After: Th e Suicid e Bereavemen t Experienc e 29 3 of Chines e i n H o n g Kon g Amy Yin Man CHOW

Chapter 2 3 Conclusio n 30 9 Cecilia Lai Wan CHAN and Amy Yin Man CHOW

Reference 31 9

Index 349

Contributors

Philip Swan Lip BEH, MBBS HK, DMJ Lond, FHKCPath, FHKAM (Pathology )

Dr Beh i s currently a Clinical Associate Professor i n forensic patholog y in th e Department o f Pathology, Faculty of Medicine, University o f Hong Kong . H e graduated from th e University of Hong Kong in 198 1 and worked a s a forensi c pathologist with th e Forensi c Pathology Service , Department o f Health fro m 1982 to 1995 , before joining th e Facult y o f Medicine . H e ha s been involve d in ove r 10,00 0 coroner' s cases , during which h e interviewe d famil y member s in a n effor t t o establis h prio r medica l histor y an d t o infor m the m o f th e requirements fo r autopsie s unde r th e Coroner's Ordinance. He i s frequentl y required t o giv e exper t medica l evidenc e i n deat h inquests , i n civi l case s involving injury an d death and in criminal cases, particularly assault, rape an d homicide.

Cecilia Lai Wan CHAN, BSocSc, MSocSc, PhD, RSW, JP

Professor Cha n ha s been instrumenta l i n th e establishmen t o f the Centr e o n Behavioral Healt h an d th e Centr e o f Suicide Research an d Preventio n o f th e University of Hong Kong . She served a s director an d associat e director o f th e two centres respectively , and a s a professor o f the Departmen t o f Social Work and Socia l Administration. Sh e is a committee member on various health-car e societies and autho r o f over 100 articles and book chapters on health , practic e research, psychosocia l oncology , bereavemen t an d palliativ e care . She use s a strength-oriented approac h i n her work on empowermen t o f chronic patients , cancer patients , divorced women, bereaved famil y member s an d traumatize d individuals. He r Easter n body-mind-spiri t approac h an d culturall y relevan t practices hav e bee n widel y adopted i n th e healt h car e and socia l work field .

xviii Contributors

Eddie Ho Chue n CHAN, BSW, RSW

Mr Chan i s the centr e directo r o f The Comfor t Car e Concern Group . He ha s over seve n year s o f experienc e i n servin g peopl e facin g deat h an d bereavement. H e ha s conducte d a numbe r o f in-hous e voluntee r trainin g workshops i n variou s organization s relate d t o th e topi c o f car e fo r th e caregiver, emotiona l handling , volunteer befriendin g visitatio n training , etc . In recent years, Mr Chan has been interested in working with bereaved Chines e males.

Timothy Hang Yee CHAN, BCogS c

Mr Cha n receive d hi s bachelor' s degre e i n cognitiv e scienc e fro m th e University o f Hong Kon g in 2002 . Currently, h e i s a research coordinato r a t the Centr e o n Behaviora l Health , Universit y o f Hon g Kong , workin g o n research project s rangin g fro m mindfulnes s an d health , deat h attitudes , t o post-traumatic meanin g reconstruction .

Kin San g CHAN , MBBS , MRC P UK, FRCP Edin, Glas and Lond, FHKCP , FHKAM

Dr Cha n ha s been th e chie f o f service o f th e Pulmonar y an d Palliativ e Car e Unit o f Haven o f Hope Hospita l sinc e 1995 . He i s one th e firs t grou p o f fiv e physicians accredite d b y the Hon g Kon g Colleg e o f Physicians as a Specialis t in Palliative Medicine in 1998 . He graduated from th e University of Hong Kong in 198 1 and receive d post-graduat e medica l trainin g a t th e Unite d Christia n Hospital o f Hong Kon g and i n hospital s in th e United State s and th e Unite d Kingdom. His main interest s include holisti c care, psychological care , medica l ethics an d rehabilitation . H e ha s bee n promotin g palliativ e car e throug h various professional societie s and NGOs . Dr Chan i s a contributing autho r i n the secon d an d thir d edition s o f The Oxford Textbook of Palliative Medicine.

Wallace Ch i Ho CHAN , BSW, RSW

Mr Chan i s currently a PhD candidate i n th e Department o f Social Work an d Social Administration, Universit y of Hong Kong . His areas of interest includ e bereavement, deat h an d dying , hospic e care , logotherap y an d existentia l psychology. In addition , Mr Chan i s a registered socia l worker in Hong Kong . He i s experienced i n elderl y service an d medica l socia l service . He i s now a medical socia l worker and i s responsible for working with patients and familie s of palliative car e i n th e Ruttonje e Hospital .

Contributors xix

Grace Yee Kam Pau CHEUNG, BSW , PhD, RSW

Dr Cheun g i s an Honorar y Assistan t Professo r i n th e Departmen t o f Socia l Work and Socia l Administration, Universit y of Hong Kong ; and a n Executiv e Committee member of the Centre on Behavioral Health in the same university. She ha s bee n engage d i n socia l wor k practic e a s a marriag e an d famil y counsellor i n Hong Kon g for th e pas t twenty-six years. Currently, sh e teache s the Sati r mode l an d famil y reconstructio n t o socia l wor k student s i n th e University of Hong Kong, provides clinical consultation an d supervision i n th e Satir model to workers in social agencies, runs a private practice in counselling , and conduct s Sati r workshops as well as life an d deat h workshops for helpin g professionals an d clien t groups .

Peter K a Hin g CHEUNG , Baccalaureatu s an d Prolytatu s i n Theolog y (University o f Propaganda Fide , Rome), BSocSc , MA

Mr Cheung was chief edito r o f a weekly publication. H e ha s also worked a s a teacher, marriag e counsellor , huma n right s organize r an d researcher . H e i s currently a Ph D candidat e i n th e Departmen t o f Socia l Wor k an d Socia l Administration, Universit y o f Hon g Kong . Hi s researc h are a i s the marita l sexual experience s o f husbands o f women treate d fo r breas t cancer .

Wing Shan CHEUNG, BSocSc , MPhi l

Ms Cheung starte d he r investigatio n int o Chines e perceptio n o f death a s a n undergraduate. He r researc h i s widely accepted b y international scholar s an d was published i n the Death Studies, an international journal specificall y focuse d on deat h research . M s Cheung the n extende d he r undergraduat e researc h into a multi-cultural compariso n stud y among adolescents , and obtaine d he r MPhil degre e i n th e Universit y o f Hon g Kong . A s a motivate d youn g researcher, M s Cheung had als o participated activel y in international researc h seminars an d ha d won tw o research award s in internationa l conferences .

Amy Yin Man CHOW, BSocSc, MSocSc, RSW, CT

Ms Chow is an Honorary Clinical Associate of the Centre on Behavioral Health , as well as an Assistant Professor i n th e Departmen t o f Social Work and Socia l Administration, Universit y o f Hon g Kong . Sh e i s a registered socia l worke r with a specialization i n bereavement counselling . She has worked a s a medica l social worker, fieldwork instructo r and centre-in-charge of the first community -based bereavemen t counsellin g centr e i n Hon g Kong . Sh e i s certifie d i n thanatology: death , dyin g and bereavement . I n 2005 , she receive d th e cross -cultural pape r awar d o f ADE C (Associatio n o f Deat h Educatio n an d Counselling).

xx Contributors

Wai FU, BSocS c (Gen) , MPhi l

Mr F u i s a researc h associat e i n th e Centr e o n Behaviora l Health , Th e University of Hong Kong. He i s currently a PhD candidate i n th e Departmen t of Socia l Work an d Socia l Administration, Universit y o f Hon g Kong , unde r the supervision o f Professor Cecili a Chan. His major researc h interes t includes analysis o f narrative s o n th e persona l experienc e o f cance r patients , th e construction o f health-relate d discourses , an d th e histor y o f psycholog y i n China an d Hon g Kong .

Samuel Mun Yin HO, BSocSc , MSocSc (Cli n Psy) , PhD Melb

Dr H o i s an Associate Professo r i n th e Departmen t o f Psychology, Universit y of Hong Kong . His research interest s includ e clinica l healt h psycholog y an d indigenous psychotherapy . D r Ho direct s th e Positiv e Psychology Laborator y of the Psychology Department an d i s doing research o n positiv e changes afte r traumatic events such as life-threatening illnesse s and bereavement . Dr Ho ha s published i n prominent healt h an d clinical psychology journals such as Psycho-oncology and th e Journal of Consulting and Clinical Psychology.

JING YIN, MA, MPhil Kelaniya, PhD Lond

The Venerabl e Jing Yi n obtaine d hi s PhD fro m th e Schoo l o f Orienta l an d African Studies , University of London, in 2001. He is the Director of the Centr e of Buddhis t Studies , Universit y o f Hon g Kong . Hi s researc h interest s ar e Vinaya, Chines e Buddhis m an d th e socia l applicatio n o f Buddhism . I n th e more than twent y years since entering the Order in 1982 , he has devoted som e of hi s tim e t o helpin g dyin g persons , t o pu t the m a t ease . H e founde d th e Buddhist Educatio n Foundatio n i n 199 6 in th e U K and edite d tw o Buddhis t texts for schoolchildren , with the intention to promote personal growth amon g young children .

Brenda Wing Sze KOO, BSW, MSocSc, RSW, CT

Ms Koo i s a bereavement counsello r a t th e Jessie an d Thoma s Ta m Centr e for th e Societ y fo r th e Promotio n o f Hospice Car e (SPHC) . The Jessie an d Thomas Tam Centre, one of the pioneer projects of the SPHC opened in 1997, is the first community bereavement counselling, education and resource centr e in Hong Kong. She is specialized in providing individual and group counsellin g for variou s bereaved clients , including widows, widowers, bereaved children , bereaved elderl y people , parent s losin g childre n an d adul t childre n losin g parents.

Contributors xxi

Elaine Wai Kwan KOO, RN, RM

Ms Koo i s a bereavemen t counsello r a t th e Jessie an d Thoma s Ta m Centr e for th e Societ y for th e Promotio n o f Hospice Car e (SPHC) . The Jessie an d Thomas Tam Centre, one of the pioneer projects of the SPHC opened i n 1997 , is the first community bereavement counselling, education and resource centr e in Hong Kong. She is specialized in providing individual and group counsellin g for variou s bereaved clients , including widows , widowers, bereaved children , bereaved elderl y people , parent s losin g childre n an d adul t childre n losin g parents.

Tracy Tak Ching KWAN, BSc (Nurs) , RN Can

Ms Kwan receive d he r BS c in Nursin g fro m th e Universit y o f Toronto . Sh e has extensiv e experienc e workin g with physicall y and criticall y il l patients i n the hospita l setting . She i s currently a research worke r i n th e Departmen t o f Psychiatry, Universit y o f Hon g Kong . Sh e ha s participate d i n studie s i n th e areas o f clinical communication , menta l illnes s and psycho-oncology .

Carmen Yuek Yan LAI, BScN (Hon) , R N

Ms Lai has been a registered nurs e sinc e th e 1990s , working i n th e medica l ward an d coronar y car e uni t i n a n acut e hospital . The increasin g numbe r o f sudden death s from hear t attac k and th e admissio n o f critically il l and dyin g patients had compelle d M s Lai and he r superviso r t o concentrate o n th e car e of dying patient s an d th e grievin g family . The y liased with severa l ward staf f members and established a working group on bereavement care in 1999 . They have gaine d valuabl e experienc e throug h th e carin g proces s an d whic h ha s been share d with frontline nurses .

Chi Tim LAI, BA, BD (Hons) , MA, PhD

Professor Ti m is professor o f Daoist studies at the Department o f Cultural an d Religious Studies , th e Chines e Universit y o f Hon g Kong , wher e h e offer s courses in histor y o f Daoism, Si x Dynasties Daois t Classics , Daoist ritual , an d Hong Kon g Daoism . H e receive d hi s Ph D fro m th e Universit y o f Chicag o Divinity School , specializin g i n Daois m an d histor y o f religions. His writings mainly cover Six Dynasties Daoism, and contemporary Guangdong an d Hon g Kong Daoism . H e ha s publishe d i n th e internationa l journals o f T'oungPao, China Quarterly, Asia Major third series , Numen, Journal of Chinese Culture (Hong Kong), Bulletin of the Institute of Modern History Academia Sinica, Bulletin of the Institute of History and Philology Academia Sinica, and Taiwan Journal for Religious Studies. He i s currently working on early Heavenly Master Daoism, Daoist ritual tradition, an d historie s o f Hong Kon g and Guangdon g Daoism .

xxii Contributors

Peter Wing Ho LEE , BSocSc, MSocSc (Cli n Psy) , PhD

Professor Le e i s professor i n clinica l healt h psycholog y in th e Departmen t o f Psychiatry, Universit y o f Hon g Kong . H e ha s a long - standin g interes t i n psychological treatment s fo r physicall y ill patients, including cance r an d end -of-life care . He i s also interested in enhancing awareness and bette r emotiona l care fo r peopl e wh o ar e physicall y ill , through workin g collaborativel y wit h medical an d allie d health-car e professionals .

Sze Man LEE, BSW, RSW

Ms Lee is a bereavement counsello r a t the Jessie and Thomas Tam Centre fo r the Society for the Promotion o f Hospice Care (SPHC) . The Jessie and Thoma s Tam Centre , on e o f the pionee r project s o f the SPH C opened i n 1997 , is th e first communit y bereavemen t counselling , educatio n an d resourc e centr e i n Hong Kong . She i s specialized in providing individua l an d grou p counsellin g for variou s bereaved clients , including widows , widowers, bereaved children , bereaved elderl y people , parent s losin g childre n an d adul t childre n losin g parents.

Wendy Wai Yin LI, BN (Hon) , R N

Ms Li ha s bee n workin g i n th e surgica l uni t fo r ove r twent y years . Sh e i s a Nursing Office r an d a tea m membe r o f bereavemen t suppor t grou p i n th e hospital. Sh e believe s tha t bereavemen t servic e shoul d b e provide d t o al l patients, and i s committed t o serving cancer patients in an acute surgical ward by spending tim e i n caring , listenin g to , supporting an d givin g informatio n to th e cance r patient s an d thei r famil y members .

Yawen LI, MSW

Ms Li i s now a doctora l studen t i n th e Schoo l o f Socia l Work, Universit y o f Southern California . Sh e was involved in a variety of studies when sh e worke d at the Centr e o n Behaviora l Health a t the University of Hong Kong from 200 2 to 2003. She studied th e psychosocial well-being of cancer patients , death an d dying, and bereavement , wit h a focus o n culturall y relevant practice .

Faith Chun Fong LIU, RN, RGN, BScN

Ms Liu i s a pioneer i n hospic e car e i n Hon g Kong . Sh e i s now working a s a bereavement counsello r a t Grantha m Hospital . A s a clinica l nurs e i n th e specialty for mor e tha n te n years , she has been ver y privileged t o learn fro m her patient s and thei r family members . They teach he r t o love, to forgive an d to let go. The journey with thos e marvellou s teacher s is a way to grow in self -awareness, self-reflectio n an d self-expansion .

Contributors xxiii

Jess Shu k Fun LO, RN, RM, BN, MN

Ms Lo i s an Advanced Practic e Nurs e o f a n adul t intensiv e car e uni t o f Th e Hong Kong Hospital Authority. Her major experienc e i s in the areas of critical care nursing and clinica l information syste m development. Sh e has also bee n involved i n th e hospita l bereavemen t suppor t servic e workin g group . He r masters degre e researc h was on deat h an d bereavemen t perception s amon g Chinese bereave d peopl e who los t a loved on e i n th e critica l car e unit .

Raymond See Kit LO, MBBS Lond, MD CUHK, MHA UNSW, MRCP UK, FRCP Edin, Di p Ger i Med (RCP S Glas), Dip Pallia t Med Waks, FHKCP, FHKAM

Dr L o graduate d fro m th e Unite d Medica l Schoo l o f Guy' s an d S t Thoma s Hospital i n Londo n an d i s currentl y Cluste r Coordinato r o f Hospic e an d Palliative Care Services for Ne w Territories East , Honorary Chie f o f Service of Bradbury Hospice, and Senior Medical Officer i n the Department of Medicine and Geriatrics , Shati n Hospital . D r L o i s accredite d i n th e specialtie s o f advanced interna l medicine , geriatric s an d i n palliativ e medicine . He i s also chairman o f the qualit y assurance subcommitte e o f HA COC Palliative Care . He undertake s regula r teachin g fo r undergraduate s an d postgraduate s in geriatrics, palliative care and ethica l issues . His doctoral thesi s is on qualit y of life i n palliativ e car e patients .

Vivian Wei Qun LOU, BE d ECNU, Med ECNU, MS W HK, PhD HK, RSW

Dr Lou i s currently a n assistan t professor i n th e Departmen t o f Socia l Work , The Chinese University of Hong Kong. Dr Lou received her B.Ed. (Psychology ) and M.Ed . (Psychology ) fro m Eas t China Normal University; and obtaine d he r Master o f Social Work and Ph.D . (Socia l Work) fro m Th e Universit y of Hon g Kong. Her research project s focus o n th e socia l adaptation an d menta l healt h of women an d olde r adults . She als o has a keen interes t i n practic e researc h on factors tha t contribute t o the enhancement o f mental health status . Dr Lou is presently a member of the American Psychological Association and the Hon g Kong Socia l Workers Association .

YvonneYi Wood MAK, MBBS Lond, DGM Lond, DRCO G Lond, MSc Wales

After qualifyin g a t Guy' s Hospital , London , D r Ma k embarke d o n genera l practice training with a particular interest in palliative medicine. Subsequently , she worked a t Bradbury Hospice a s a Medical Officer , durin g which tim e sh e completed th e Diplom a an d Maste r Program s i n Palliativ e Medicin e a t th e University of Wales, receiving distinction fo r bot h modules . Her dissertation , 'The meanin g o f desire for euthanasi a i n advance d cance r patients " received the 200 1 UK Association o f Palliative Medicin e Award and th e 200 4 Londo n

xxiv Contributors

Royal Society of Medicine Innovativ e Researc h i n Palliative Car e Prize . She i s involved in undergraduate educatio n a t the Chinese University of Hong Kong . As an honorary lecturer in palliative medicine a t Cardiff University , Wales, she coordinates th e postgraduat e palliativ e car e course s fo r Asi a pacific . Sinc e becoming a cancer patient, her mission has extended beyon d th e hospice walls and sh e serve s a s a n honorar y adviso r fo r th e Hon g Kon g Breas t cance r Foundation. Sh e aim s t o promot e a positiv e attitud e t o livin g throug h education an d creativ e writing .

Siu Man NG, BSc , BHSc, MSc

Mr N g i s an Assistan t Professo r an d Clinica l Coordinato r a t th e Centr e o n Behavioral Health , Universit y o f Hon g Kong . Hi s researc h are a i s th e application o f Chines e medicin e an d traditiona l Chines e philosophie s i n mental healt h practice .

Samantha Mei Che PANG, RN, Ph D

Dr Pan g i s a nurse b y professional training , an d a researcher i n th e fiel d o f health car e an d nursin g ethic s b y scholarly endeavour . D r Pan g starte d he r career a s a nurse academi c i n 1990 , when sh e too k up a teaching pos t a t th e Hong Kon g Polytechnic University , where sh e no w serves a s professor i n th e School o f Nursing . Ove r th e pas t te n years , sh e ha s taught , lectured , an d published i n th e area s o f nursing ethics , caring practices , and ethic s i n end -of-life care . She i s on th e editoria l boar d o f Nursing Ethics, Chinese Journal of Nursing Education and Journal of Modern Nursing Education and Research.

Michael Mau Kong SHAM, MBBS HK, FHKCP, FHKAM (Med) , FRCP Lond, FRCP Edin, MH A NSW

Dr Sham , specialis t an d traine r i n palliativ e medicine , i s the consultant-in -charge o f th e Palliativ e Medica l Unit , Grantha m Hospital , Hon g Kong . D r Sham i s also co-chairman o f the Centra l Coordinatin g Committe e (Palliativ e Care) o f the Hong Kon g Hospital Authority, and Honorar y Clinica l Associate Professor o f the Department of Community Medicine and Unit for Behavioura l Sciences, Universit y o f Hon g Kong . Dr Sha m als o help s with palliativ e car e service i n Maca u an d mainlan d China , an d i s honorary consultan t o f th e Hospice an d Palliativ e Car e Centr e o f Kian g W u Hospita l i n Maca u an d honorary consultan t (hospice ) o f th e Firs t Affiliated Hospita l o f Shanto u University Medica l College .

Contributors xxv

Agnes Fong TIN, MSW, RSW, CT Ms Tin i s a bereavement counsello r a t the Jessie and Thomas Tam Centr e fo r the Society for th e Promotion o f Hospice Care (SPHC) . The Jessie and Thoma s Tam Centre , on e o f the pionee r project s o f the SPH C opened i n 1997 , is the first communit y bereavemen t counselling , educatio n an d resourc e centr e i n Hong Kong. She i s specialized i n providin g individual an d grou p counsellin g for variou s bereave d client s including widows , widowers, bereaved children , bereaved elderl y people , parent s losin g childre n an d adul t childre n losin g parents.

Chun Yan TSE, MBBS HK, FRCP , FHKCP, FHKAM (Med) , MHA NSW

Dr Tse graduated fro m th e Universit y of Hong Kon g in 1973 . He becam e th e consultant an d hea d o f th e Departmen t o f Medicin e o f Unite d Christia n Hospital i n 1984 . He was a pioneer o f the hospice movemen t i n Hon g Kong , and establishe d th e hospic e servic e i n th e hospita l i n 1987 . He becam e th e Hospital Chie f Executiv e o f th e hospita l i n 199 4 and wa s the Cluste r Chie f Executive (Kowloo n East) o f the Hospital Authority in 2001 until his retirement in 2005 . He le d th e Workin g Grou p i n formulatin g th e Guideline s o n Life -sustaining Treatmen t o f the Hospita l Authority, i n 2002 .

Doris Man Wah TSE, MBBS HK, FHKCP, FHKAM (Med) , FRCP Lond, FRCP Edin

Dr Tse i s currently th e Chie f o f Servic e o f th e Departmen t o f Medicine an d Geriatrics and Intensive Care Unit of Caritas Medical Centre. She has also been the physician-in-charg e o f th e Palliativ e Car e Uni t o f Caritas Medical Centr e since its establishment in 1992 . Dr Tse is accredited in the specialty of advanced internal medicine , critica l care medicine an d palliative medicine o f the Hon g Kong Colleg e o f Physicians . Dr Tse was the chai r o f th e Hon g Kon g Societ y of Palliative Medicine fro m 200 2 to 2005 . Currently, sh e i s the editor-in-chie f of the newslette r o f the Hon g Kon g Society of Palliative Medicine .

Heung Sang TSE, BSW, RSW

Mr Ts e i s an experience d socia l worker , particularl y i n hospic e socia l work . He i s keen o n developin g innovative services for termina l cance r patient s an d their families . H e wa s in charg e o f th e Medica l Socia l Work Departmen t o f the former Na m Lon g Hospital . Currently Mr Tse is in charge o f the Medica l Social Work Departmen t a t Ruttonjee Hospital .

1 Introduction

Amy Yin Man CHOW an d Cecilia La i Wan CHA N

Chinese Culture and Deat h

Fear marks the boundary between the known and the unknown. Some Chines e people believ e tha t talkin g abou t deat h wil l increas e th e likelihoo d o f occurrence. Also, by talking about death , evi l spirits will be attracte d t o haun t people.12 I n facin g death , individua l respons e i s inevitably moulde d b y th e values, attitudes , an d belief s o f one' s culture. 3,4 Despit e th e larg e Chines e emigrant population i n major citie s in th e world, available materia l in Englis h on death , dyin g an d bereavemen t amon g Chines e peopl e i s scarce . Onl y recently ha s a book, Fieldin g an d Chan's 5 Psychosocial Oncology and Palliative Care in Hong Kong: The First Decade addressed cance r deaths , psychosocial an d palliative care , i n English . Leun g an d Cheung's 6 book , Viewing Death, i n Chinese, i s a collection o f papers presente d a t a 2002 conference o n lif e an d death. Bagle y and Tse's 7 book i s on suicid e an d bereavemen t o f adolescent s in Hon g Kong . Othe r Chines e book s o n th e topi c o f deat h an d dyin g ar e translated works from th e West ^ lQ o r from Japan.11"13 There ar e a number o f Chinese book s o n thanatolog y i n Taiwan 14-18 and Hon g Kong. 19,20 However , Chinese peopl e i n differen t communitie s ma y hold very different belief s an d practices related t o death an d dying . For example, Chinese i n Taiwan want t o die a t home,2 whereas thei r counterpart s i n Hon g Kon g would prefe r t o di e in a hospital. 21 A s Hon g Kon g i s a plac e wher e Eas t meet s West , mos t professionals workin g i n th e fiel d o f death , dyin g an d bereavemen t adap t knowledge fro m th e West to thei r practic e with th e Chines e population . Th e intention o f thi s volume i s to consolidat e an d disseminat e valuabl e practica l wisdom wit h professional s i n th e loca l an d internationa l communitie s wh o serve Chines e patient s an d thei r family members .

2 Amy Yin Man CHOW and Cecilia Lai Wan CHAN

Death: A Chinese Experienc e

Chinese peopl e ar e know n fo r thei r inabilit y t o articulat e thei r feeling s an d for commonl y resortin g t o somatizatio n i n time s o f stres s an d emotiona l difficulties.22 Grie f an d bereavemen t i s even harde r t o articulat e tha n ar e feelings, a s death i s seen as a curse in the Chines e culture. 123 The intensit y of the loss , pain, guilt and sham e can be so acute tha t Chinese bereaved person s are unable to put their feelings into words. As well as somatizing their suffering , the pragmatic an d action-oriente d Chines e people focus o n th e performanc e of funeral an d buria l rituals , i n th e hop e tha t suc h actio n ca n contribut e t o the smoot h reincarnatio n o f th e disease d person . Thus , activ e participatio n in ritual s and religiou s complianc e t o advice from authorit y ar e common . As a result of heavy reliance on expert s and medica l technology , ordinary peopl e are exclude d fro m takin g a meaningful rol e i n end-of-lif e decision s both fo r themselves and fo r thei r love d ones . What is left afte r deat h i s a strong sens e of helplessness , frustration an d guil t among bereave d famil y members .

Disclosure o f grie f t o non-famil y member s migh t b e perceive d a s inappropriate. Chinese family members are very close to each other. Discussing family matter s i n publi c would be disloya l t o the family . Survivor s shoul d sa y only goo d thing s abou t th e decease d famil y member . Siblin g rivalry , interpersonal tension s o r conflict s previousl y hidden ma y surface soo n afte r a deat h i n a family, a s death i s a stressfu l an d traumati c even t for everyone . There ar e als o conflictin g rol e expectations , alliance s a s well as questions o f power an d control , especiall y when i t comes t o th e divisio n o f the estat e an d for right s ove r th e item s th e decease d perso n ha s bequeathed .

Death Denia l

Despite th e knowledg e tha t everyon e dies , there i s a general denia l o f deat h among th e Chines e population . I t i s believed tha t deat h wil l come knockin g if the wor d "death " i s called o r mentioned. 21 Eve n th e though t o f th e wor d "death" would bring bad luck . As people d o not tal k about death , the y do no t prepare fo r it . Whe n peopl e di e withou t preparin g fo r it , the y di e wit h unfinished business . Such denial of death may result in deep regret and sever e self-blame amon g th e bereave d love d ones. 24

Similar t o saying 'Tou r Excellency " or "You r Honour", peopl e addresse d the emperor in China as 'Ten Thousand Years Old, Ten Thousand Years Old". Princes an d princesse s ar e "Thousan d Year s Old , Thousan d Year s Old" , t o signify tha t the y ar e clos e t o heavenl y gods who ar e immortal . Deat h i s no t acceptable t o thos e i n power . Th e attendin g doctor s who faile d t o hea l th e emperor would have to be buried with him, for thei r incompetence a t curin g disease. Enormous resource s were investe d i n th e constructio n o f tomb s fo r

Introduction 3

kings and emperors , eve n when the y were young. The mos t sceni c places i n China are the tombs of ancient emperors. Most of the treasures recovered from tombs are now being turned ove r to heritage museums all over the world. Th e tombs at Xi'an are a good example of the magnificence o f an emperor' s tomb .

Talking abou t deat h i s taboo i n th e Chines e culture . Words tha t soun d like "death " ar e avoide d a s far a s possible. For example , th e numbe r "four " (xi) sound s like "death " (xi) an d s o is avoided. Ca r registration number s with the numbe r fou r ma y invite accidenta l death . Th e number s "fourteen " an d "twenty-four" o n ca r plates are worse, because fourteen sound s like sure (ten ) death (four) , an d twenty-fou r lik e eas y (two ) deat h (four) . Som e car-owner s will withdraw their randoml y assigned plate number i f it includes the numbe r four, eve n at the expense o f paying extra, to have another chanc e o f a licence plate withou t four . Th e numbe r "9413 " will neve r appear , a s i t means nin e out o f te n wil l die (four) , an d onl y one ou t o f te n wil l live (three) . Flat s o n the fourth , fourteent h an d subsequen t floor s endin g i n fou r i n multistore y buildings i n Hon g Kon g usually cos t less than d o flat s o n othe r floors . Som e developers eve n deliberatel y omi t al l floors tha t en d wit h th e numbe r four . More superstitiou s developer s als o remov e th e thirteent h floo r fro m th e numbering. Living on a floor tha t ends in the number four i s seen a s unlucky, as it can haste n deat h i n th e family , althoug h ther e i s no empirica l evidenc e of this .

Death: A Failure to Care

In the midst of the rapid advancement of medical technology, people are given a fals e impressio n tha t moder n medicin e ca n cur e al l previousl y incurabl e diseases, an d peopl e d o no t hav e t o die . Doctor s se e termina l illnes s a s a "failure" o f medica l treatment , an d famil y member s se e deat h a s a n "unsuccessful" cure . N o matte r ho w ol d th e patient s are , famil y member s usually believe tha t thei r love d one s have died to o young. This strong refusa l to accep t deat h reinforce s prolonge d grie f among famil y members , becaus e their loved ones continue t o fight vigorously until the very last moment o f life. When we get an injection, i f we relax our arms and muscles , there is very little pain afte r th e injection . I f we are tens e an d tighte n up , th e insertio n o f th e needle wil l bring greate r an d prolonge d pain . The sam e phenomeno n take s place in deat h an d dying . If one i s willing to accept death an d relax , ther e i s greater comfor t an d peace . If one fight s deat h vigorously, the death ca n leav e severe damage an d suffering , no t onl y on th e decease d bu t als o on th e love d ones. Thus, if one i s more willing to let go of life, one has more energ y to live and di e with peac e o f mind . A study on cance r patient s foun d tha t fatalis m and a fighting spiri t is a continuous positive variable in the Chinese population . 25 Accepting fat e ca n actuall y free u p one' s energ y t o cop e mor e effectivel y with life-threatening illnes s and trauma .

4 Amy Yin Man CHOW and Cecilia Lai Wan CHAN

Chinese famil y member s ar e closel y kni t b y a sophisticate d we b o f mutua l obligations an d responsibilities. 26 T h e refusa l t o embrac e deat h i s also drive n by a survivor' s guil t a t failur e t o fulfi l filia l obligation s toward s elderl y parents , the dut y o f a husban d t o car e fo r hi s wife , an d th e responsibilit y o f parent s t o look afte r thei r children . Fo r failur e t o protec t love d one s fro m il l healt h an d death , Chines e person s ma y indulg e i n self-blame , sham e an d guilt. 27

The Case of a "Crazy" Doctor

Dick was a well-known TCM (traditiona l Chinese medicine) practitione r who had a very good relationship with his wife and mother . He lost both of the m t o cance r i n on e year . H e fel t tha t h e was totally "useless" , a s he could no t cure his mother an d hi s wife. He closed his clinic and lived in self-blame . Te n year s later , a community worke r identifie d hi m a s a "crazy herbalist" who was living on welfar e i n a slum an d spendin g hi s time talkin g t o insects .

Death: Isolation of Bereaved Family Members

Accord ing t o ol d t radi t ions , a whit e l an te r n i s h u n g outs id e th e hous e i f s o m e o n e i n tha t famil y ha s died . T h e n , th e ne ighbour s an d o ther s i n th e communi ty wil l kno w wha t ha s happened . Peopl e woul d com e t o m o u r n an d offer thei r condolence s t o th e famil y durin g th e firs t tw o days . Then th e corps e would b e bur ied . T h e chi ldren , friend s an d relative s wil l sta y awak e i n th e house , b u r n pape r mone y continuousl y an d cha t unti l th e nex t day . Storie s a r o u n d th e decease d perso n wer e told , an d peopl e fel t th e re-establishmen t of connect ions . I n psycho-social-spiritua l terms , suc h a ritua l i s a debriefin g exper ience a s well a s a n occasio n fo r th e livin g tryin g t o pav e th e wa y for th e deceased t o mov e int o th e nex t world . Burnin g pape r mone y i s seen a s a wa y to provid e th e decease d perso n wit h th e necessar y financia l suppor t s o tha t h e o r sh e ca n bu y hi s o r h e r wa y t h r o u g h t h e g u a r d s a n d god s o f t h e underworld, t o ensur e a good reincarnatio n i n th e subsequen t lif e assignment . Daoists an d Buddhis t s describ e th e e laborat e pun i shmen t s i n hel l fo r th e various crime s on e commits , a s deterrent s fo r th e livin g t o violat e th e socia l expectations o f a goo d citizen. *

# Book s and other publications on what punishments in hell are like can be obtained fro m temples in China, Taiwan and Hong Kong. Buddhists believe that, by promoting knowledge of karma (cause s and consequences) , on e ca n accumulat e credit s i n Heaven . Thus, the y would sponsor books to be given out freely to temple visitors. Some of these books can also be found i n vegetarian restaurant s run b y practising Buddhists .

Introduction 5

After th e burial , peopl e wil l sto p visiting . I n fact , th e hous e i n whic h a person die s will be see n a s a place tha t radiates bad energ y (qi, M*). I t may be difficult t o understand thi s from a Western viewpoint. Why do peers shy away when th e family need s suppor t most ? In th e old rura l communitie s i n China , a significant numbe r o f deaths might have been cause d by infectious diseases . The ba d qi around th e family o f someone who died migh t have been bacteri a and viru s tha t ma y sprea d infectio n an d illness . Naturally , th e communit y would ten d t o avoi d goin g nea r tha t household .

Also becaus e o f th e fea r o f infectiou s diseases , al l clothe s wor n b y th e family members during the funeral an d burial will have to be burnt. The famil y will have to eat a good mea l after goin g to the burial , take a bath i n hot wate r with herbs, and the n burn al l clothing. Although th e original intention o f such rituals was to stop infection, thes e measures reinforced th e traditional concep t that ther e i s negative energ y aroun d death . Anythin g relate d t o th e funera l and buria l ritual s carry bad luck or evi l energy and thu s have to be destroyed . Therefore, fo r thre e month s afte r th e death , neighbour s an d friend s wil l no t visit a home where someone died . They have to walk over a burning fire befor e entering thei r ow n home , i n orde r t o burn awa y the "bad " or "toxic " energ y that the y migh t hav e picke d u p i n th e hom e o f th e decease d person . If we look a t i t fro m th e perspectiv e o f moder n medicine , thes e measure s wer e performed fo r th e preventio n o f the sprea d o f epidemics i n olde n days .

Bereaved family members may not be able to concentrate an d be accident -prone. I f somethin g goe s wrong , th e hypothesi s tha t th e bereave d perso n carried "ba d luck " is confirmed. Withou t tryin g t o find ou t th e tru e reason s for cultura l myths , the concept s of toxic energy and bad fate aroun d bereave d family member s continue d int o moder n society . The fea r o f deat h an d th e reluctance t o go near a house i n which someon e die d ar e stil l very common , despite th e fac t tha t ver y fe w peopl e actuall y di e o f infection s i n moder n Chinese citie s suc h a s Hong Kong . Th e mas s infection o f SAR S in Toront o during th e SARS outbreak i n 200 3 reminded u s of the possibilit y of infectio n at funeral services .

When friends ar e not willing to visit, the bereaved ar e lef t t o grieve alone . Besides the loss of a loved one, bereaved person s have to bear socia l isolatio n from friend s an d peers . The y ar e expecte d t o sta y awa y fro m happ y celebrations suc h a s weddings and birthday parties , because th e bereaved wil l bring bad luck . I t is a stressful experienc e t o have someone di e in th e family , especially when th e bereave d ar e see n a s carryin g negativ e energ y aroun d them.

Funerals an d buria l ritual s giv e bereave d famil y member s a sens e o f security, a s i t create s structur e fo r th e bereave d t o hol d o n to . Ther e ar e specific task s to carry out during each day after deat h unti l the forty-ninth day , when th e decease d i s suppose d t o b e reincarnated . Traditiona l Chines e mourning rituals las t for thre e years, according to Confucius' teaching . Widows

6 Amy Yin Man CHOW and Cecilia Lai Wan CHAN

in traditiona l Chin a ar e expected t o mourn fo r th e res t of their lives , because a woman ca n be married t o only one man . Details of the Daois t rituals can b e found i n Chapte r 4 .

Death: The Great Teacher of Life

Death i s often see n as a bad experience , yet there can be precious discoveries . The positiv e reactio n t o th e boo k Tuesdays with Morrie28 is a good example . Through th e pain o f facing death , we can appreciate th e blessings in life . I t is in th e mids t o f th e fea r o f deat h o f ou r belove d famil y member s tha t w e treasure eac h an d ever y on e o f the m mor e dearly . I n fact , deat h i s no t necessarily sad and miserable . Death can be a precious moment of completion , fulfillment an d a perfect endin g to lifelong learning . Our funeral i s equivalent to ou r graduatio n ceremon y t o celebrate a life worth livin g and th e legacie s we leave. Awareness o f death lead s us to the appreciatio n o f the vulnerabilit y of life an d lif e itself .

Life

Life i s an opportunity , benefi t fro m it . Life i s beauty, admire it . Life i s bliss, taste it . Life i s a dream, realiz e it . Life i s a challenge, mee t it . Life i s a duty, complete it . Life i s a game, play it . Life i s love, enjoy it . Life i s mystery, know it . Life i s a promise, fulfi l it . Life i s sorrow, overcom e it . Life i s a song , sing it . Life i s a struggle , accep t it . Life i s tragedy, confron t it . Life i s an adventure , dar e it . Life i s life, fight fo r it .

Author Unknown

If we replac e th e wor d "life " in th e abov e verse with th e wor d "death" , most o f th e sentence s i n th e passag e stil l mak e sense . Deat h i s part o f life . Life i s uncertain. Th e onl y certain promis e i n lif e i s tha t al l o f u s wil l die . According t o Eastern philosophers , lif e i s a difficult journey ful l o f suffering . Infants star t th e journey b y crying an d en d wit h a sense o f relie f when the y

Introduction 7

die. Mos t peopl e refus e t o acknowledg e th e inevitabilit y o f death . A s we become attache d t o people , t o possessions , t o power , t o materia l comfort , i t is hard t o say goodbye t o life .

Life an d death , sicknes s and health , meetin g an d parting , love and hate , attachment an d lettin g go , apath y an d involvement , disengagemen t an d integration, dependency and alienation ar e part of the reality of our existence . We have a n impressio n tha t thes e fact s o f life ar e opposites , like th e su n an d the moon . I n reality , we can alway s find th e moo n shinin g i n th e sk y befor e the sunset . Lif e i s in te res t in g becaus e o f it s i m p e r m a n e n c e an d unpredictability. The processes of gain and loss can be both joyful an d painful . For example , when a couple get s married, the y are happy and joyful. Despit e the wish t o live happily eve r after , on e certai n outcom e o f marriage i s that i t will end . I n pre-marita l classes , couple s lear n t o handl e matter s o f trust , intimacy, in-la w relationships , famil y plannin g an d asse t management . However, ther e hav e ye t t o b e offere d anticipator y divorc e o r bereavemen t courses to help people prepare for th e end o f marriage, through spousa l deat h or marita l breakdown .

Death, Dying and Bereavement

In th e firs t par t o f the book , we focus o n th e discussion o f death. Chapter 2 is the recollection s o f ou r clinica l experience s i n th e are a o f death , dyin g an d bereavement. A t time s w e witnessed th e pai n o f th e famil y whe n a famil y member faced death . Some patients isolated themselves or used all their energ y to figh t th e unbeate n enem y — death . Ther e ar e thos e wh o us e thei r fina l days to atten d t o unfinished business , t o reconcile an d t o forgive thei r love d ones a s wel l a s t o realiz e thei r dreams . Thos e tha t ca n giv e th e patien t permission to die have an easier bereavement. Effective communicatio n amon g family member s seem s to be a crucial step t o restructure a mutually accepte d way of facing th e impendin g death .

In Chapte r 3 , Yvonne Mak shares her persona l experienc e a s a patient, a hospice physician , a researcher an d a care-give r o f her ow n famil y member s with life threating illness. She affirms tha t death can be transformational. Ther e can b e growt h throug h th e proces s o f confronting ou r deat h an d en d o f lif e and tha t o f our love d one s and th e peopl e we serve .

In additio n t o socia l worker s an d physicians , a professiona l activel y involved in the area of death is the funeral director . The funeral arrangement s in Hon g Kon g ar e quit e differen t fro m thos e i n th e West . Usually , differen t rituals dominate funerals . Base d on a n intervie w with a funeral consultan t i n Hong Kong , personal reflection s a s well as literature review , Ka Hing Cheun g and colleague s contribut e th e fourth chapte r o f this book, unveilin g som e o f the mysterie s aroun d th e Daois t funera l ritual s i n Hon g Kong . Usin g th e

8 Amy Yin Man CHOW and Cecilia Lai Wan CHAN

continuum o f letting go and holding on, they analysed th e meaning behind th e different ritual s and ho w they contributed t o the adjustmen t t o bereavement . Chapter 5 is also abou t funera l rituals , bu t fro m a n academi c poin t o f view. Chi Tim La i shares his reflections o n Daois t funerary liturgy . A chapter b y Jin Yin follows, o n th e Buddhis t view of death , dyin g and bereavement .

Forensic pathologists deal with unnatural death s such as suicide, homicid e and accident. About thirty percent of deaths in Hong Kong involve pathologists in identifyin g th e cause s o f death . Phili p Beh , a n experience d forensi c pathologist, brief s u s o n th e procedure s i n handlin g unnatura l deaths , i n Chapter 7 . Facing th e deep-roote d traditiona l belie f o f being burie d whole , he share s th e interactio n an d dynamic s wit h famil y member s o n th e negotiation o f autopsies .

Wing Sha n Cheun g an d Samue l H o shar e thei r stud y o n th e persona l meaning of death amon g Chinese, through th e images or metaphors of death . The mos t common them e i n th e drawings of death amon g thei r respondent s is "a separation fro m th e love d one" . The interpersona l natur e o f death an d bereavement i s obvious . Althoug h th e majorit y o f th e respondent s use d negative adjectives t o describe death , as well as black and white to draw images of death , a substantia l percentag e o f respondents use d positiv e adjective s o r bright colours . The perceptio n o f death amon g Chines e i s not necessaril y al l negative. Wallace Chan an d hi s colleagues reconsider th e topics of good deat h through a historica l revie w o f traditiona l philosoph y an d publi c opinio n studies. Physica l an d psychosocia l well-bein g ar e th e tw o ke y factor s contributing t o a good death .

The secon d sectio n o f ou r boo k i s on th e proces s o f dying . About one -third o f the deaths in Hong Kong are caused by cancer. Palliative hospice car e is for thos e who have incurable cancer . Through hom e care and hospice beds , professionals addres s th e physical , psychosocial , an d spiritua l need s o f thei r patients throug h th e las t months, weeks and day s of thei r lives . The Chines e name fo r hospic e car e ha s been translate d a s xian zhong (HH-, literally , goo d ending). More recently , ther e ha s been a change i n th e use o f term, becaus e the publi c resent s th e concep t o f th e hospic e an d equate s i t with deat h an d the terminatio n o f life. New terms, such as xian ning ( H ^ , literally , good an d peaceful), ningyang ( ^ H , peacefu l an d nurturing) an d shu huan (ffift , rela x and relief ) ar e being used in the name o f service units instead o f the ol d ter m of "goo d ending" . Chinese i n Hong Kong probably find th e ter m "zhong" (H-, ending) har d t o accept . N o matte r wha t nam e i s used, th e professional s o f palliative hospice care in Hong Kong are committed t o providing quality car e to all who are facing death . When we first shared ou r idea of editing this book, responses fro m th e palliativ e car e team s were very positive . Contributor s o f the secon d sectio n o f thi s boo k ar e fro m th e palliativ e hospic e car e professionals i n Hon g Kong .

Michael Sham, Doris Tse, Kin Sang Chan an d Raymon d L o are leaders of

Introduction 9

hospital and palliative care in Hong Kong. Their chapter , "Impac t of Palliative Care on the Quality of Life of the Dying", succinctly describes the key concerns from th e perspectiv e o f healt h car e providers . With a ric h historica l revie w and detaile d researc h findings , Chapte r 1 0 guides u s throug h a timelin e o f palliative car e developmen t i n Hon g Kong . Raymond L o furthe r elaborate s on the medical and psycho-social-spiritual aspect s of the final month o f a dying patient. Afte r discussin g th e problem s face d b y patient s an d families , h e proposes strategie s t o reliev e bot h th e physica l symptom s an d psychosocia l distresses.

Chinese peopl e us e th e term s "euthanasia " and "palliativ e hospic e care " interchangeably. Th e confusio n lie s in th e similaritie s in thei r Chines e nam e and poo r publi c knowledg e o f what death , euthanasi a an d palliativ e hospic e care are about . Chun Yan Tse and Samanth a Pang offer th e term "euthanasia " from medical , lega l an d cultura l point s o f view in Chapte r 12 . They furthe r differentiate th e ter m fro m "palliativ e care " an d "forgoin g life-sustainin g treatment". Though forgoin g life-sustainin g treatmen t seem s to be a patient' s individual decision , suc h a decision i s affects th e whole family a s well.

Nursing and communit y care are two significant component s i n palliativ e hospice care . Fait h Liu , a n experience d nurs e specialis t i n palliativ e care , highlights th e developmen t o f communit y palliativ e car e i n Hon g Kong , i n Chapter 13 . Because o f he r extensiv e experienc e i n carin g fo r familie s wit h end-stage cancer , thi s chapter blend s her exper t knowledge an d he r devotio n to promoting humanity . At the en d o f her chapter , sh e suggests practical tip s that health-car e professional s shoul d note .

Despite the fact tha t Western medicine dominates the health-care deliver y system i n Hon g Kong , patient s pragmaticall y see k differen t source s o f care , including Chinese medicine, when disease progresses. Siu Man Ng, a registered practitioner i n Chines e medicin e with ric h experienc e i n th e fiel d o f menta l health, describe s th e contributio n o f Chines e medicin e t o cance r palliativ e care, i n Chapte r 14 . Fo r thos e unfamilia r wit h th e concept s o f Chines e medicine, thi s chapte r i s a n excellen t start . Chines e medicin e ca n b e a complimentary treatmen t an d help s t o reduc e undesirabl e sid e effect s o f chemotherapy, radiotherap y an d surgery . Chinese medicine ca n als o enhanc e the tota l well-bein g o f th e dyin g patient s an d increas e th e participatio n o f family members , by helping the m t o accept th e inevitabilit y o f death .

Human resource s are the most important assets in the health-care system , especially i n palliativ e care . Pete r Le e an d Trac y Kwa n remin d u s o f th e importance o f staf f suppor t i n palliativ e care . Compared wit h othe r unit s i n health care , palliative hospice car e has the highest "deat h rate" . In repeatedl y confronting death , which migh t be take n a s professional failure , health-car e professionals respon d with grea t emotional an d spiritua l pain . Lee an d Kwa n share thei r visio n o f ho w appropriat e staf f suppor t ca n facilitat e greate r effectiveness i n th e deliver y of palliative care .

Death ca n als o be cause d b y illnesses other tha n cance r an d ca n happe n

70 Amy Yin Man CHOW and Cecilia Lai Wan CHAN

in ward s othe r tha n hospic e wards . Amy Cho w an d nurse s i n Kwon g Wa h Hospital describ e ways of handling deat h i n acute wards like medical , surgica l and intensiv e car e units , i n Chapte r 16 . Strategies i n workin g with patient s and familie s facin g deat h wit h littl e tim e t o prepar e fo r i t ar e describe d through tw o case stories. A CDE model is introduced fo r working with familie s facing impendin g death .

Although th e majorit y o f death s tak e plac e i n lat e life , childre n an d adolescents can die . In Chapte r 17 , Vivian Lou an d Cecili a Chan discus s thei r study of grieving parents o f children wit h cance r i n Shanghai , where couple s are allowe d onl y one child . Thus th e impendin g deat h o f the onl y child ma y mean a n end t o their future a s parents. The parents may spend al l their mone y or eve n ge t themselve s int o heav y debt , a s there i s limited financia l suppor t for medica l car e i n China . Th e parent s griev e th e los s of the chil d a s well a s the en d o f thei r dreams . I t i s hoped tha t thi s chapte r ca n rais e th e concer n of policy-maker s o n th e establishmen t o f prope r medica l insuranc e an d protection fo r th e populatio n i n mainlan d China .

The thir d sectio n o f thi s book focuses o n bereavement , th e los s of love d ones throug h death . I n Chapte r 18 , w e describ e th e developmen t o f bereavement car e i n Hon g Kong . As there i s no equivalen t Chines e ter m fo r bereavement, we increase the awareness of the needs of bereaved persons an d generate guidin g principle s i n working with th e Chines e population . Thes e strategies have been wel l received b y professionals al l over th e world an d ca n be applie d t o Chines e who ar e migrant s t o other countries .

Agnes Tin , Brend a Koo , Elaine Koo , and Se e Man Le e o f th e Jessie an d Thomas Tam Centr e (JTTC) , the community-base d bereavemen t counsellin g centre i n Hon g Kong , contribute d t o Chapter s 1 9 an d 20 . Chapte r 1 9 integrates th e traditiona l Easter n values and culture s into counsellin g model s and offer s practica l guidelines in serving different bereave d groups of widows, widowers, parents , childre n an d grandchildren . Chapte r 2 0 discusse s th e theoretical background , design , application an d implementation o f structure d therapeutic bereavemen t group s i n Hon g Kong . Th e author s introduc e creative an d culturall y sensitive group activitie s as well as outcome evaluatio n on th e effectivenes s o f these groups .

In addition t o professional care , volunteers provide bereavement services . Eddie Chan , fro m th e Comfor t Car e Concer n Group , a volunteer-oriente d organization i n providin g service s fo r terminall y il l an d bereave d persons , shares his experience i n using volunteers in bereavement care . Chan discusse s the difficultie s encountere d i n recruitment , selection , training and mobilizin g volunteerism in the Chinese culture. Contrary to common beliefs that bereaved Chinese perso n i s well supporte d b y the family , Cha n sa w growing deman d for volunteers in bereavement car e as well as in guidance throug h funera l an d burial rituals .

Introduction 7 7

Suicide is considered a family shame . Along with guilt , shame, confusion , the traumati c scene o f the suicide and th e complicated crimina l investigation s before gettin g a death certificate , th e pathwa y t o recover y fo r th e bereave d family o f a suicide i s often prolonge d an d difficult . I n th e las t chapter, Cho w portrays th e pathwa y o f th e bereave d familie s o f suicide s i n Hon g Kong . A SUICIDE bereavement mode l i s proposed a s the intervention with thi s specia l target group .

We hope th e ric h cultura l illustration s o n a different tempora l fram e o f death ca n hel p t o pain t a n impressionis t pictur e o f death amon g Chinese , a forbidden an d mysteriou s ye t necessary pat h tha t we al l have t o tak e i n ou r lifetime. Let' s star t the adventurou s journey .. .

Index

Abandonment 140 , 295, 303 Accident an d emergenc y roo m (A&E )

226 Accomplishments 12 9 Active treatment 15 2 Acupuncture 201 , 202 Adult children ,

Grieving 26 7 Advance directive s 31 3 Adversity 31 4 Altruism 28 1 Anatomy 114 , 11 5 Ancestor worship 25 9 Anniversaries 25 8 Appreciation 217 , 314 Assumptive world 26 3 Attachment 10 0 Attitudes toward s death an d dyin g 14 0 Audits 144 , 145 , 154, 16 5 Autopsy, 105 , 108, 113 , 114, 235, 299

Resistance t o 112 , 11 3 Autonomy, 158 , 172, 18 8

Family 17 4

Bad luck 5 , 67, 214, 264, 276, 290, 296, 305

Bad news , Breaking o f 226 , 266 Receiving 226 , 29 8

Balancing har m wit h benefi t 15 4 Bardo, semi divine being 10 0 Befrienders 28 6

Bereaved childre n 266-26 7 Bereaved persons ,

Guilt o f 2 0 Isolation o f 4-5 , 21 4 Self-actualization o f 26 4 Self-care o f 26 4 Self-identity o f 26 4 Self-image o f 264 , 27 7 Support fo r 26 5 Unsolicited suppor t o f 1 9

Bereavement, 25 3 Suicide 293,29 5

Bereavement a s social construction 26 1 Bereavement care , 25 , 286

Coordinated multidisciplinar y 26 0 Indigenous 258 , 259

Bereavement counselling , 225 , 236, 254, 255, 261, 275, 286, 289

Effectiveness o f 257 , 276 Universal nee d o f 25 7

Bereavement counsellor s 31 2 Bereavement experience ,

Sharing o f 25 9 Bereavement group s 254 , 265, 273, 277,

283, 28 6 Bio-psycho-spiritual 14 0 Bo-soul 71 , 88-89 Body of the decease d

Bathing o f 73 , 85, 134, 231, 232 Claiming o f 30 8 Contact with 83 , 231 Handling o f 134 , 230

350 Index

Identification o f 209 , 286 , 290, 291 Touching o f 73 , 83, 192, 231 Viewing o f 134 , 231, 232, 299

Body-mind-spirit approac h 254 , 315 Body-related expression s 258-25 9 Bowel obstruction 15 6 Breaking o f bad new s 22 6 Browning ou t 22 0 Buddhist practice s

Avoid crying 9 9 Don't touch the body of deceased 9 9 Meditation 9 9 Reciting th e nam e o f Buddha 9 9

Buddhism 93 , 128, 143 , 215, 262 Burden o f illness 13 9 Burden t o others 130 , 131, 172, 186, 246 Burial 68 , 11 3 Burnout 22 0

Cachexia 147 , 16 2 Calmness 30 7 Care a t home 185 , 186 Caring fo r

the dea d 9 0 the livin g 9 0

Cause an d effec t 9 6 CDE Model 23 3 Chants 92 , 98, 99, 302 Children a s possession 24 2 Chinese Medicin e 19 5 Ching Ming Festival 115 , 263 Chung Yeung Festival 26 3 Cleansing afte r funera l 5 , 70 , 76 Commonality,

Sense o f 26 3 Communication,

Facilitating 23 3 Indirect 26 2 Non-verbal 228,23 3

Communication skill s 227 , 23 3 Communication wit h patient s an d

families 165,22 8 Community-based service s 243 , 255, 273 Community car e 164 , 18 3 Community education 147 , 153, 256, 286 Community nursin g servic e 18 4 Compassion 215 , 217, 218, 219, 222, 227,

311

Compensation 24 4 Complementary and alternative medicin e

(CAM) 195,31 3 Concealment o f cause of death 29 5 Condolence card s 25 4 Confucian tradition s 6 9 Confucians 90 , 128 , 142, 143, 186, 211,

216, 242 , 267 Connectedness 35 , 45, 46, 57, 217, 311 Consensus-building approac h 17 6 Constipation 14 2 Consultative servic e 147 , 184 Continuing Bond 258 , 259, 263, 267, 270,

283 Continuous effor t 30 8 Continuous Qualit y Improvement (CQI )

163,164 Coroner 10 5 Coroners Ordinanc e 10 8 Cremation 68 , 113, 286, 291, 308 CT-scans 11 4 Culture 258 , 261, 271, 277, 291, 295 Cycle o f life an d deat h 9 3

Daoism, 87 , 128 , 14 3 Definition o f 8 7 History of 8 7

Daoist masters , daoshi 9 1 Daoist philosophy 17 1 Daoist rites

Attack o n hel l 9 1 Bathing an d dressin g 9 1 Crossing th e bridg e 91 , 92 Invocation o f Daoist God 9 1 Penitential litanie s 88 , 91 Retreat 8 8 Recitation scare d scripture s 88 , 91 Rituals of merit 8 8 Summons o f th e sou l 8 9 Universal deliveranc e o f hungr y

ghosts 9 1 Untying th e knot s 9 1

Daoist texts Scripture of Great Peace 87, 89

Day care 16 4 Death,

Acceptance o f 131 , 230 Acknowledgement o f 261 , 279

Index 351

Adjectives abou t 121 , 124 Announcement o f 22 6 Avoidance o f 3 , 17 Awareness o f 12 9 Causes o f 106 , 108 , 110, 113 , 114 Certifying 10 7 Colours describin g 12 0 Community educatio n o f 147 , 15 3 Continued existenc e i n 11 7 Denial o f 2 , 1 7 Drawing about 121,122-12 3 Fear o f 118,14 2 Full meal befor e 7 0 Good 127 , 129 , 131 , 132, 133 , 215,

231, 25 6 Meaning o f 117 , 119, 123, 125, 126,

262 Metaphors o f 118 , 119, 126 , 261 Negative energ y around 5 Positive orientation o f 12 4 Preparing fo r one' s 216 , 225 Registration fo r 304 , 308 Undignified 15 2 Unexpected 26 8 Unnatural 105 , 132 Untimely 88 , 268

Death an d Lif e 11 7 Death Anxiety 12 5 Death a s beginning o f afterlif e 11 8 Death a s extinction 11 8 Death certificat e 107 , 291 Death concepts ,

Biological 121-122 , 12 3 Psychological 121-12 2 Metaphysical 121-12 2

Death construct s 11 8 Death educatio n 31 3 Death o f children 68,231,241,24 3 Death rattl e 15 6 Death scen e 23 5 Debriefing 289 , 309 Deceased,

Continuing bon d wit h th e 65 , 72 Identity o f 11 0 Photographs o f 77 , 80-8 1 Relationship with 83 , Talking about 7 6

Throwing awa y belongings o f 7 7 Transformation o f 8 3

Decision-making proces s 174 , 176 , 231, 233

Delivery of messages 23 4 Demons 8 9 Dependent origination ,

Principle o f 9 4 Destagnation 203 , 205 Diagnosis o f terminal illness ,

Disclosure o f 1 8 Informing 21 2

Die a t home 147 , 18 8 Die o n tabl e 22 7 Dilemma,

Ethical 139 , 152 Practical 13 9

Disclosure o f information 174 , 191 , 245 Discretion 23 5 Disease 26 2 Disease-centred 14 0 Dreams 25 9 Dying,

Fear o f 15 7 Dying a t home 130 , 144 , 19 3 Dying patient ,

Communication wit h 8 1 Decision-making o f 174 , 175 , 231,

233, 31 2 Dignity of 15 8 Existential concer n o f 15 9 Incompetent 17 5 Permission t o die for 2 6 Reassurance fo r 25-26 , Self acceptance o f 16-17 , Struggle o f 24-25 , Suffering o f 45 , 132, 152 , 156, 157,

174 Vulnerabilities o f 3 7

Dying phase 15 1 Dying with dignit y 15 ,

Dynamic equilibriu m 19 8 Dyspnoea 147 , 153, 155, 165, 204

Eating 142 , 161, 191, 229 Elderly,

Grieving 268-26 9

352 Index

Eldest son 74,75 , 191,23 0 Emotion-oriented 26 5 Emotions,

Angry 228 , 302, 304 Anxious 211,22 2 Coping o f 24 3 Expression o f 210 , 214, 247, 254,

258, 262 , 263, 266, 267, 277, 279-280, 28 2

Intense 210,233,26 5 Sorrowful 30 4

Emotional well-being 21 8 Empathetic approac h 145 , 217 Empathy 237 , 287, 307 Empowerment 158 , 278, 309, 310 Empty nest 26 9 End-of-life car e 209 , 227 End-of-life concern s 16 1 End-of-life decisions , 25 6

Communication o f 2 4 Ethical consideration s 30 2 Eulogies 8 4 Euthanasia, 16 9

Chinese ter m fo r 17 1 Definition o f 16 9 Legal 16 9 Legalization o f 170 , 17 3 Patient requestin g 36,38,17 6

Evidence-based practic e 25 6 Evil spiri t 89 , 296 Exhaustion,

Emotional 22 0 Mental 22 0 Physical 22 0

Existential well-being 158 , 281 Experiential learnin g 31-32 , 36, 43 Explanation 23 5 Expression o f grief 92 , 270, 277 Extension,

Biological 27 0 Psychological 27 0

Face 142 , 160-161 , 262 , 295 Family,

Ambivalence o f 24 8 Angry 111 , 132 Consensus within 16 1 Decision makin g o f 235 , 247

Discrepancies within 15 2 Gathering o f 79 , 81 Good 13 0 Needs o f 185 , 229-230, 24 4 Protecting 31 2 Relationships with 19 0 Self-actualization o f 26 4 Self-care o f 26 4 Shame o f 26 2 Suffering o f 48 , 50, 89, 106,186, 312

Family affairs 25 9 Family autonomy 17 4 Family communication 24 3 Family continuity 24 2 Family determination 17 4 Family dreams 24 6 Family involvement 17 4 Family obligations 130 , 133 , 211, 215,

228, 229 , 248, 263, 276, 305 Family support 15 8 Family ties 14 2 Fate,

Clashes o f 29 6 Fatigue 146 , 153 , 204 Fee-for-service mode l 24 2 Feelings, sharing o f 2 Feng Shui (Geomancy ) 67 , 262, 296 Festivals 25 8 Filial piety 15 , 70, 85, 186, 229, 267, 313 Final momen t o f consciousness 99 , 10 0 Financial consideration s 173 , 186, 242-

243, 247 , 290 Five elements 196-19 7 Food a s care 142 , 162 , 229 Forces,

Facilitating 19 7 Repressing 19 7

Forgoing life-sustainin g treatmen t 169 , 173

Fragility of life 30 5 Fu (Blessing ) 7 0 Funeral,

Extravagant 13 0 Function o f 5 , 6, 6 8 Happy 21 6 Invitation t o 30 2 Involvement i n 267 , 270

Index 353

Laughing 13 0 Meaning o f 8 4 Preparing for one' s 82,130 , 216, 256

Funeral hall s 30 2 Funeral industr y 84-85 , Funeral rite s

Attack on hel l 74 , 91 Bathing an d dressin g 73 , 85, 91 Break a comb 7 3 Burning pape r mone y 7 5 Crossing th e bridg e 75,91,9 2 Hero's sheddin g o f mournin g

clothes 76,8 4 Last adornment 7 3 Last repects 7 5 Longevity meal 7 7 Receive th e head s o f longevity 7 7 Untying th e knot s 74 , 91

Funeral ritual s 253 , 277, 279, 286, 291, 302

Funeral services , Buddhist 6 6 Daoist 66 , 73-76, 83 , 88, 91

Funeral suppor t 28 9

Gender 265 , 266 Goodbye,

Saying 82 , 83 Good deed s 30 1 Gratitude 21 7 Grief, 254,27 5

Accommodating o f 27 6 Definition o f 27 5

Grief Reactions Assessment Form (GRAF ) 258, 27 3

Griever, Instrumental 26 6 Intuitive 26 6 Silent 30 8

Gut (Ghost ) 89,92,29 6 Guilt 142 , 152, 162 , 216, 217, 259, 268,

295, 302 , 304

Habit 9 5 Healing 6 3 Help-seeking,

Reluctance i n 190 , 258 Helplessness 24 7

Herbalist consultation 18 6 Holistic car e 145 , 227, 315, 317 Holistic perspective 196 , 20 3 Home car e 164 , 243 Homicide 30 3 Homogenous 27 7 Hope 159,270,28 1 Hopelessness 25 0 Hospice 255,28 5 Hospice car e 18 3 Hospice Care Performance Inventor y 14 4 Humanity 22 2 Humour 22 1 Hun soul 71,88-8 9 Hungry Ghosts Festival 10 1

I Ching 19 6 Imbalance i n system s 19 9 Immortality 12 8 Impermanence 100 , 103 , 128 Incompleteness 30 3 Incontinence 15 8 Independence,

Loss of 14 2 In-depth interview s 244 , 245 Indigenous practic e 256 , 258, 259, 31 3 Infantilizing 26 8 Information,

Sharing o f 249 , 308 Inner Canon of Yellow Emperor 196 Integration o f

Chinese an d Western Medicin e 20 7 Intensive Car e Uni t (ICU ) 226 , 231 Interdependent 117 , 143 , 214, 242, 264,

268, 269 , 276, 312 Interpersonal 118 , 122, 230, 263, 264,

273,276,277,311 Interpersonal learnin g 28 2 Insurance,

Healthcare 242,25 0 Insurance claim s 10 6

Joy 22 2

Karma 67 , 95, 96, 97, 98, 102, 313 Weighty 97-9 8 Habitual 9 8 Death-proximate 9 8

354 Index

Lactation 23 2 Lama 9 8 Last office 226,230,23 5 Last month o f life 15 5 Last thought 9 7 Last weeks of lif e 14 6 Last wish 130 , 13 3 Law of Conservation 9 4 Law of nature 27 0 Law-abiding 11 1 Legacy,

Leaving a 31 6 Legislations 11 1 Let-go 259 , Let nature tak e it s course 146 , 15 8 Leukaemia 241,246,24 9 Life afte r deat h 93 , 94 Life-saving orientatio n 21 2 Limited time 21 9 Listening 3 5 Loss of dignity 14 2 Loss of future 24 6 Loss of independence 14 2 Loss of socia l role 14 2 Love 215,217,311,31 7

Making sense o f death 30 3 307 Malignant hypercalcaemi a 152 , 154 Manifestation o f seeds 9 6 Meaning,

Positive 31 4 Reconstruction o f 127 , 134-135, 227

Meaning making 313 , 314 Meaning of death 263 , 270, 295, 296, 303 Meaning o f grief 270,27 7 Meaning o f life 158-159 , 160 , 183 , 222,

281 Meaning o f work 217,22 2 Medical device s 11 4 Medical expense s 25 0 Medical malpractice s 11 4 Medical socia l worker 249 , 254, 312 Meditation 9 9 Memorial service s 101-10 2 Memories,

Sharing of 236 , 263 Meridian theor y 19 8

Microscopic examinatio n 11 5 Mindfulness 4 1 Moment o f death 97-9 9 Mood disturbance s 205 , Morphine,

Intravenous 15 5 Oral 15 5 Reluctance i n usin g 19 0 Subcutaneous deliver y of 15 5

Mortuary 13 4 Mourning,

Chronic 24 9 Mourning clot h 11 5 Mourning period ,

Duration o f 8 4 End o f 71,72,8 4

Mouth car e 14 4 MRI 11 4 Multi-disciplinary 30 7 Murder 30 0 Mutual suppor t 254 , 288, 302, 317 Mystery 12 4

Nasogastric tub e 15 6 Natural Instinct s 11 3 Nausea 142 , 14 4 Next-of-kin 10 8 Niche 29 1 No-show rate 25 8 Non-cancer 147 , 15 3 Non-judgemental 157 , 263 Non-maleficence 17 3 Non-possessiveness 31 1 Normalization 27 7 Nourishing life , 8 7 Now 22 0

Offerings 101,26 3 Ongoing in-servic e trainin g 28 7 One-child polic y 24 2 Organ donatio n 30 0 Organs,

Yin 19 7 Yang 19 8

Outreaching consultativ e servic e 18 4 Overnight sta y facilities 16 4

Index 355

Paediatrics 24 3 Pain, 142 , 143 , 144, 147 , 153 , 154, 204,

314 Avoidance o f 14 3 Assessment o f 14 3 Mutli-dimensions o f 14 3

Pain managemen t 143 , 144, 15 8 Palliative care , 139 , 144 , 151 , 172

Art of 31,33,3 7 Audits o f 144-145 , 154 , 165 Chinese term s for 17 1 Community 18 3 Curriculum o f 6 2 Definition o f 18 3 Effectiveness o f 14 6 History of 140-14 1 Purpose o f 18 3 Satisfaction toward s 143 , 145, 184,

185 Training i n 140 , 153 , 164

Palliative car e worker , Avoidance o f 21 3 Commitment o f 21 9 Demoralization o f 21 3 Duty of 15 8 Emotional managemen t o f 21 7 Failure o f 21 6 Goal-setting o f 21 9 "I" or "me " of 21 9 Involvement o f 209 , 210, 213 Over-identification wit h patien t b y

213 Personal distres s of 210 , 238 Self-care o f 21 5 Sense o f helplessness 212-213 , 238 Stress of 220 , 226 Struggle o f 53 , 152, 209, 214, 226 Suffering o f 34 , 46-47, 20 9 Transference 209,21 0 Uncomfortable i n communication o f

152, 20 9 Palliative Home Car e Team 184 , 313 Palliative medicin e 147 , 154, 212 Parent,

Grieving 269-27 0 Parent-child 243,27 0 Paternalistic 17 4

Pathologists 10 6 Pathology 11 4 Patience 14 5 Peace o f body 12 9 Peace o f mind 12 9 Peace o f though t 12 9 Person-centred 14 0 Personal growt h 27 6 Personhood 45 , 46 Play 26 7 Police Investigation 108 , 300, 30 8 Postvention 29 3 Practice,

Reflective 3 9 Pre-diagnostic phas e 15 1 Pre-group interview s 27 8 Preferred plac e o f death 1 Preferred wa y of death 21-23 , Presence 35 , 217 Presence o f famil y

in time o f death 15 , 70, 130 , 131, 132, 229, 230, 234

Priorities Life 117,31 5

Privacy 163 , 188, 209 Professionalism 21 0 Prolongation o f dying process 163 , 172 Prolongation o f physical life 87 , 139, 140 Proxy assessment 16 5 Psychologist,

Clinical 249,254,31 2 Psychosocial 243 , 249 Psycho-socio-spiritual 157 , 205 Public awareness 31 3 Public donation ,

Appeal fo r 24 8 Punishments 30 5

Qi, 198,200,20 1 Stagnation o f 20 0

QKonifying herb s 201 , 202, 204 Quality of Life 139 , 141 , 142, 144, 145,

146, 157 , 160, 162 , 165 , 183, 196 Quiet room 16 4

Rebirth 93 , 94, 95, 99-100, 10 2 Reciprocal 28 1

356 Index

Reconciliation 92 , 130 , 159 , 16 6 Registrar o f Births and Death s 10 7 Regrets 30 4 Re-grief 26 7 Reincarnation 67 , 70, 71, 85, 94,

117, 128 , 230, 234, 259 Relational-oriented grie f 24 4 Relational sel f 17 4 Relationship

Between th e deceased and family 89 , 92

Religious belief s 15 8 Remembrance 86 , Ren, a moral standar d 128 , 264 Renqing debt 24 2 Repaying th e deb t 29 6 Research,

Hermeneutics 38 , 39 Research an d Practic e 12 7 Resilience 31 5 Respect 15 8 Resuscitation 99 , 162-163 , 226 Retirement 26 9 Revised Death Fantasy Scale (RDFS ) 118 ,

119 Right heart s 21 5 Risk assessment 25 4 Risk-taking behaviours 26 6 Rites of bathing an d dressin g 7 3 Rituals,

Death 65,9 1 Purifying 29 6 Spirit return hom e 7 9 Therapeutic 281-28 2

Role o f professional s In deat h 72 ,

Safety 30 7 Screening 27 8 Secondary loss 27 0 Self,

Interdependence o f 214 , 242, 264, 268, 269 , 276

Relational 17 4 Self-attribution 29 6 Self-development 4 0 Self-healing 20 1 Self-reflection 21 7

Sense of control 196 , 203, 227, 233, 262, 263

Separation betwee n livin g and th e dea d 70, 83 , 89, 92, 253

Seventh da y 7 1 Sexuality 14 6 Shame 26 4 Shan bei 25 4 Shared decisio n makin g mode l 17 6 Shortness o f breath 142 , 146 , 155 , 157 Siblings,

Grieving 23 2 Sin,

Inheritance o f 89-90 , Sins of ancestors 85 , 90 Social discrimination 24 9 Social suppor t 250 , 253, 276, 27 8 Somatization 2 , 258, 263, 277 Space 30 7 Spiral 30 6 Spiritual car e workers 15 8 Spiritual growt h 31 6 Spiritual well-being 21 8 Spirituality 143 , 145, 158-159, 218 , 227 Stagnation,

Blood 201,20 4 Depression a s 20 5 Qi 200 , 20 4

Stigmatization 276 , 277, 279 Stillbirth 231-23 2 Subsequent temporar y upsurges o f grie f

(STUG), 306- 7 Cyclic 30 6 Linear 30 6 Stimulus cues 30 7

Suicide, Avoiding th e word o f 29 5 Discovering o f 29 7 Media reports o n 301 , 302 Physician-assisted 16 9 Sub-intentional 29 4 Thought o f 14 2

Suicide i n hospital s 22 7 Suicide note s 30 5 Suffering, 31 , 44, 102 , 128, 129, 217, 315

Alleviation o f 147 , 158 , 173 Cause o f 128 , 216 Cessation o f 128 , 133 , 14 3

Index 357

Family 48 , 50, 89, 106 , 186 , 312 Fear o f 14 2 Meaning o f 36 , 37, 52 Prolongation o f 15 2 Relief o f 10 1 Trajectory o f 4 4

Suppression o f grie f 9 2 Supervisors 22 1 Susceptible o f vulnerability 29 5 Sympathy mone y 29 0 Symptom,

Alleviation o f 15 4 Control o f 153 , 165, 188 Identification o f 153 , 188

Syndromatic diagnosi s 196 , 19 9 Systemic balance 19 7

Taboo 261,27 9 Tai chi 16 4 Templer's Death Anxiety Scale (DAS ) 11 9 Terminal illnes s

As a failure 3 , 26 Terminally il l patients ,

Problems o f 18 7 Treatment fo r 143-14 4

Thematic analysi s 24 5 Total well-being ,

Enhancement o f 196 , 203 Tranquility 21 7 Transfer o f merits 10 1 Transference 209 , 210, 237 Transformation 311 , 314 Treatment,

Active 152 , 153 , 158 Adjunctive cance r 196 , 202 Aggressive 15 5 Forgoing life-sustainin g 169 , 173,

226 Individualized 15 5 Invasive 15 2 Life-sustaining 17 5 Withholding an d Withdrawin g 152 ,

173, 22 6 Triggers, 30 6

Smell as 29 8

Ultrasound 11 4 Uncertainty 30 5 Underworld 7 0 Unfinished busines s 155 , 238, 244, 292,

299 Universality 27 9 Unspoken word s 30 4 Untaken action s 30 4

Vicarious Traumatization 29 4 Viewing of the body 72 , Viewing room 13 4 Visitation,

Grave 26 3 Hospital 23 5

Visiting hours , Flexible 15 8

Volunteer, Assessment o f 28 9 Bereaved 28 9 Recruitment o f 28 7 Supervision o f 28 8 Training o f 164 , 286, 287 Use o f 28 5

Vomiting 142 , 144 , 153 , 156, 161 , 165, 202

Vulnerability 31 1

Walking a tightrope 246 Washing away of wrongs 11 0 White affair s 214,29 0 Wholeness 4 5 Widowers, 26 5

Meaning o f 26 6 Widow-to-widow 28 6 Widows 264 , 265 Withholding an d withdrawing treatmen t

152, 226 Withholding informatio n 17 4 Women a s carers 18 7 Wounded healer s 32 , 33, 34

Yin 26 2 Yin-yang 196-19 7 Yuan 26 2