PALLIATIVE care is an emerging medical care service in mainland China. In the past decade, it has been gradually known and accepted by Chinese medical professionals and the publics. However, no delivery model for palliative care has been demonstrated to best fit the medical system and social environment of mainland China.

The practice of palliative medicine in Peking Union Medical College Hospital (PUMCH), one of the most acknowledged tertiary hospital in mainland China, started when Dr. Xiaohong Ning completed her study on hospice and palliative care in Chinese Taiwan in 2012. Currently, PUMCH plays a leading role in promoting palliative care in mainland China. Here we give a glance to the implementation of palliative care in this tertiary hospital, hoping to throw a light for developing or improving palliative care practice in a typical hospital in China.

Initially, one doctor and three head nurses who were interested in end-stage patients care, or who had experienced sorrow and confusions in caring end-staged family member were invited to join the team. The proficiency of our core team member was great boosted by the Quality End of Life Care for All (QELCA) training program,¹ which was sponsored by the Beijing Living Will Association. Dr. Ning was the first trainee of QELCA from China. Through this training project, 8 doctors and 5 nurses at PUMCH from department of geriatrics, emergency, anesthesia and pain, nutrition, physical rehabilitation and international medical center have mastered the concepts and primary practical skill of palliative care, and are proactive to incorporate the concept of palliative care into their daily clinical practice. Particularly, a senior dietitian has played an excellent role in disseminating palliative care concepts in hospitals after training.

It is crucial to find the right person who has passion and internal initiatives. Involving them in, boosting their ability, and stitching them together are important.

Doctors and nurses who face the dying patients in their daily work and are also interested in making the dying better were invited to join in a WeChat networking group on palliative care, where they share, interact and support each other. They were from the department of cardiology, nephrology, GI, hematology, neurology, neurosurgery, ER, ICU, etc. Besides, psychologists, nutritionists and volunteers are also invited to join us.

We had a social worker who volunteered in part-time providing social supports to patients and their family members in the geriatric department. She also serves as the leader of the volunteer team, which play an important role in ensuring smooth and effective work of the whole team.

An aromatherapist has participated as a volunteer, who has taken care of end-stage patients for years. The aromatherapist also trains our nurses, thus they can help patients with aromatherapy after training. Some of these nurses have become licensed aromatherapists working actively in our team. The funeral staffs were also invited. They initiatively joined us hoping that our team can give them professional instruction in the final stage of hospital death.

With the extensive involvement of the hospital staff, the concept of palliative care has been recognized across the hospital, not only by medical professionals, but also those in rear service department of the hospital. Upon these efforts, palliative care has been acknowledged and supported by leaders of the hospital. The Palliative Care Nursing Group was established in 2017, and the Hospice and Palliative Care Team at the hospital level was formally established in September 11, 2018. Thus palliative care service has been delivered formally on a team-working base, which is a great milestone of palliative care service in the hospital.

It is important to have extensive involvement across the hospital. Being known and recognized by not only physicians and nurses, but also supervisor and the support crew of the hospital can provide rich supportive resources for continuous progress.

We strive to provide supports for team member to participate various training programs, such as those in the United Kindom, Singapore, Chinese Taiwan, Chinese Hong Kong. We also invited lecturers specialized in palliative care from the United States and Chinese Taiwan to bring the up-to-date knowledge to us.

In February 2014, an optional course named “Palliative Medicine” was officially launched in Peking Union Medical College (PUMC) for postgraduate students. The course starts in spring once a year, with 40 credit hours in total, including lectures, role-playing and clinical placement. There are 30-40 students each year who complete this course.^2,3 This course has been highly evaluated by the students.⁴

In September 2015, we launched the Ubiquitous Massive Open Online Course System (UMOOC),⁵ which provides a more flexible and convenient training platform for students and teachers. It was designed to become a compulsory course for postgraduates of clinical medicine. The course was awarded the First Prize of Online Course in Beijing. We also designed a two-hour group-based palliative medicine course for postdocto-ral students in 2016.

With the mature of training programs for postgraduates, the “Palliative Medicine” has been implanted in the fundamental subject of the Diagnostics and as an optional course for internship undergraduates of PUMC from April 2018. Clinical cases of end-stage patient were presented and discussed in group-based learning. Thus, the concepts of palliative care and hospice were delivered ahead to the undergraduate medical students.

The core team hold a national palliative care training program 1 or 2 times each year. Teaching formats include lectures, case-based discussions, and problem solving consultation. About 400-600 participants national-wide receive palliative care training through this continuing medical education (CME) program each year. Trainees include physicians, nurses, visiting physicians, social worker, volunteers etc. Outside specialists in the field from Taiwan China was invited to join in the lecturer team, which enhanced the quality of training.⁶ Sponsored by the Beijing Health Planning Commission and National Health Commission in 2017, we carried out a pilot training programs to cultivate trainer in the field of hospice and palliative care in China,^7,8 which greatly improve the overall quality of training across the country. Investigations on appropriate educational approaches in palliative medicine in mainland China have been conducted.^9-12

Education is time-consuming but has long-lasting effects. Training programs for medical students and professionals at various levels of their career life actually promote the progress of palliative care in both academic and social societies. The educational system and the strong teaching ability of a tertiary hospital can empower the development of palliative care greatly.

At present, patients in advanced or terminal stage who seek for symptom control and general supports usually come to the geriatric clinics for palliative care service, as there hasn’t a clinic dedicated for palliative care at PUMCH. There have been over 1110 patients and 1890 visits in total that Dr. Ning has seen in her clinic since 2016. Among them about 72% were patients with malignant tumor. There are a few doctors who are able to provide service in terms of symptoms control for end-stage patients, Advance Care Planning (ACP), and help with communication among family members.

A dedicated clinic for palliative care is crucial in order to expand the service to more patients who need palliative care. However, challenges exist for hospital regarding the issue of cost benefit, as these services are usually time consuming with low charges according to the on-going fee-scale in Chinese medical system.

Hospice ward has not been established in PUMCH. Terminal patients are hospitalized isolately in a variety of departments, including ICU and ER. In the department where our palliative team member works, for instance, the department of geriatrics, international medical center, and gynecologic oncology, the concept of palliative care has been gradually accepted and partially implemented in the practice. When the staff in other departments feel difficult in the management of their patients, they are apt to seek in-hospital palliative care consultation for help.

Since 2014, the request of in-hospital consultation for palliative care has grown remarkably, exceeding 120 times by far. Initially, these requests were mainly for the symptom control, and recently more are for spiritual pain and difficult communications. The in-hospital consultation helps primary care team members to overcome helplessness, helps patients to alleviate symptoms and reach social, mental and spiritual peace. It also helps the family members who are struggling with suffering. Importantly, it eases doctor-patient tension to a great extent. At present, 3-4 doctors in palliative team are competent of initial consultation. It is urgent to strengthen their expertise to meet the increasing requests of consultation.

Clinical practice is the cornerstone-the foundation of palliative medicine. In the care service of outpatient clinics and in-hospital consultation, patients and their families benefit from the services we provide, which in turn bring more end-stage patients coming to us for help. Additionally, the in-hospital consultation is also an opportunity to get medical staff learn and understand the palliative care in their practice, which in turn bring more clinical demands for consultation.

There are a few research projects going on currently in the field of palliative care at PUMCH. Some are in collaboration with the National University of Singapore, as well as the Asian American Foundation. We are also exploring the community-based hospice care where tertiary medical center serves as the supporter of care provider in community. Main research interests have also been focused on education module and current palliative care status in mainland China.^13-20

The importance of research lie in that hospital leaders, policymakers and peers can better understand the value, role and benefits of palliative care, so that they can bring more resources for further development. Therefore, research and article-based communication are very important in the long run, although many professionals in this field would commit themselves more in caring patients.

The Fund for Palliative Care was launched by Peking Union Medical Foundation²¹ in December 2013, how-ever, the fund-raising seems hard, very limited donation has been recieved from some team members and one patient’s family by far. Dedicated personnel for fundraising is needed. In 2018, we initiated a public welfare project on an online self-helping platform, entitled as the "99 Charity Days", hoping to absorb social fund to support our team.²²

Charity foundation from non-profit organizations is an important support resource. Beijing Ren-Ai Charity Foundation, an organization aiming at helping people to die peacefully,²³ has supported us in an extensive way in the past two years. The Inspirational Scholarship, established by Beijing Living Will Promotion Association in cooperation with St Christopher's Hospice of UK,²⁴ fund an advanced training program in palliative care, which has educated some pioneers in the field of palliative care in China, including Dr. Ning herself.

Support other than funding is also very important. The Educational Department and the Youth League Committee of PUMCH have been giving us immeasurable assistance to our education program and volunteer team.

It has been always said that hospice care worldwide is in shortage of financial support, and there is no exception for us. It is not practical to solely rely on support from government. Fortunately, there are people and organization who share the same passion and values, and always try to understand and support us in various ways. The available resources should be integrated and well utilized in the future. Only in this way can we survive and develop along with the difficulties of social environment.

The team members of the palliative care at PUMCH actively participate in the public propaganda through public media, such as newspaper, ^25-27 magazine,²⁸ and TV shows.²⁹ We also build an official WeChat platform "Henian Yuan", facilitating communication and releasing useful information in the community. The involvement of media makes an extensive social effect and has been a great push to the palliative care movement in mainland China.

The power of the media is strong. Looking back the past five years, the concept of palliative medicine being widely spreaded, understood and accepted by the society can be attributed to the friendly and active help from social media. They are actually an indispensable part of our team. In the future, social media can take roles in educating publics about life, death, and Advanced Care Planning.

To implement the palliative medicine in a tertiary hospital in mainland China is quite challengeable. Compared to the total population of 14 billions in mainland China, the population of professionals in the field of hospice and palliative care is so sparse.³⁰ The concept and the benefits of palliative care have not been understood by all hospital staff, especially it has not been well recognized by hospital leaders and the government yet. Resources put in the care service for the seriously ill or terminal patients do not bring profits to hospitals financially, which is a very important issue even for non-profit hospitals in China. Besides, the general publics have not fully understood the benefits that patients can get from palliative care, and some misunderstandings exist among them, especially the perception and the attitude towards death.

The development of palliative care in PUMCH provides an example of implementing palliative care in a comprehensive hospital in China under the circumstance of Chinese culture and social environment. This may serve as a model for Chinese hospitals to develop palliative care practice, or to improve the quality of existing palliative care service. Our next work task is to explore the appropriate strategies to implement palliative care in the entire hospital, and to promote the acceptance of the concept in a board field of medical societies.

The author has no conflict of interest disclosed.