European Journal of Oncology Nursing xxx (2015) 1e8

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Caring for dying cancer patients in the Chinese cultural context: A

qualitative study from the perspectives of physicians and nurses
Fengqi Dong*, Ruishuang Zheng, Xuelei Chen, Yanhui Wang, Hongyuan Zhou, Rong Sun
Tianjin Medical University Cancer Institute and Hospital, Tianjin, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To explore the experiences of Chinese physicians and nurses who care for dying cancer pa-
Received 8 May 2015 tients in their practical work.
Received in revised form Method: This was a qualitative study using semi-structured face-to-face interviews. Fifteen physicians
25 September 2015
and 22 nurses were recruited from a cancer center in mainland China. The data were analyzed by
Accepted 9 October 2015
qualitative thematic analysis.
Results: Disclosure of information on death and cancer to dying cancer patients is taboo in traditional
Keywords:
Chinese culture, which greatly decreases the physicians' and nurses' effective communication with dying
Cancer
Death
patients in end-of-life (EOL) care. Both physicians and nurses described strong ambitions to give dying
Dying cancer patients high-quality care, and they emphasized the importance of maintaining dying patients'
End-of-life hopes in the death-denying cultural context. However, the nurses were more concerned with dying
Experience patients' physical comfort and wish fulfillment, while the physicians placed greatest emphasis on pa-
Nurses tients' rights and symptom management. Both physicians and nurses suffered whilst also benefitting
Physicians from taking care of dying patients which helped with their personal growth and allowed greater insight
Qualitative research into themselves and their clinical practice. Our results also indicated that Chinese physicians and nurses
require improved methods of communication on EOL care, as well as needing more support to provide
quality EOL care.
Conclusion: Chinese physicians and nurses experience a challenge when caring for dying cancer patients
in the Chinese cultural context. Flexible and specific education and training in EOL cancer care are
required to meet the needs of Chinese physicians and nurses at the cancer center studied.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction
Health professionals working in cancer centers are often con-
fronted with dying patients and bereaved family members. In their
role as supporters, they are the ones to facilitate a dignified,
comfortable death that honors patient and family choices, no
matter where the setting of death occurs. However, caring for dying
cancer patients and experiencing patient death can stir myriad
emotions and thoughts within them, such as raising doubts about
their competency, feelings of guilt, loss or injury from failure to
meet their expectations of care (Cevik and Kav, 2013; Gibbins et al.,
2011; Penson et al., 2000; Wang et al., 2004a).
The presence of dying cancer patients has been thought to be a
significant contributor to burnout and turnover of health
* Corresponding author.
E-mail address: dfq3090@126.com (F. Dong).
professionals (Kendall, 2006; Penson et al., 2000). They are under
pressure to return to an environment where they must care for
other cancer patients who may also be critically ill and expect an
imminent death. Researchers (Lange et al., 2008; Peterson et al.,
2010) have stated that health professionals with better skills and
more experience tend to provide good-quality EOL care and
establish meaningful and supportive relationships with patients
and family members, leading to improved patient outcomes and
satisfaction of patients and their families.
Cultural factors take an important role in the practice of medical
issues. To a large extent, people's beliefs and attitudes about health
and disease are influenced or determined by their traditional cul-
ture (Ekblad et al., 2000). Chinese culture has a particular
perspective on dying and death developed over five millennia due
to the profound influences of Taoism, Confucianism, and Buddhism
(Cui et al., 2011; Hsu et al., 2009). Confucianism, which is a vital
aspect of non-disclosure in China, to some extent greatly influences
Chinese medical ethics, and it tends to advocate a beneficence-

http://dx.doi.org/10.1016/j.ejon.2015.10.003
1462-3889/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
2 F. Dong et al. / European Journal of Oncology Nursing xxx (2015) 1e8
oriented stance (Jiang et al., 2007). Even for contemporary Chinese,
including health professionals, talking about death and dying is
very challenging (Dickinson et al., 2008; Wang et al., 2004b; Xu
et al., 2006), especially for those who are dying; discussion about
death is avoided as such talk may hasten the pace of their dying
process and incur bad luck (Hsu et al., 2009; Wang et al., 2004a).
Compared to Chinese culture, Westerners are better prepared to
face death, and talking about death with dying patients and making
necessary preparation to deal with death are encouraged in
Western cultures where the majority of people identify themselves
as Christians (Xu, 2007).
The perception of cancer is also influenced by culture. There is a
common belief in Chinese societies that cancer diagnosis is
regarded as a metaphor for death because of its high mortality
rate. Due to the family-oriented cultural context (Lu et al., 2011;
Olsen et al., 2010), Chinese physicians and nurses are required to
give priority to families who decide whether or not to tell the
patients the terminal diagnosis (Sun et al., 2011; Wong and Chan,
2007). The family members usually exclude telling the patient the
truth, even when they are at the EOL stages, which is considered
by their families as an good way to protect them emotionally
(Wang et al., 2004b; Xu et al., 2006). However, some dying pa-
tients may know very well what their health condition is, even
though they are kept uninformed (Zeng et al., 2008). In fact, some
Chinese physicians preferred disclosure to dying patients, as they
thought such disclosure may allow dying patients to resolve un-
finished business and manage the last days of their lives (Jiang
et al., 2007). On the other hand, Chinese cancer patients’ attitude
toward truth-telling was greatly influenced by their disease stage;
fewer patients wanted to know their diagnosis during terminal
stages than early stages of cancer (Jiang et al., 2007). Consequently,
Chinese health professionals are in a dilemma whether terminal
cancer information should or should not be disclosed to dying
patients, and how to deliver quality EOL care to facilitate a good
death for the patients.
Researchers indicate that culture imposes certain limitations on
health professionals' options and behaviors when caring for dying
patients (Clark, 2012; Mystakidou et al., 2004). Chinese physicians'
and nurses' experience of caring for dying cancer patients may have
different implications and significance for each (Schlairet, 2009; Xu
et al., 2006; Zhai and Dai, 2006). To our knowledge, no study has
simultaneously involved Chinese physicians and nurses in
exploring the experiences of caring for dying cancer patients in a
Chinese traditional cultural context. Thus, a public discussion is
essential to develop a better understanding of the points of view of
Chinese physicians and nurses, and also to learn how to integrate
these perspectives.
The purpose of this study was to identify Chinese physicians'
and nurses' perceptions of caring for dying cancer patients who are
in their final days or hours in Chinese cultural contexts, with the
objective of illuminating similarities and differences in experiences
and helping to develop effective training.
2. Methods
A qualitative research design was chosen for this study as
qualitative study is considered to be an ideal way of yielding in-
formation and exploring a specific phenomenon; it also helps to
gain a full view of the phenomenon under research. This study was
based on the phenomenology study approach (Merriam, 2009) and
was presented according to the Consolidated Criteria for Reporting
Qualitative Research (COREQ) checklist for qualitative research
(Tong et al., 2007). Research ethics approval was gained from the
Human Research Ethnics Board of Tianjin Medical University Can-
cer Institute and Hospital.
Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
2.1. Sample
This descriptive qualitative research was conducted in a 2400-
bed cancer hospital in northern mainland China. Purposive sam-
pling (Merriam, 2009) was used to include participants with a va-
riety of professional titles, ages, and years of clinical experience in
different departments of the hospital during May to October 2014.
To be eligible to participate in this study, the participants had to
have worked with and been exposed to dying cancer patients for at
least half a year; to be more than 18 years old; to be willing to
participate; and to be a Chinese speaker. Fifteen physicians
participated in this study, with a mean age of 34.56 years
(SD ¼ 8.50); the youngest was 27 years old, and the oldest was 54.
The mean number of years of clinical experience of the physicians
was 8.31 (SD ¼ 7.71); the maximum experience was 25 years, and
the minimum was 1 year. Twenty-two nurses were also recruited.
The mean age of the nurses was 29.34 years (SD ¼ 6.63); the
youngest was 24 years old, and the oldest was 49. The mean
number of years of clinical experience of the nurses was 7.47
(SD ¼ 6.52); the maximum length of clinical experience was 27
years, and the minimum was 0.5 years.
2.2. Data collection
A semi-structured face-to-face interview guide was developed
based on the purpose of the study; this was pretested with two
nurses and two physicians to ensure the questions were under-
standable and answerable, on the basis of which we adapted this
interview guide again. Prior to the one-to-one interviews, partici-
pants completed a demographic form, were made aware of the
aims of the study, and provided written information consent. They
were guaranteed that they could withdraw from the study at any
time; the study was anonymous, and identifying factors were
removed from the data. All the material and information was
locked by the first researcher in a cabinet and accessed only by the
researchers.
The interviews, ranging in length from 30 to 60 min, were car-
ried out at a site of each participant's choosing by a single
researcher (R.S. Zheng) who had received training in qualitative
research. Each participant was asked to recount their feelings and
personal experiences regarding caring for dying cancer patients.
Interview questions included ‘How do you feel when you are caring
for a dying cancer patient?’, ‘What are your thoughts and feelings
when doing that?’, ‘What do you think of quality EOL care?’, ‘What
would you do for a dying cancer patient?’ and ‘How does the
experience of caring for dying cancer patients impact you?’ Probes
were used to encourage participants to elaborate on their experi-
ences: for example, “Could you tell me more about that?”, “What do
you mean by saying that?” etc.
2.3. Data analysis
Interviews were digitally recorded and transcribed verbatim.
Data analysis was done independently by the first and second au-
thors, who followed the standard methods for qualitative thematic
analysis. Data analysis began with the first interview and was done
in conjunction with data collection (Merriam, 2009). The method
used for analyzing qualitative data was Colaizzi's approach
(Colaizzi, 1978): (1) to read the transcripts repeatedly while
listening to the digital recordings; (2) to extract essential elements
and meaningful statements from the transcripts; (3) to code the
same elements and statements; (4) to arrange the formulated
meanings into clusters of themes; (5) to state detailed descriptions
for every extracted theme; (6) to read the themes and the de-
scriptions again; (7) to return the transcripts to the participants to
 F. Dong et al. / European Journal of Oncology Nursing xxx (2015) 1e8
obtain their views and to be verified. The first and second authors
compared and determined the final themes together and collabo-
rated when there were differences. Data collection did not cease
until no new information was obtained, which indicates data
saturation has been reached.
To maximize credibility, the themes and citations were trans-
lated from Chinese into English by two independent translators.
The two translated versions were compared, analyzed, and modi-
fied by the first and second authors. A bilingual person who was not
connected to the research was then asked to translate the English
version back into Chinese. Finally the research team reviewed the
results and revised some of the English until it was closer in
meaning to the original Chinese.
3. Results
Five main themes emerge from this qualitative research: (1)
strong senses of obligation and crisis; (2) hope and spirit mainte-
nance; (3) improvement of quality of life; (4) promotion of family
function; (5) dilemmas during EOL stage.
3.1. Strong senses of obligation and crisis
At the beginning of the interviews, both the physicians and
nurses were asked to describe their feelings and thoughts at the
very moment of their recognizing that a cancer patient was dying.
As disclosed through their narratives, the physicians and nurses
expressed similar views and emphasized the importance of their
presence and availability at the patients’ bedside, which they
thought demonstrated their concern to the patients and family
members.
“Their conditions were worsening dramatically … may go away at
any time. I stayed in the hospital, went to their bedside every ten
minutes, looked at their vital signs, or just let them know I was
there and available at any time … For 24 hours I kept my cell phone
on, so they can reach me at any time. They need us more than ever.”
(D5)
The physicians and nurses gradually became experienced in
recognizing a dying patient's imminent death. On noticing one
patient was dying, they would have a sense of crisis and pay extra
attention to him or her. At the same time, they were alert and fully
prepared for attempting resuscitation.
“I go to their wards numerous times, and keep an eye on them. They
need much more attention. I can tell that he might die this night or
tomorrow, no later than the day after tomorrow. I am under
pressure and have a sense of crisis because it will come very
quickly. We should face it with them together.” (N12)
3.2. Hope and spirit maintenance
The narratives of this study indicated that the maintenance of
hope was considered to be quite critical in the care of dying pa-
tients, as hope creates a positive attitude and reduces suffering.
That is, living with terminal cancer did not mean living without
hope for dying patients. The physicians and nurses spontaneously
expressed, albeit in different terms, the importance of maintaining
dying cancer patients’ hope for life.
3.2.1. Death denying and information non-disclosure
The participants clearly described that Chinese traditional death
culture did not allow them to discuss the death event with dying
patients, especially at the terminal stages. Instead, the physicians
Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
3
and nurses did their best to foster and maintain dying patients'
hope. However, keeping dying patients' hope within such a cultural
context was not an easy job. They experienced an ethical dilemma
between keeping dying patients' hope and truth; the latter may
diminish dying patients' hope. Instead of using the word ‘cancer’
and ‘tumor’ when speaking with patients, the physicians and
nurses used the word ‘the disease’, which they believed helped to
maintain the patients' hope even at the EOL stage.
“The essential obligation for a physician is to keep their patient’
hope, not to diminish it, depending on which the patients fight the
cancer as long as possible, even at the last minute. They still ima-
gine they can be cured, feel safe and be positive towards life and
treatment …. If they know they are dying, they probably lose hope,
feel desperate … I also ask the families to conceal the secret. No
matter what the patients ask about their condition, we're not
supposed to let out any bad information.” (D1)
“They were doing their best to fight with the disease, and how could
you tell them they've got advanced cancer? There was not much
time left? They might be depressive, gloomy or even committing
suicide, no hope towards life … It's much better to die in hope than
live in despair.” (N8)
However, deception was reported to be difficult to maintain, and
the nurses and physicians identified deficits in non-disclosure.
They questioned the effectiveness of hiding cancer diagnoses
from patients, and provided examples of patients suspecting the
diagnosis. A few physicians thought dying patients should be told
about their health conditions since everyone has his right to know
about his disease and die without regret.
“It's really difficult to tell a lie as his health condition is worsening
dramatically. His time is coming. But how could I tell him? It is so
difficult to deal with that … But we should tell him.” (D2)
Both the physicians and nurses attributed their cancer informa-
tion non-disclosure behavior to Chinese traditional culture. They
stated that the lack of belief or faith resulted in dying patients’ fear
and ignorance of death. In order to better tackle this difficult issue,
some physicians reported that they tried to seek information and
knowledge about death and its related issues, which they thought
might help with their understanding of death, and then in turn
improve their ability to interpret the death event with their patients.
“Few people have religious belief in our country, so when one is
diagnosed with cancer and death is coming, most would lose
control over life, no inner sustenance at all, as if death was a
mysterious issue. They show ignorance, fear, complete rejection …
Neither do I know how to interpret death from a religious stand-
point. I have begun to read some books about death, such as the
Bible, the Buddhist … to find out how to recognize death and
explain it in a common way … just to help my patients and myself
as well.” (D11)
3.2.2. Strengthening inner energy
Individual patient's worth as a source of hope was emphasized
by the physicians in this study. That is, it gave dying patients hope
when their physicians made them feel valuable and cared for. The
physicians also supported their dying patients through physical
contact, which was thought to be an important way to express their
concern. Shaking hands was especially emphasized by the physi-
cians to convey their support.
“A physician's hand is just like a life-saving straw, to give them
hope and support. So whenever I went to their bedside, I held their
4 F. Dong et al. / European Journal of Oncology Nursing xxx (2015) 1e8
hands tightly. They might have no strength at all, but I do … By
shaking hands you tell them you do care about them and they can
rely on you. On the other hand, shaking their hands can help you
read what they were thinking … I just wanted them to know I
would be always there with them.” (D1)
How to preserve dying patients' faith or a meaning of life until
the very end of life was reported by the participants to be quite
difficult. However, quite surprisingly, an experienced and respected
physician might have a more positive influence on the dying pa-
tients’ hope for life during the last few days.
“The president of the hospital (an experienced and respected expert
in the country) came to the dying patients' bedside, and checked
their health condition. His words, even a slim smile had magical
power for them, gave them much hope to live. They trusted and
relied on him so much … The families even begged this expert to see
their relatives at the last few days.” (D9)
The nurses did not mention holding hands with dying patients,
but they expressed hope as the inner energy that drove dying pa-
tients to keep on living well until the end of life. Both the physicians
and nurses suggested that allowing dying patients to hope for
something was quite important for nurturing hope; even fostering
fake hope would help dying patients a lot. The younger health
providers, who were less skilled in communicating with dying
patients, usually kept quiet or told outright lies when encountering
challenging questions. As a junior nurse said:
“Some patients with consciousness pretty knew what was going on.
How to help them within such a cultural context? To maintain their
hope, comforting them is the only way … ‘Please do not worry. You
are getting better. I guess you can discharge in two weeks. But I felt
so embarrassed to cheat them.” (N4)
3.2.3. Spiritual care
From the narratives of both physicians and nurses, it is indicated
that spirituality and religion were thought to be important aspects
of care that improved coping with the disease and symptoms as
well as strengthening quality EOL care. The nurses emphasized that
their sensitivity to dying patients’ religious background was
essential, and they were expected to meet their patients’ spiritual
and religious needs.
“Spirituality provides a foundation that helps them transcend
suffering and despair … Trying to find some meaning or purpose
might do some help … One woman wanted to die in a Buddhist kind
of room, to play Buddhist songs and decorate the room with
Buddhist pictures and portraits … We did as she wished. Two days
later, she passed away peacefully. It was meaningful.” (N16)
Besides this, some nurses reported that connection with families
and friends was an important element of spirituality for the dying.
They established meaningful relationships with their patients as
friends by showing respect, care, love and kindness.
“Those patients near the EOL stage always struggle to find a pur-
pose or meaning in life. So, I always tell them, ‘you are a great man,
have achieved so many successes, and have an amazing life legacy’
or ‘You have a great family. They all love you so much’. These words
I think will help them feel relieved.” (N24)
The physicians in this study did not mention spirituality but said
it was not their job to pay attention to spiritual care for dying
patients.
Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
“Spiritual care? No, it's out of my realm of expertise and impractical
to me, you know, we're just too busy … But indeed, they must have
been in a struggle to find life meaning, something spiritual …” (D8)
3.3. Improvement of quality of life
3.3.1. Control of physical symptoms
All the participants mentioned that minimizing dying cancer
patients’ suffering at the EOL stage was a core responsibility for
them. When they were asked what was done for dying patients at
this stage, they mentioned that pain management had priority.
“Good symptom alleviation and optimized quality of life for dying
cancer patients is of importance to maintain a life's meaning.
They're in unrelieved pain, so disturbing … Analgesic administra-
tion is the most important at the moment.” (D10)
Good symptom control was viewed by the physicians and
nurses as a sign for keeping up dying patients' hope. However,
difficulties in palliating dying cancer patients' suffering, such as
dyspnea or ascites, were associated with both the physicians and
nurses’ feelings of helplessness and empathy.
“We try to relieve their suffering, but the disease is there, dyspnea is
getting worse and worse. Their other conditions are also worsening.
Little we can do now … So sad to see that.” (N5)
3.3.2. Providing comfort
The nurses indicated that they did their best to promote dying
patients’ physical comfort as keeping them comfortable was their
essential responsibility. They cleaned and dressed dying patients
regularly, turned them over in bed and did mouth care. The nurses,
especially the junior nurses, also tried to avoid invasive nursing
procedures for dying patients.
“I usually do not perform invasive nursing procedures for them,
such as drawing blood, as my nursing skills are too poor to do it
well, which might make them suffer more. I tell a senior nurse to do
that … I do pay great attention to mouth care as it is quite easy.”
(N9)
Resuscitation and other aggressive treatments did not mean-
ingfully extend dying patients' lives at this stage, so the physi-
cians preferred comprehensive treatments to alleviate the
patients' pain and to offer maximal physical comfort. However,
the physicians found it difficult to avoid these treatments in the
provision of EOL care for dying patients, as some family members
requested ongoing aggressive treatments to prolong a dying pa-
tient's life.
“We should discontinue inappropriate interventions, such as blood
tests and vital signs measurements. But some families still focus on
active treatments. These (treatments) ultimately aggravated the
patients' suffering and distress. We had no other choice but to do
it.” (D2)
3.4. Promotion of family function
3.4.1. Encouragement of being with dying patients
Both the physicians and nurses stated the importance of family
members being together with the dying, which was a beneficial
interaction not only for the dying but also for the families. Also,
they addressed the importance of family function in EOL care. Just
as a physician said:
 F. Dong et al. / European Journal of Oncology Nursing xxx (2015) 1e8
“Families' support is a main impetus to keep dying patients going,
to gain more time … They are fully loved by their relatives, and feel
satisfied when all are around them. We tell the families that their
loved one will die, so they have the opportunity to stay with the
patient, and spend some time together.” (D7)
Furthermore, both the physicians and nurses reported their
suggestions for the families e such as not leaving the patient alone,
using positive physical contacts such as holding hands tightly,
touching, or making eye contact e which were described as
meaningful ways of expressing love. The physicians emphasized
the importance of the family role at the EOL stage. They chose to
communicate with family members rather than dying patients
about any decision-making, treatments and arrangements for
dying patients. They stated that reducing delays in communication
with family members regarding the patient's illness may provide
more opportunities for families to say goodbye to dying patients,
and the family members then had time to help complete dying
patients' personal and financial business and plan the last few days
of the patients' life.
“Timely, effective communication about the irreversible and pro-
gressive illness is urgent at this time. It can promote their [family
members'] preparation for saying goodbyes to them [dying pa-
tients], or contacting relevant people to have a last visit with the
patients, which I think is quite important for all of them.” (D3)
3.4.2. Encouragement of patient care and advocating
The nurses promoted family function by providing the families
with certain caring skills such as “taking care of ill relatives was
thought to be a good way to express love”. Thus, supporting and
enhancing a family's ability in taking care of dying patients then
became a professional duty of the nurses.
“Some family members really liked to do something for their loved
ones. But they had no such experience and knowledge; we just
show them how to take care of the dying patients.” (N21)
Family members tended to advocate for dying patients, espe-
cially at the EOL stage, as family members in Chinese culture were
seen as the decision-makers when dying patients were unable to
make decisions for themselves. Both the physicians and nurses
emphasized that fulfilling dying patients' wishes required high
skills in communication without involving discussion of death with
dying patients. They often encouraged the families to express dying
patients’ wishes and needs.
“Since we are not allowed to talk about death … I don't ask them
[dying patients] directly about their final wishes because I am
inexperienced to do that. I encourage their families to communi-
cate with them, whether they have any wishes … After all, to fulfill
final wishes and die with no regret is part of death with dignity.”
(N20)
3.4.3. Family preparedness for impending death
The physicians mentioned that they communicated with family
members about the patient's life expectancy in advance, so that
they could be mentally prepared and anticipate the patient's
impending death without too much loss of hope and faith.
“When their vital signs get worse dramatically and an inevitable
death nears, I would have a serious discussion with their families,
to inform them that they should understand aggressive treatments
change only the time but not the patient's ultimate fate. I then give
suggestion that sensible and humane decisions should be made,
but, it still depends on the families.” (D5)
Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
5
The physicians and nurses stated that family members were
sometimes unaware of the dying process and had no idea how to
prepare themselves for a relative's death. Thus, they appreciated
cultural and religious traditions related to the dying phase and
taught the family members how to prepare for the coming event.
“We have a traditional death ritual, but some family members have
no idea about how to do it. So we tell them what they are supposed
to do, to buy what kind of wardrobe.” (N14)
From the narratives of the participants, it is clear that the phy-
sicians and nurses helped facilitate death at a place that was in
accord with the dying patients' and family members' preference,
which was thought of as a meaningful way to maintain the patients'
dignity, and even the quality of death itself. For most patients who
did not know their health conditions, the health professional asked
their families’ preference of a place; for those few patients in full
awareness of their disease, the families would ask for their opinion.
“Some patients often choose a specific setting as their preferred
place of death. So we encourage the families to ask them (in full
awareness of their disease) where they want to die. Some may
express their desire … at home. Then we would arrange an
ambulance to escort them to go home.”(D12)
3.5. Dilemmas during EOL stage
3.5.1. Communication in the Chinese cultural context
The informants in the present study expressed the view that for
the provision of quality EOL care, it is essential that dying patients
were cared for by clinically competent health professionals. One of
the attributes of quality care was “good communication skills”.
However, communication around sensitive areas of EOL care was
thought to be the most challenging topic even for the experienced
physicians and nurses as a result of Chinese culture's taboo around
death.
“A physician is able to enhance, maintain or destroy hope in pa-
tients through his attitude, behavior, and ways of communication.
So, whenever I go to that kind of ward, on the way there I always
slow down, think over what to say, how to comfort them. I need to
design some nice words in advance to perform well. Then I fake a
happy expression with sweet smile to go to his bedside … I try to be
relaxed, to tell them their health condition is not that bad.” (D1)
However, both the physicians and nurses stated that cheating
dying cancer patients was not always a good strategy to meet dying
patients’ emotional demands. Communicating bad news was
thought by the healthcare professionals to be a source of job burnout,
including emotional exhaustion, and decreased personal accom-
plishment. The younger health professionals especially expressed
their needs for improving communication skills in EOL care.
“How could you say to a dying patient, ‘I am sorry, there is nothing
more we can do.’ Nobody wants to hear those fateful words, then
how could I comfort them? The question has confused me for nearly
ten years. I have not got any proper answer to it.” (D11)
“I dare not to look at their desperate eyes, which makes me scared
… I went to that ward, delivered the nursing procedure, and ran
away … I was reluctant to stay long in that ward.” (N5)
3.5.2. Inexperienced in psychological care
The informants recognized that dealing with life and death is-
sues was an integral part of daily practice. They understood they
6 F. Dong et al. / European Journal of Oncology Nursing xxx (2015) 1e8
could not control life, but as a health professional they thought they
should provide psychological support to the dying and the relatives
of the dead. However, some nurses pointed out the psychological
interventions provided to the dying patients were far from suffi-
cient due to the influence of Chinese culture of death and dying.
They learned from “errors” while “doing the job” or just “being left
to learn from experience”.
“I should provide some specific help to relieve their fear about
death, and talk death with them; just like the Western countries'
nurses do for their patients … talk about death openly, and say
goodbye with them … However, I absolutely have no any idea on
how to do it … we should learn something …” (N5)
From the narratives of the participants, we found that although
spiritual or existential distress, as well as fear of the unknown,
could manifest anxiety in dying patients, the physicians and nurses
did not foster frank discussion of the patients’ fear. This lack of
discussion was thought to be an unsupportive environment.
“When they were confronted with death, most were poorly pro-
tected, resulting in experiences of both hopelessness and despera-
tion. All they thought was to how to survive, how to get better. How
could we destroy their ‘confidence’?” (N11)
Compared with the nurses, fewer physicians mentioned psy-
chological care for dying patients as their skills and knowledge
were quite limited on psychological care.
“There were no psychological courses for medical students. And the
hospital also doesn't have many specialists on psychology. But
addressing the dying patient's psychological issue indeed is an
extremely critical issue.” (D7)
3.5.3. Personal growth versus negative influence
Nearly all the physicians and nurses stated that death of their
patients caused them to reflect on their own value and personal life.
These challenging experiences motivated significant changes in
those involved. Some nurses pointed out their professional growth
from caring for dying patients and their families.
“I have acquired much knowledge through caring for the dying, for
example, how to prepare for [the patient's] death and how to
communicate with the family members. I have never done that
before.” (N5)
Besides this, the staff reported that involving themselves in such
events was rewarding and they benefited a lot from their experi-
ences, such as developing positive outlooks on life.
“At that moment, you realize that the most important thing in life is
you're healthy and happy; it's not how wealthy you are. Money
might prolong one's life, but it can't save a person's life.” (D3)
However, working with dying cancer patients costs the physi-
cians and nurses considerable energy. They reported that they were
particularly busy and under great pressure both physically and
psychologically when dying patients were on their shifts.
Compared to senior staff, the junior physicians and nurses reported
feeling more powerlessness and incompetence when facing dying
cancer patients.
“I feel nervous if there is a dying patient on my shift, and feel much
better when he dies or goes home, because I'm probably not that
busy physically and psychologically. When another dying patient is
coming, I feel stressed and worried again.” (N13)
Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
Working with dying patients left a big impression on both the
physicians and nurses which, in turn, generated a significant
impact on their daily lives, such as causing bad moods, nightmares
and poor sleep quality. A lack of education and experience might
contribute to negative attitudes and adverse effects.
“If there was a dying patient during my shift, I felt gloomy and
nervous … I would probably have a nightmare about him or her … I
think they have not influenced me so much, but I do dream about
them for several days.” (N15)
4. Discussion
The current study has identified the experiences of Chinese
physicians and nurses when caring for dying cancer patients in a
Chinese traditional cultural context. A unique contribution of the
present study is that it allows a comparison of the perspectives of
physicians and nurses on this topic. The views and experiences of
Chinese physicians and nurses were similar, suggesting that all of
them cared about the dying patients, showed deep compassion,
and did their utmost to ensure quality EOL care and a dignified
death.
The physicians and nurses in this study emphasized the need to
keeping dying patients' hope alive even in the last few minutes,
which is consistent with other findings (Ellershaw and Ward, 2003;
Von Roenn and von Gunten, 2003). Several previous studies argued
that preserving and maintaining a dying patient's hope is a major
barrier to discussing prognosis and EOL care (Knauft et al., 2005;
Shirado et al., 2013; Von Roenn and von Gunten, 2003); health
professionals should help dying patients refocus their hopes onto
more realistically achievable things while not giving them false
hope, which is generally perceived as an influencing factor in
building trust between health professionals and patients (Knauft
et al., 2005; Shirado et al., 2013). In this study, however, the phy-
sicians and nurses did offer some unrealistic hope or expectations
to dying cancer patients, which was not only perceived as beneficial
to the dying but also to the family members. Furthermore, they
managed to hold the truth from dying patients even during the
dramatic deterioration of their physical symptoms in the last days
or few hours. These results were non-consistent with previous
studies from other cultural contexts (Knauft et al., 2005; Shirado
et al., 2013; Von Roenn and von Gunten, 2003). However, little
research has been done about whether Chinese cancer patients and
family members actually prefer realistic versus unrealistic goals
regarding a patient's imminent death.
The findings of the present study revealed that Chinese culture's
death taboo permeates the society, especially when it comes to
cancer-related issues. The physicians and nurses avoided talking
about death and cancer with dying patients, and even pretended to
foster a false hope as illustrated above. It is not surprising in Chi-
nese typical death-averse society that the majority of physicians
and nurses find it quite difficult to deal with EOL issues (Balaban,
2000), especially when communicating with dying patients.
Some studies have suggested that promoting a good death by
listening to dying patients' fears, concerns and feelings regarding
grief and loss, would allow health professionals to understand
dying patients' points of view (Caton and Klemm, 2006; Cevik and
Kav, 2013). However, these approaches may not be applicable in the
Chinese traditional context. Although the physicians and nurses
showed great concern in relieving dying cancer patients' fears
about death, EOL-related communication with dying patients may
also need further exploration within the predominant cultural be-
liefs. Thus, understanding Chinese specific cultural values on death
issues is vital to address culturally sensitive care to dying patients
 F. Dong et al. / European Journal of Oncology Nursing xxx (2015) 1e8
and their family members. How to meet dying cancer patients'
wishes, needs and preferences is still under-researched; further
study is recommended.
The physicians and nurses did their best to ensure that their
dying patients died without uncontrolled symptoms, which might
lead to a distressing and undignified death. They promoted family
functions to help dying patients and family members, and to make
sure of a good death. However, Chinese medical education is
currently failing to prepare junior physicians and nurses for their
role in caring for dying patients and dealing with patient death (Yeo
et al., 2005). They receive little formal teaching about palliative or
EOL care in their role and the culture in traditional China does not
encourage learning about this subject. From the findings of the
present study, we came to the conclusion that the physicians and
nurses were eager to enrich their skill and knowledge for taking
care of dying cancer patients and family members. Adequate
preparation of oncology health professionals for the care of dying
cancer patients could in turn improve patient outcomes, satisfy
family members, and increase professionals’ job enthusiasm (Caton
and Klemm, 2006). That is, the more experience that physicians and
nurses have with dying patients, the more positive the care expe-
rience becomes.
This study has shown that Chinese physicians and nurses had a
limited knowledge of EOL care due to a dearth of formal training in
caring for dying patients. Providing support to Chinese physicians
and nurses and tailored death education specific to meeting their
needs are imperative. Thus, death education in EOL care is essential
to reshape Chinese health professionals’ views about death. EOL
simulation in diverse clinical sites may provide health professionals
with a valuable lesson and help them to cope with their emotions,
and to equip themselves with skill and knowledge about death and
dying. EOL care programs and nursing training models e such as
the End-of-life Nursing Education Consortium (ELNEC) program
(American Association of Colleges of Nursing, 2004) which aims to
improve EOL care abilities of nurses e could be adapted specifically
for wider use in the Chinese cultural context. In addition, studies to
develop coping strategies on how to effectively take care of dying
cancer patients should be conducted.
There are several limitations to this study. First, the number of
participants interviewed is small and the findings may not be
generalizable; however, we achieved saturation of data and showed
a good picture of how Chinese health professionals took care of
dying cancer patients. Second, all the physicians in this study were
male and the nurses were female, which might lead to findings that
are dependent on gender. Thirdly, these participants were known
to the research team, which suggests that their experiences may be
‘superficial’ as they might have been unwilling to describe their
inner thoughts and worried about the confidentiality of what they
reported. However, it was much easier to build trust and properly
comprehend responses to the questions between the researchers
and the participants.
5. Conclusions
Chinese physicians and nurses caring for dying cancer patients
expressed their great concern on treating distressing symptoms,
maintaining diminishing hope, meeting spiritual needs and
addressing psychological issues. However, there is a lack of infor-
mation and training programs about quality EOL care in the
mainstream textbooks to which Chinese physicians and nurses turn
for information about care of dying patients. Therefore, external
programs and individually tailored orientation plans including EOL
care should be developed and offered to Chinese physicians and
nurses who need guidance to enrich their knowledge, clinical skills
and coping strategies.
Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003
7
Conflict of interest
None declared.
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Please cite this article in press as: Dong, F., et al., Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the
perspectives of physicians and nurses, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.10.003