Professor Wang Ying Wei is the director of the Centre for Palliative Care and medical consultant in Hualien Tzuchi Hospital. He received his MD degree from Taiwan University and PhD from Tulane University in US. He completed his residency training in Family Medicine in Taiwan University Hospital. He was the former Director General in Health Promotion Administration MOHW, the chief in Heart Lotus Hospice in Tzuchi General Hospital, and director in the Department of Medical Humanities, Tzuchi University. He started the first Buddhist hospice programme in East Taiwan since 1996. He is a council member of APHN. He developed many innovative programs for geriatric care, palliative care and medical humanities in Chinese Taipei in the past few years. His specialty included palliative care, geriatric care, medical education, and health promotion.
Tell us a bit more about your background. What made you get into palliative care, and what made you stay?
I am a family physician working in east Taiwan. In the past, I served primary care patients in communities and in rural areas in the aboriginal country, and I met a lot of patients at the end of their lives. When I started my program 27 years ago, one of my staff members was very interested in palliative care. Since I thought there was a need from the patient and that there will be a change in the future, we started the program. Around 26 years ago, I started the first hospice unit in east Taiwan. We are the third formal hospice in Taiwan.
You were one of the first doctors to develop palliative care wards in Taiwan. Could you tell us more about your thought process, philosophy, and motivation at the time? What challenges did you face?
More than 30 years ago, when I was trained as a family physician, there was no understanding of palliative care or end-of-life care. But at the time, there was a campaign in Taiwan by many former scholars who advocated for palliative care—[specifically] two professors: Professor Chao and Professor Qian. Professor Chao is regarded as the pioneer of palliative care in Taiwan.
She advocated that this is the main issue for hospice care in Taiwan and the community. She visited our foundation head—I call her my boss! My boss is named Master Cheng Yen, who works at the Tzu Chi Foundation, the largest foundation in Taiwan, with over 20 branches, all around the world, also in Singapore. They talked to our boss about how this is a very important issue—caring for dying patients, and quality care for these dying patients; my boss agreed.
But at the time, Chinese culture was [prominent]—most people wanted to die at home, and die in their communities, not in hospitals. But many hospitals at that time did have hospice care, but it was only really a few beds, and no people taking care of the patients, because they believed there was no possible treatment for people at this stage.
My boss originally had the wrong concept about palliative care, but Professor Chao corrected these misconceptions. Then, we started this program.
At that time, I visited Japan—because they developed hospices earlier than Taiwan did—and did distant calls with Hong Kong. I also visited different hospices in Japan and participated in many international conferences about palliative care development, especially in the UK.
Thus, we developed the first hospice in east Taiwan and the first Buddhist hospice in Taiwan.
How would you describe your personal philosophy and approach to palliative care?
When I was training as a family physician, we trained in the biopsychosocial approach to patient care. However, in palliative care, we emphasize the biopsychosociospiritual approach—including the spiritual aspect.
Working in a Buddhist hospital, I had always regarded religion as another aspect [of patient care] for us, but not for me. I thought that the biopsychosocial approach is very specific to a physician [‘s role]; the spiritual [part is the responsibility of] a chaplain or a religious worker. But after working and caring for a lot of patients, we think that spiritual care should be the responsibility of everybody, not just for those [specifically] providing religious care. It should be integrated into the biopsychosociospiritual caring process.
At that time, Taiwan had three trains [of thought]: Buddhist, Christian, and traditional culture of palliative care. Although the physiological and biological care [we provide] is similar to other hospices, we developed [additional care following the traditional and Buddhist trains of thought] as we provide physical or psychological care for both the patient and the family together.
Overall, I changed my philosophy: I thought that the physiological [aspect of care]—taking care of the patient, relieving their suffering and pain—that’s all my job is; the rest should be done by others. But now, I think it should be a holistic approach and integrated together.
Was there a particular moment that changed your understanding of palliative care?
It is internationally taught that you have to approach the patient holistically. Sometimes, when you care for patients, [it can be limiting] if you only focus on one aspect—you have to consider [the patient] as a whole. So, this is the experience for many.
[Around 21 years ago], when I was working hard to care for my patients, I realized [my experience was limited]. So, we discussed with the National Taiwan University and also the veteran’s hospitals — those are the largest two hospitals in Taiwan, and also the start of the palliative care unit. Whilst I was working in east Taiwan, [these hospitals were in] the north in Taipei.
[Thus,] almost 21 years ago, we developed a distant conference for case discussion over the telephone—we didn’t have the internet at the time. We discussed the patient’s problems, how we can treat this problem, and shared our experiences. I think that this was a very supportive experience and is very important. [It’s not enough to] read articles, textbooks, papers to read patients—we must also discuss with others about how they treat the patients with their holistic care.
The teleconference we started 22 years ago we’ve continued up until now. About 10 years ago, when the internet became more available, we used the internet. Now, every other week, on Thursday mornings at 7:30am, there are 60 to 70 spots joining the case discussion. With around five people in each spot, there are 300 people discussing a case. Each time, the case is presented by a physician, nurse, social worker, spiritual care provider – it’s a holistic care presentation and sharing of the experience of caring. I think it is a very useful experience for learning.
What do you think is a common misunderstanding that people have about palliative care?
Look at the development of palliative care. Initially, it started from the UK, and was called ‘hospice.’ Then, in Canada, it was [termed] ‘palliative care.’ Then, in the United States, they call it ‘supportive care’—so, earlier intervention rather than late intervention.
In Chinese, we [traditionally] use an’ning (安寧) which means ‘peace,’ or ‘peaceful care.’ But when people think about an’ning, they think about ‘hospice care.’ That means terminal care, and the stigma that comes with that—people think they are going to die. So, we are trying to change [people’s understanding] to ‘palliative care’—for symptom relief, for psychological support, for social support, spiritual support—not only for those at the terminal stage, but also for early intervention.
We tried to make it a social movement. Four or five years ago, we started with a so-called social movement with compassionate communities, for caring for patients with severe illness in the communities, not only dying patients. We also have some programs in primary and high schools about life and death, [and] programs about how caring is not just for the dying.
It’s about changing the terms. We are even training our specialists doing consultations to not mention they come from the hospice, otherwise “nobody wants you to come see them, just say you come from a unit that provides palliative care to relieve your symptoms, not from a unit that is caring for dying patients.”
I like the program in Singapore called si’dou’yao’jiang (死都要講) (‘Die Die Must Say’). It’s a very interesting program. I also introduced something similar in Taiwan.
I’d like to mention [some of Taiwan’s] government regulations. [There is something called] the Hospice Palliative Act, and also the Patient Autonomous Act. Those are two acts from the government that are appointed for patient’s autonomy. When I talk with my patients, I always say that it’s a very important issue, that I myself have signed this act. The patients see [I am] quite young and that “[I’m] not a dying patient.” This means we can talk about it earlier, not just when we are in the dying process.
So, there are a lot of activities we have to promote the concept [of having conversations about dying]. We go into communities, into churches, and continue to discuss the Hospice Palliative Act—the patient can sign on their national insurance card, and then they have a record, even if they are very healthy. I think that even if you are healthy, you can still consider [and have conversations about the taboo topic of] dying.
What was the most important skill or mindset that you have developed throughout your career and how does it help you in your work?
Being open-minded is very important.
[Aside from being a physician,] I’m also teaching at university as the Director of the Department of Medical Humanities, and acting as the Director General in Health Promotion Administration in the government. I am also responsible for the promotion of health and palliative care project. I think we have to think out of the box—don’t limit your thinking. You have to think about things systematically at the different domains or aspects of one issue.
When I left the government 2 years ago, there was a take-home message. There are four important M’s for program development. The first ‘M’ is money. The second ‘M’ is method. The third is monitor. But, I think these are not so important. The most important is the 4th: mindset change. We should try hard to change the people’s mindset, to encourage palliative care to be integrated into the traditional healthcare system, [rather than existing] outside of the system.
Taiwan has been very successful in integrating it into the healthcare system. This is very important for hospice palliative care development in Taiwan.
[With regards to] skill… reading, reading, reading, discussion, discussion, discussion, being open-minded, sharing. That is the skill.
Do you have any favorite quotes or sayings that you would like to share?
I think I am one of the key people in forming palliative care in Taiwan. We have a lot of programs that start and then stop very early on, without any progression. So, I like the words ‘think big, start small, move fast.’ Thinking big—that’s systematic thinking. And we can start small. But once it’s successful, we have to move fast.
Look out for our next mini interview with our Assistant Treasurer, Ms Choo Shiu Ling!
Transcribed and edited by Ms Jacqueline Chan (APHN Intern)