Despite cool and misty skies that prevented our aircraft from landing after several attempts, our team received an exceptionally warm welcome on arrival. Dr Kinley Bhuti, the only doctor in Bhutan with some specialist palliative care training, greeted several faculty members with deep familiarity and affection. For those who have travelled to Bhutan five or six times previously, it felt less like arriving in a new destination and more like returning home.
Bhutan is a small Himalayan nation of approximately 700,000 people, situated between China and India. The country is a constitutional monarchy, with the King serving as head of state and held in deep respect by the Bhutanese people. Renowned for its breathtaking mountainous landscapes, Bhutan has become a sought-after destination for trekking and reflection, and is globally recognised for its unique national philosophy that prioritises happiness and wellbeing.
This visit marked the sixth of seven Modules of the Asia Pacific Hospice Network (APHN) – Lien Collaborative’s Train-the Trainers Programme delivered in Bhutan. Some participants have been engaged since 2018, when the inaugural module was led by Professor Cynthia Goh, whose pioneering vision established the foundation for this ongoing collaboration.
Our faculty team, with strong representation from Singapore, included experienced educators such as Bhutan Lead Dr Shirlynn Ho from the National Cancer Centre Singapore, Dr Jamie Zhou, and Sister Nandar Swe from Assisi Hospice. New faculty members included Sister Tan Li Kuan from Dover Hospice and myself, representing St Vincent’s Hospital Sydney, Australia. As first-time faculty participants in Bhutan, we were filled with anticipation as we observed our seasoned colleagues skillfully engage with the Bhutanese participants.
The diversity of the participants was remarkable. Clinicians from a wide range of specialties and disciplines attended, including but not limited to orthopaedic surgery, gynaecological oncology, general surgery, intensive care, and community palliative care nursing. This interdisciplinary mix enriched discussions and reflected the growing relevance of palliative care across many areas of practice.
While previous modules had focused primarily on the principles of palliative care in oncology, this year’s module explored a new frontier: palliative care in non-malignant disease. Over five days, participants revisited key concepts—symptom management, identifying appropriate referrals to palliative care, and recognising triggers for advance care planning—through the lens of patients living with advanced heart failure, renal disease, chronic lung disease, and neurodegenerative conditions.
Across these conditions, several recurring themes emerged. Disease trajectories were often complex and unpredictable, making prognostication particularly challenging. As a result, the patient’s voice—expressed through advance care planning—became even more central to care planning and decision-making.
These discussions also prompted important reflections for participants. Questions such as: How do we approach decisions not to insert a nasogastric tube? When is it appropriate not to intubate? How do we have honest conversations about death and the outcomes with or without such interventions? formed the basis for rich dialogue. Workshops on interdisciplinary collaboration, communication skills, policy development, and discussions comparing palliative sedation with voluntary assisted dying further broadened the learning experience.
Some of these issues also highlighted important legal and ethical considerations. Current legislation in Bhutan does not provide clear protection for health professionals who advocate for the withdrawal or withholding of life-sustaining treatments when such interventions are considered futile. These challenges underscore the need for continued dialogue and policy development as palliative care services evolve in the country.
One of the clinical highlights of the module was the opportunity for hospital and home visits. Consistent with the module’s focus on non-malignant illness, we met patients living with advanced heart disease, renal failure, and chronic neurological conditions. We were also honoured when Bhutan’s only cardiologist joined us to discuss the patients we had seen in what became an impromptu multidisciplinary team meeting. His thoughtful engagement and clear appreciation for supportive care reinforced the importance of early integration of palliative care services.
In Bhutan—where there are currently no medical or radiation oncologists—the role of palliative and supportive care services is particularly vital. Increasingly, the value of these services is being recognised beyond cancer care. Since the establishment of the home-based care program, growing numbers of patients have been able to spend their final days comfortably at home.
The Jigme Dorji Wangchuck National Referral Hospital’s President, Dr Pem Namgay, who graciously attended the opening session, acknowledged the progress that has been made and shared his vision for earlier integration of palliative care across the country. Encouragingly, plans are underway to incorporate palliative care training into the curriculum of the newly established Bhutan Medical School. Developing a future workforce will be crucial, particularly as many highly trained health professionals leave the country to pursue opportunities overseas.
For our faculty team, participating in this program carried a deep sense of responsibility. It was a privilege to contribute in a small way to the development of palliative care in Bhutan. Although much work remains, it is evident that this growing community of generalist palliative care clinicians has come a long way. Participants shared stories of how their practice has evolved, with care becoming increasingly patient-centred compared with the early days of the program eight years ago. As we departed Bhutan, we did so with a profound sense of hope for the future of palliative care in the country—and with the feeling that we had found family in the Land of the Thunder Dragon. In a fitting final moment, even Bhutan’s beloved King happened to be on our flight home, as though offering a symbolic farewell to our journey.
Written by: A/Prof Davinia Seah, Director of Palliative Medicine, St Vincent’s Hospital Sydney, Australia