\nDay care patients like Mr Christopher So, 86, can take part in rehabilitation exercises to maintain their independence and autonomy.<\/p>\n
ST PHOTO: SARAH LEE<\/p>\n<\/figcaption><\/figure>\n
\u201cLong before you reach the buildings, you become aware of the smell of tung oil and the peculiar odour associated with the houses of death,\u201d according to a 1947 report by the Sunday Tribune about Singapore\u2019s \u201cbiggest health scandal\u201d, its Chinatown death houses.<\/p>\n
Before the first hospices were established in Singapore, their predecessors were licensed sick receiving houses \u2013 also colloquially known as \u201cdeath houses\u201d or \u201cdying houses\u201d \u2013 first established in the 19th century to shelter the sick and dying.<\/p>\n
In the years leading up to Singapore\u2019s independence, they were concentrated around Sago Lane, Jalan Ampas and Balestier Road.<\/p>\n
These death houses were cramped spaces, with the lower floors occupied by the deceased and dying, and the upper floors by the dying who could afford to pay more. Outside, mourners and religious leaders would come to perform last rites, filling the streets with the smell of smoke and the noise of mourning.<\/p>\n\n\nA photo of the Sago Lane death houses taken in 1962 by K.F. Wong.<\/p>\n
PHOTO: NATIONAL ARCHIVES SINGAPORE<\/p>\n<\/figcaption><\/figure>\n
The Sunday Tribune\u2019s correspondent writes of a 72-year-old woman huddled over a dirty stool, so sick that she could no longer lie down. \u201cI wonder what must be her thoughts and feelings to be dying in such surroundings. Surprisingly enough, I was told that, as repulsive as they are, these receiving houses are often looked upon as a refuge.\u201d<\/p>\n
Standard charges at a death house were $150, including a $10 admission fee and $1 a day for the night and day attendants, according to a 1948 report by the Singapore Free Press. This included the fee for laying out the dead in the funeral silken robes that every Chinese, no matter how poor, hopes to be buried in.<\/p>\n\n\nA funeral in\u00a0Sago Lane in 1951.<\/p>\n
PHOTO: ST FILE<\/p>\n<\/figcaption><\/figure>\n
In a time when the average hourly wage for non-government workers was 65 cents, these were exorbitant rates. Still, the services proved popular \u2013 with an average of six deaths in Sago Lane every day \u2013 often because of superstitions surrounding death in the home and the lack of affordable alternatives.<\/p>\n
One mourner told the Free Press\u2019 correspondent about why he took his father to a Sago Lane Death House: \u201cI hated to bring him to this strange place, but nothing I said would alter the attitude of my mother and other adult relatives.\u201d<\/p>\n
Despite this persistent demand, Singapore\u2019s death houses were places of immense controversy.<\/p>\n\n\nSago Lane today is unrecognisable from its days as a centre for Singapore\u2019s death industry.<\/p>\n
ST PHOTO: KELVIN CHNG<\/p>\n<\/figcaption><\/figure>\n
Foreign media reports highlighting the squalid conditions of death houses, and the quirks of last rites happening en masse created a small and embarrassing tourism boom of \u201cgiggling, gawking tourists\u201d, according to media reports at the time.<\/p>\n
Nearby residents were also outraged over the unsanitary conditions of these death houses and their role in spreading disease. \u201cSometimes, there are 14 corpses at a time in a room 18ft by 30ft,\u201d notes a 1958 report by ST.<\/p>\n
All of this led to a health committee recommendation to stop licensing these houses and to shift them away from the city centre.<\/p>\n\n\nA 1958 story about the bitter debate and residents’ backlash surrounding Singapore’s death houses.<\/p>\n
PHOTO: ST FILE<\/p>\n<\/figcaption><\/figure>\n
When the city council vetoed the move in 1958, in a close vote with 15 councillors against and 14 for the move, it sparked an unusual challenge from the enraged residents. They called for the councillors who voted against the move to spend two weeks living in Sago Lane.<\/p>\n
In response, councillor Tang Peng Yeu said he and another councillor would accept the challenge and \u201coccupy their rooms and prove that we are representatives of the people and can live with the poorest under any conditions\u201d.<\/p>\n
Still, mounting backlash eventually led to these death houses being banned from taking in the living and being converted into funeral parlours by 1962, with care for the dying shifting instead to hospitals and homes.<\/p>\n\n\nA 1962 article by The Straits Times on the end of the Sago Lane Death Houses.<\/p>\n
PHOTO: ST FILE<\/p>\n<\/figcaption><\/figure>\n\n\nSuch was the sensitivity surrounding hospice care that a hospice featured in this 1986 story by The Straits Times preferred that its name be left out of the newspaper\u2019s pages.<\/p>\n
PHOTO: ST FILE<\/p>\n<\/figcaption><\/figure>\n
Dr Liew Li Lian, chief executive of Dover Park Hospice, says the reputation of these death houses cast a long shadow over how many perceived the hospices that would later emerge in Singapore.<\/p>\n
\u201cBut actually, these death houses are the result of an absence of a hospice system,\u201d says Dr Liew. \u201cThis is the bad stuff that happens when we\u2019re not here.\u201d<\/p>\n
Before the hospice, people were often told to go home when they learnt that their condition was terminal, says Dr Noreen Chan, senior consultant of the National University Cancer Institute\u2019s division of palliative care.<\/p>\n
\u201cHospices were a grassroots movement of people who believed we can do more than this,\u201d she adds.<\/p>\n
For doctors like Dr Angel Lee, who began working in palliative care in 1992,\u00a0this meant working with community and voluntary organisations to bring palliative care into the homes of dying Singaporeans.<\/p>\n
\u201cThirty years ago, palliative care was in the community,\u201d says Dr Lee, a board member of the SHC and director of St Andrew\u2019s Community Hospital. \u201cYou didn\u2019t have it in the hospitals. And you had only a little of it in the inpatient hospices.\u201d<\/p>\n
Singapore\u2019s first hospice opened in 1985 at St Joseph\u2019s Home as a 16-bed hospice wing extension to the home for the elderly run by Catholic nuns. This would be followed by other charities like the Assisi Hospice and the Singapore Cancer Society.<\/p>\n
That the rise of the hospice care movement was so driven by charities and voluntary organisations also came down to the government stance at the time.<\/p>\n
\u201cThe health ministry is sticking to a decision not to establish hospices of its own because it fears Singaporeans might abandon their aged relatives there, said a ministry spokesperson,\u201d according to an ST report in 1986.<\/p>\n
NIMBYism (not in my backyard) also changed how the country approached hospices. After news broke that Dover Park Hospice would be established in Dover Road, residents and schools in the area argued against having a place for the dying so close to their institutes and homes.<\/p>\n
It was a move that sparked bitter debate. In one forum letter response in 1992, an ST reader wrote: \u201cI am amazed that Singapore Polytechnic students and staff should be so vocal in their wish to have the proposed hospice located somewhere else.\u201d<\/p>\n
Dover Park Hospice was eventually established in Jalan Tan Tock Seng instead, keeping its original name despite the move.<\/p>\n
Dr Lee notes that this NIMBY syndrome was one contributing factor behind why there has not been a standalone hospice since Dover Park, with hospice services now delivered within community hospitals.<\/p>\n\n\nVolunteers at Dover Park Hospice\u2019s day care prepare kopi for patients to evoke a coffee-shop vibe.<\/p>\n
ST PHOTO: SARAH LEE<\/p>\n<\/figcaption><\/figure>\n
To Dr Lee, the biggest shifts in palliative care over the past few decades is that something that was once a philanthropy-driven movement focused on providing home care has become increasingly state-led.<\/p>\n
Some of these changes have taken place under the surface, such as the introduction of government subsidies towards home and hospice care in the 1990s.<\/p>\n
Others are more visible, such as the 2007 recognition of palliative care as an official sub-speciality that doctors could train in, after two decades of hospices and newspaper reports warning that the country was short on palliative care specialists.<\/p>\n
It was not until 2023 that the Healthcare Services Act was amended to describe hospices as a distinct category of care. Singapore\u2019s hospices are still licensed as nursing homes.<\/p>\n\n\nPalliative care doctors were once referred to as a dying breed in Singapore in 2005, but their number has nearly doubled from 47 in 2014 to 88 in 2024.<\/p>\n
PHOTO: ST FILE<\/p>\n<\/figcaption><\/figure>\n
\u201cThat is the huge transformation of the last 10 years,\u201d she says, pointing to SHC data indicating that inpatient palliative care figures have increased by 43 per cent between 2013 and 2023. Rather than seeing palliative care as a cost-cutting measure, society now sees hospices as a means of achieving a good and dignified end of life that is affordable.<\/p>\n
Today, every major hospital in Singapore has a palliative care unit, and the line that once existed between the hospital and hospice has blurred considerably.<\/p>\n
Much of this has to do with demographic trends and medical advances making caring for the terminally ill and dying less and less remote for the general population.<\/p>\n
However, key obstacles remain.<\/p>\n
The median time from first referral to death is 21 days, according to SHC data from 2023 and 2024. This indicates a need to incorporate more palliative care into the domain of primary care physicians and generalist doctors, so they can better spot warning signs in patients and ensure they receive timely care.<\/p>\n
To Dr Lee, a paradox of hospice care today is that as palliative care has formalised, resources and career opportunities are concentrated in hospitals, when there is a pressing need to dedicate resources to the community and home-based care that defined the early history of Singapore\u2019s hospice movement.<\/p>\n
As Singapore is set to become a super-aged society in 2026 \u2013 meaning that over a fifth of the population is aged 65 and up \u2013 the number of people who will need palliative care is likely to exceed that of the country\u2019s inpatient facilities.<\/p>\n
This means that Singapore has had to rapidly expand the palliative care ecosystem\u2019s capacity, says Dover Park Hospice\u2019s Dr Liew.<\/p>\n
Dover Park Hospice works under an integrated care model, where patients can be referred directly from Tan Tock Seng Hospital. The hospice shares a building with Tan Tock Seng\u2019s palliative care unit. Home care is the segment where the hospice sees the largest growth in patients.<\/p>\n
Associate Professor Melvin Chua, a senior consultant at Sengkang General Hospital\u2019s department of geriatric medicine, says looking ahead, there is a need to break down traditional taboos and normalise conversations about end of life.<\/p>\n
\u201cWe need broader uptake of Advance Care Planning, greater caregiver support and stronger community capabilities to manage end-of-life care outside the hospital setting,\u201d says Dr Chua.<\/p>\n
\u201cWith Singapore\u2019s rapidly ageing population, building compassionate, community-based end-of-life care is not just a medical priority, it is a societal one.\u201d<\/p>\n\n\nMs Joanne Gan volunteers at Dover Park Hospice and the Institute of Mental Health, sometimes playing the harp as part of musical therapy for patients.<\/p>\n
ST PHOTO: JASON QUAH<\/p>\n<\/figcaption><\/figure>\n
For many patients, the end is often less cathartic and less tranquil than what is portrayed on television screens, says Ms Joanne Gan, a former palliative care nurse from 2017 to 2024.<\/p>\n
Trying to bring solace to dying patients can be difficult because they are often unaware of what is going on, says the 44-year-old, who is now a researcher. She also volunteers at the Institute of Mental Health and Dover Park Hospice as part of their programmes accompanying those who would otherwise die alone.<\/p>\n
\u201cSometimes, you have delirious patients saying they saw something, or they\u2019ll say they saw a black image going past,\u201d says Ms Gan. \u201cEspecially during my night shifts, they\u2019ll talk like this. If you\u2019re not prepared, it can be a difficult thing.\u201d<\/p>\n
Terminal delirium is a condition where patients \u2013 in the final weeks of their life \u2013 experience confusion, hallucinations and restlessness. For many patients, this also occurs alongside breathlessness and pain.<\/p>\n
To Ms Gan, part of the reason she made the mid-career switch to nursing from the education sector was to better understand how she could care for her ageing parents. She is their primary caregiver.<\/p>\n
Still, Ms Gan says these vigils, as patients enter the active dying phase, feel essential because nobody wants to be left alone when they are about to die. \u201cIt\u2019s something unavoidable and will happen to everyone,\u201d she adds. \u201cIt gives me comfort to know that we\u2019re here as volunteers to give a proper farewell.\u201d<\/p>\n