Diversity and Integration: Exploring the Role of Religion in End-of-Life Care in Rural Gansu Province, China

Abstract

In the face of death, different ethnic groups have unique coping ways. The physical care and spiritual care for the dying can demonstrate the diversity and particularity of ethnic cultural thought. Taking two villages in the interlaced residential areas inhabited by Han, Tibetan, and Hui ethnic groups in Linxia and Wuwei of Gansu Province as examples, this paper focuses on the presentation and significance of multi-ethnic cultural integration in the process of end-of-life care, with a focus on spiritual care. One main point of this paper is that, although hospice care in the modern medical sense is not really implemented in the vast rural areas of China, local end-of-life care, based on the village medical system and religious rituals, equally plays an important role. This is mainly manifested through the implementation of the Narcotics Card System and the widespread spiritual care. The second main point of this paper is that the form of end-of-life care, which embodies the integration of ethnic cultures, contains a certain degree of nursing functions, while taking into account the spiritual care needed by the dying and the grief consolation needed by the bereaved family. Considering the lack of spiritual care and bereavement management in China’s medical space, the religious approaches to end-of-life care, as delineated in this study, could serve as a source of inspiration for the country’s efforts to integrate hospice services into its healthcare system. In short, compared with Western forms of hospice care, in which modern medicine constitutes the main body, China’s local end-of-life care is more reflected in the diversity and integration of spiritual care for the dying.

1. Introduction

Since 2017, more than 185 pilot areas for the palliative care approach have been set up across China. This approach, which belongs to the category of hospice care, takes the city as the center, with city hospitals and community health centers as the carriers. In the vast rural areas of China, it is unrealistic to implement the urban type of hospice care. Rural residents live far away from city hospitals, and the institutional capacity of village clinics is not as good as that of urban community health centers. Moreover, county hospitals and township hospitals generally do not have the mechanism and conditions to implement the work model of palliative care. At present, hospice care, which may benefit rural residents, is only implemented in a part of rural areas under the Narcotics Card System (maka xitong 麻卡系统). Narcotics Card is a popular term that refers to the registration system for narcotic drugs. The system requires patients to inject painkilling drugs on the spot at a township hospital or county hospital, based on the patients’ capacity. At the end of their lives, if they can no longer go to the hospital, the patient’s family will have to exchange the empty bottle for a course of painkillers. Distance, transportation, and labor are major barriers to obtaining painkillers, and the amount of narcotics exchanged at a given time is not enough to control the pain. Although patients can take morphine, pethidine, fentanyl, and other drugs orally at home to reduce pain, injection anesthetics need to be administered by a registered nurse or physician. A certificate of diagnosis, a certificate from the village committee, and copies of ID cards of the patient and the agent are required for applying for the Narcotics Card. No one other than the registered agent may collect medicine for the patient, and the Narcotics Card must be renewed every two or three months after obtaining the card. In other words, for the majority of farmers, palliative care only exists in the form of limited access to narcotic drugs and their use.

However, this does not mean that there is no hospice care in rural China. On the contrary, the tradition of end-of-life care in rural China has a long history. It is a kind of spiritual care, which is pluralistic, practical, rooted in folk traditions, integrated with ethnic cultural thoughts, and closely related to the ethics of end-of-life nursing in rural areas. From July to September 2021, members of the research team completed a three-month survey on the quality of death of cancer patients in Yadang village 牙塘村 and Honggeda village 红疙瘩村 in Gansu Province 甘肃省. It was found that the uniqueness of end-of-life care there is reflected in the integration of Han, Tibetan, and Hui cultural traditions, thus forming a pluralistic and integrated model of end-of-life care that combines features of Confucianism, Tibetan Buddhism, Islam, Taoism, and folk religions. The purpose of this paper is to discuss the significance of this pluralistic integration model and imaginatively explore local experiences and facts of end-of-life care within the context of ethnic integration regularities. Specifically, the less widely discussed forms of end-of-life care in rural China are highlighted as rich spiritual care resources. These resources incorporate the views of various religions on life and death and the final farewell ritual, including Confucianism, Tibetan Buddhism, Islam, Taoism, and folk religions. The relevant theories and ritual practices are the focus of this paper; another focus of this paper is to analyze the commonality and feasibility of various spiritual care resources in ethnically interlaced areas and to discuss related issues with Western scholars to find the value and significance of the existence of Chinese local end-of-life care.

2. Review of Studies on the Diversity of Local End-of-Life Care

Compared with the Western Christian–Catholic cultural tradition of late-life care, it seems that Chinese traditional culture lacks attention to the quality of life of late-life groups. On the contrary, traditional thoughts, especially Confucianism, pay more attention to the remembrance and worship of the deceased. The practice of lovingly remembering the ancestors after their death while not letting them pass away in good quality is quite common in the vast rural areas of China. Family members are mainly emotionally attached to the dying person, often finding it difficult to meet their final needs in life (Weng 2019, pp. 37–42). Some scholars also point out that due to the cultural custom of “valuing life and hating death” (zhong-sheng-wu-si 重生恶死), upheld by Chinese traditional Confucian ethics, both elderly dying patients and their families often have a strong sense of fear and repulsion towards death, so they tend to spare no effort to provide medical treatment to prolong the patient’s life. This kind of behavior not only brings a huge economic burden to the family members but also brings more serious physical pain to the patients. Meanwhile, the country and society also have to devote enormous medical resources to terminally ill patients (Liu et al. 2018, pp. 745–48). Such views seem to be directly appropriating the norms of hospice care from the West to the Eastern context and do not fully conform to the reality of rural China. The cultural background of the concept of valuing life in China’s indigenous Confucianism is indeed not suitable for the simple direct introduction of hospice care—which originated from Christianity—namely, focusing on the quality of death rather than the simple extension of life. This fact requires us to focus on exploring and developing the strategies and cultural systems of hospice care that are derived from local culture and guided by life-and-death science (Guo et al. 2013). However, so far, few articles specifically discuss the diversity of hospice care patterns in China, especially in western China. The few available articles mainly focus on mono-ethnic studies, such as Buddhist spiritual end-of-life care among Tibetans, Islamic religious care for the dying among the Hui people, and Taoist ritual care among the Han people (in folk traditions).

This paper first takes the practical application of Chinese native Buddhist cultural tradition in end-of-life care as an example. Some scholars have pointed out that after it was introduced by the psychologist Carl Jung, the Tibetan Buddhist perspective on life and death, based on the Tibetan Book of the Dead (xizang du-wang-jing 西藏度亡经)1 as the core, had a great impact on American society. It aroused public concern and led to the emergence of Buddhist hospice care societies (Jung 2014, p. 168; Chen 2012, p. 161; Kathleen 2003, pp. 342–45). The long history of Buddhism in China, as well as the integration and mutual influence of Buddhism and Confucianism, makes it highly possible for the Buddhist art of “life and death guidance” (sheng-si-yin-dao 生死引导) to become the foundation and carrier of the cultural construction of end-of-life care in China in the context of modern hospice care. It can become a beneficial complement to the multi-cultural beliefs, local social humanistic care, and their development (Chen 2021). The Buddhist approach to death is comprehensive, multi-layered, and pluralistic, with a range of practices, doctrines, and creeds to help individuals undergo a mental and spiritual transformation for achieving inner transcendence (Li 2014). The Buddhist end-of-life care tries to make both the dead and the living transcend death and coexist in peace, so it has a complete set of end-of-life rituals and funeral rituals to guide the living, to accompany the dead, and protect the dead. Through the practice of these rituals, they can escape life and death and achieve spiritual care (Zheng 2008).2 Nonetheless, in the ontological sense, the concept of “good death” (haosi 好死) in Buddhism does not directly reflect “hospice care” in the modern sense, but points to the highest realm of practice. This is also why Buddhism, in modern times, has failed to transform from scholasticism’s “divine care” to universal “humanistic care”, as Christianity has done. It has not spawned institutionalized organizations and academic theories, remaining mainly at the stage of religious belief (at least in mainland China) (Guo et al. 2013). Nonetheless, the soothing effect of Buddhist belief on the dying in vast rural areas, which has been sufficiently proved in our survey, cannot be ignored. Particularly, Tibetan Buddhist beliefs exist in both villages and are not limited to the Tibetans; some Han people and even Hui people regularly visit the temple to light lamps.

Another example is that when Islam was introduced into Mainland China, it was deeply influenced by the traditional culture of Confucianism. Therefore, the Hui Muslims are often influenced by the traditional concept of “raising sons to provide against old age” (yang-er-fang-lao 养儿防老) in their late life. Especially at the end of his life, the old man should finish his last journey in his son’s home, no matter what. The concept of “hospice care” in the modern sense holds that to achieve the “peaceful death” of the dying, it is necessary to “release” loneliness, despair, fear, and other negative emotions as much as possible before dying. However, the traditional concept of “raising sons to provide against old age” and the faith in the omnipotence of Allah can precisely meet the psychological needs of dying people who fear loneliness (Yan 2013). As a case study, some scholars have discussed the application of the belief of “the Heavenly Lord Tai Yi of Salvation from Misery (Taiyi Jiuku Tianzun 太乙救苦天尊)” in end-of-life care. The research shows that the belief of Taoist “Heavenly Lord Tai Yi of Salvation from Misery” and its related rituals have a soothing effect on the dying patients and a comforting effect on the families of the dying patients. More importantly, the authors analyzed the application conditions and environment of this end-of-life care ceremony (Wen 2013, pp. 16–17, 23).

Perhaps due to limitations in context, a lack of in-depth field investigation, or a narrow vision, such studies did not delve deeply into the social reality of hospice care models3, nor did they notice the diversity and integration of end-of-life care models in ethnically interlaced regions. However, through solid field investigation and analysis, this paper focuses on the existing hospice care model of “the Narcotics Card System + village doctors’ participation + multiple ritual care” in rural Gansu Province, trying to find a path based on multi-ethnic cultural integration and in line with the reality of rural areas in western China.

3. Methodology

This qualitative study is an integral part of the broader project titled “Research on the Diversity Model of Hospice Care in China”, a collaborative initiative between Tsinghua University and Ping An Insurance (Group) Company of China, aimed at exploring the diversity model of hospice care in mainland China. The primary method employed in this study was in-depth interviews, supported by observational data.

The lead investigator, serving as the primary author, directed the sub-project, titled “Hospice Care in Linxia Rural Group”. The research team consisted of six members, with three local research coordinators playing a pivotal role. Their main responsibilities included facilitating communication/translation between the local dialect and Mandarin Chinese. Furthermore, their profound knowledge of local customs and rituals greatly enhanced the introduction phase within the research team. The remaining three members were experts in end-of-life care from China and the UK. This diverse composition ensured a comprehensive blend of local and international perspectives. The field research was conducted in Linxia Hui Autonomous Prefecture 临夏回族自治州 and Wuwei City 武威市 from 10 July to 20 September 2021.

A total of 17 respondents were interviewed in this study, encompassing five government staff members from the County Health Bureau, County People’s Hospital (medical department, medical insurance office), Town Party Committee (Administration), the township hospital, and the village health clinic. Additionally, nine respondents who were primary caregivers or family members of deceased patients and three religious figures (including one Taoist priest, one Hui imam, and one Tibetan Buddhist monk) were included in the study. To maintain consistency and structure, an interview guide was prepared in advance. The open-ended interview outline comprised seven key sections: oral informed consent, demographic information, illness biography, physical feelings and emotions, the medical treatment process, care experiences, and ritual/alternative medicine. The interview duration varied, ranging from a minimum of 90 min to a maximum of 160 min. During fieldwork, team members observed the “wiping ceremony” conducted by the Taoist priest, which lasted less than 30 min. Following the ritual, they engaged in extensive communication with the Taoist priest for over an hour. The research team diligently documented daily file notes and conducted group discussions about findings after each interview. The study was approved by the Academic Committee of the School of Liberal Arts of Henan Normal University. To protect our participants, confidentiality and anonymity was maintained throughout the process and in the manuscript.

4. Diversity and Integration of End-of-Life Care in Rural Gansu

4.1. Overview of Field Sites

The sites for the survey of end-of-life care and quality of death selected by the team were mainly two villages in the Han-Tibetan interlaced zone in Gansu Province: Yadang Village, Maijiaji Town 买家集镇, Hezheng County 和政县, Linxia Hui Autonomous Prefecture, and Honggeda village, Zhuaxixiulong Town 抓喜秀龙镇, Tianzhu Tibetan Autonomous County 天祝藏族自治县, Wuwei City. Geographically, both places are located at the northeast edge of the Qinghai-Tibet Plateau, with high altitude and mixed agriculture and animal husbandry production modes. There are also Tibetan, Han, and Hui people living in both of these places.4 They reside in ethnically interlaced zones, where ethnic cultures are mixed and integrated. Therefore, when dealing with diseases, weddings, funerals, and other matters of life, they often adopt multiple ways and follow a variety of cultural traditions.

Historically, the Yadang area was under the jurisdiction of Hezheng and the Tibetan region of Amdo 安多藏区 for most of the period, being located at the intersection of Gansu and Qinghai 青海. According to historical records, before the Qin Dynasty 秦朝, Yadang and its surrounding areas belonged to the Qiangrong community 羌戎聚居区. Since the Han Dynasty 汉朝, the politics, economy, population, and especially the culture of the Han people began to develop towards the northwest, and the Yadang area gradually became an ethnic corridor (minzu zoulang 民族走廊). During the Tang Dynasty 唐朝, Yadang belonged to the Tibetan Empire 吐蕃王朝. During the Song Dynasty 宋朝, Yadang was alternatively governed by the Tibetan Chio-ssu-lo Regime 唃厮啰政权 and the Song Empire. Therefore, although today’s Yadang people are called Han, most of them should be descendants of Tibetan tribes and armies. Since the end of the Yuan Dynasty 元朝 and the beginning of the Ming Dynasty 明朝, the Yadang area has been inhabited by the Luo 罗, Shi 石, Bai 白, and Gou 苟 families, all of which were Sinicized Tibetan people (Linxia Hui Autonomous Prefecture Annals Compilation Committee 1993, p. 1290).5 The people of the four families still believe in Tibetan Buddhism, and every family worships the Tibetan Buddhist Dharma protector Palden Lhamo 班丹拉姆, also known locally as the “Heavenly King of Mule” (luozi tianwang 骡子天王). Although the Yadang area is now under the jurisdiction of Linxia Hui Autonomous Prefecture, where the people in the surrounding area are mostly Hui people who believe in Islam, there are still many Tibetan customs preserved intact locally. For example, during the ceremony of offering sacrifices to ancestors or local gods, Tibetan Buddhism’s Weisang ceremony 煨桑仪式 is retained. During the Shehuo 社火 (a traditional festivity) Niu-du-ye 牛犊爷, held from the 13th to 15th day of the first lunar month, the Weisang ceremony is also kept, and the dances performed by the public to please the gods are similar to the Guozhuang dance 锅庄舞 of the Tibetan people. Among the sacrificial foods, there are also Tibetan traditional foods, such as tsamba (zanba 糌粑) and cheese (ganlao 干酪) (Zhao and Luo 2020). In addition, the names of most local places come from Tibetan, and there exists transliteration of Tibetan in local dialects. For example, Yadang 牙塘 comes from the transliteration of a Tibetan word, which means village or an upper village. Another example is Mazang 麻藏, which also comes from the transliteration of a Tibetan word and means field or a lower village. As of today, there are Tibetan Buddhist monasteries in the area, as well as living Buddhas.6 These monasteries are historically under the jurisdiction of Labrang Monastery 拉卜楞寺.

The other research site of the team is Honggeda village, Zhuaxixiulong Town, Tianzhu Tibetan Autonomous County. Established in 1983, Zhuaxixiulong Township 抓喜秀龙乡 (upgraded to Zhuaxixiulong Town 抓喜秀龙镇 in 2010), currently governs five administrative villages, namely Daiqian 代乾, Honggeda 红圪垯, Nannigou 南泥沟, Tanyaogou 炭窑沟, and Chenjiagou 陈家沟. Zhuaxixiulong Town is located at the foot of Wushaoling Mountain 乌鞘岭, which is more than 3000 m above sea level. The region is extremely cold and oxygen-deficient, with a frost-free period of only about two months during the whole year. Tianzhu Tibetan Autonomous County is in the Huarui Tibetan area 华锐藏区7, which was one of the main channels on the ancient Silk Road (si-chou-zhi-lu 丝绸之路), known as the Gateway of the Hexi Corridor (hexi zoulang 河西走廊). According to the legend, the Tibetan people in this area belong to the Tianzhu Tibetan tribes. They are descendants of the border troops stationed here after Sontzen Gampo 松赞干布 unified the Tibetan Empire.

Similar to the Yadang area, there are also Tibetan, Han, and Hui ethnic people living in the area, and the folk beliefs are complicated. It is quite often that Han people believe in Tibetan Buddhism, and Tibetans invite Taoists (in folk traditions) 民间道士 to deal with life matters. These practices are also manifested prominently in the treatment of diseases, deathbed practices, and matters related to death. For example, the upper three villages of Zhuaxixiulong Town, namely, Daiqian village, Honggeda village, and Nannigou village, hold a folk belief activity called the Mani Gathering (ma-ni-hui 嘛尼会) in the second and seventh months of the lunar calendar every year. Local herdsmen, including Han people, also call the event Cuan Manai (cuan-ma-nai 攒嘛乃), which is divided into Da Manai 大嘛乃 and Ga Manai 尕嘛乃. Da Manai refers to the large Manai, which is organized jointly by the three villages in the second month of the lunar calendar. Ga Manai refers to the small Manai, which is organized spontaneously by several or more than a dozen herdsman families on the fifteenth day of the seventh lunar month. During the ceremony, the guru (shangshi 上师), who recites sutras, plays a key role. The most common local guru is from the Gelug Sect 格鲁派 or Nyingma Sect 宁玛派. Other local monks and layman Buddhists (some of them being Han people) also play an important role in the activity. With the development of the society and economy, people of all ethnic groups are attaching more importance to Buddhist culture and local culture. In recent years, some young Tibetan and Han people have gone to places such as Qinghai and Sichuan 四川 to learn to recite sutras. After learning the sutras, they will also take part in local Mani activities and other religious activities. An important function of the members of the Mani Gathering is to hold sutra-reciting ceremonies for the dying, but the family members sometimes also invite Taoist priests or Bon monks to preside over it, depending on the main faith of the client. In addition, it should be noted that in the Hezheng region of Linxia, there are also Mani societies, whose main members are the Han people, and the sutras they use are the Precious Scrolls (baojuan 宝卷), in Chinese. However, some sutras are recorded in Chinese while pronounced in Tibetan, which fully proves the integration of folk beliefs in the interlaced regions.

4.2. Narcotics Card System and Participation of Village Doctors in End-of-Life Care Models in Rural Gansu

According to the survey, in addition to the County People’s Hospital (xian renmin yiyuan 县人民医院), there are 14 township hospitals, 112 village clinics, and 4 private hospitals in Hezheng County. However, the number of medical professionals who can engage in hospice care is almost zero, and the treatment of local cancer patients is almost all carried out in state hospitals and facilities of higher levels, while county hospitals are unable to treat them. Below are the comments from the locals:

“Our common practice here is to have a medical check. If there’s no hope, then we will bring the patient home straightaway and prepare for the death. Or for reasons of conscience, we put the patient under medical treatment for a period. But if the disease really cannot be cured, we normally go back home and prepare for death. For the young or those with better economic conditions, they may go to see a doctor in Beijing 北京. Therefore, not to mention township hospitals, even county hospitals do not have the treatment (ability) for cancers. Some patients also received medical treatment in provincial hospitals for a while and then are transferred to the county hospital.”8

Moreover, according to relevant persons in charge of the Health Bureau of Hezheng County (he-zheng-xian wei-sheng-ju 和政县卫生局), the Healthcare Commission of Gansu Province (gan-su-sheng weisheng yu jiankang wei-yuan-hui 甘肃省卫生与健康委员会) has organized hospice care training in the past two years, which mainly involved doctors from county hospitals and above in the province, but not township doctors. The provincial government has also issued documents on the requirements for setting up terminal care wards (namely, hospice wards), but there are no professional doctors, especially psychologists, so hospice wards do not actually exist. The more important reason is that people in rural areas do not attach much importance to psychotherapy, and are influenced by traditional Confucianism. Once the patients realize that there is no cure, they often ask to leave the hospital and go back home. This makes it impractical to provide hospice care in rural areas by setting up hospice wards in hospitals. But if the patient needs some analgesic or psychotropic anesthetic drugs after going back home, they need a Narcotics Card.9 Such drugs can only be prescribed in county hospitals and above by qualified physicians with deputy senior titles or above. Injection of anesthesia must be given on the spot, at the hospital. After injection, the empty bottle must be left in the hospital and cannot be taken outside. If it is taken to the market, it will become a drug. If patients are unable to go to the hospital, oral analgesics will be prescribed (the empty bottle must be also sent back after taking the medicine). However, the reality is that many patients with terminal cancer in rural areas are in unbearable pain, while the painkillers—which have limited availability—are also less effective. This kind of situation is the hardest to deal with.

The survey found that the use of narcotic drugs in both places is strictly controlled. There are mainly two ways to obtain them. First, if the patient can tolerate the current pain, the hospital will require the family members to bring the patient to the hospital for injection of painkillers, which are prescribed by a prescribing doctor from a hospital at the county level and above, and the dosage and daily injection frequency must be confirmed and injected by the doctor. After the injection is completed, the drug packaging shall be left at the hospital. Second, if the patient is in severe pain and does not want to go to the hospital, the family can ask the hospital to prescribe some painkillers for the patient to take at home. The dosage and daily injection frequency should be decided by the prescribing doctor of the upper-level hospital, and the drug packaging after taking the medication must be handled by the prescribing doctor. This option is the last resort.10 In this case, the village doctor has the right to refuse to administer painkillers (if strictly following state regulations), but out of human sympathy and empathy, the village doctor often agrees to administer painkillers. The village doctors in the two places are familiar with the villagers. If a seriously ill patient in a village needs medical care from the village doctor, the village doctor will do his best to help the patient and his family free of charge. For example, in 2021, an old man suffered from pancreatic cancer in Honggeda village. One month before his death, the patient could no longer receive treatment. To make the patient feel comfortable, the family asked the village doctor to come home for hospice care, mainly including infusion (nutritional solution and painkillers), massage, and small talk.

As for the selection of village doctors, Gansu Province once organized a special folk doctor examination, namely, the Examination for Doctors with Traditional Chinese Medicine Skills (zhongyi yi-ji-zhi-chang kaoshi 中医一技之长考试). Those who passed the examination were granted the qualification of village doctors, rather than seen as quack doctors (jianghu langzhong 江湖郎中).11 We found that at the village-level health institutions, village doctors focus on public health and community-level medical care services. Here we mainly introduce the basic situation of two village doctors in Yadang village and Honggeda village, as well as the main work of hospice care, to understand the social reality of hospice care models in western rural areas.

Doctor Zhao, in his 40s, is the only village doctor in Yadang village. The village health clinic in Yadang is located next to the village committee (cun-wei-hui 村委会). The 10-square-meter clinic is equipped with a computer, a desk, and a clinic bed, and a separate small room of 3–4 square meters is used as a dispensary. In the dispensary, there are three or four medicine cabinets, with many medicines neatly placed. Next to the dispensary is another small room used as a public health room (gonggong wei-sheng-shi 公共卫生室). There is also a village doctor’s information board at the entrance of the clinic, which has his contact number and activities. According to Doctor Zhao, in the past, when there was no unified management (by the government), the clinic was either in his shop or in a spare room of his house, but now it is uniformly located within the village committee. In this way, when the old doctor retires, at the age of 60, the new doctor does not have to worry about the right to use the premises, let alone work in someone else’s home. It is known that Doctor Zhao alone is responsible for the public health work and community-level medical care services, catering for 419 households and more than 2000 people in the village, leaving him no time for hospice care—the only thing he can do is to help patients by administering painkillers out of human sympathy and empathy.

Doctor Hu, the village doctor in Honggeda village, is also in his 40s. His wife is also a village doctor but works in a neighboring village. The clinic is more than a dozen square meters, equipped with a computer, a desk, and a clinic bed. The clinic is comprised of three small rooms. The middle room is designated as the treatment area, the left room as the dispensary, and the right room as the physiotherapy room. The basic structure is similar to that of Yadang village. Doctor Hu manages more than 170 kinds of Western medicines, but all of them are essential medicines, which can meet the needs of ordinary patients in the village. In the dispensary, there is also a special display cabinet for storing traditional Chinese medicine (zhongyao 中药). Doctor Hu graduated from Wuwei Health School (wuwei weixiao 武威卫校) in 2000 and came to Zhuaxixiulong Town in 2003 to work as an unofficial village doctor. In 2016, Hu received formal training in public health for half a year. Before this training, he had received similar training, but it was not organized by the country. During the training, Doctor Hu primarily received training on 12 items of public health, including hypertension, management of 0–6-year-old children, psychiatry, and TCM management (zhong-yi-yao guanli 中医药管理). Doctor Hu had not received any special training on hospice care, but he had taught himself about it while preparing for the examination for the licenses of the medical practitioner and physician assistant. According to his recollection, there were some questions related to hospice care on the paper.

According to Hu, out of human sympathy and at the request of the patient’s family, he sometimes visits the homes of terminal cancer patients in the village to provide professional medical care—such as infusion (mainly nutritional fluids and painkillers) and treating bedsores—for free, which is especially valuable. The fluids, of course, are taken from hospitals at the county level or above, and the main components are energy and albumin, or pain relievers. According to the relevant regulations, the state prohibits village doctors from offering IV treatment to patients, but because patients generally live far away from the county or city hospital, and their bodies cannot bear the torture of getting to and from the hospital, village doctors sometimes have to offer this treatment. The clinical manifestations of terminal cancer patients are mainly physiological symptoms, such as intensified pain and bedsores. At this time, the family usually asks the village doctor to deal with this situation at the patient’s home and help the patient with psychological counseling. In the past five years, not many people have died of cancer in Honggeda village, and only three patients died of cancer in 2021. Doctor Hu had visited the patients’ homes to offer medical care before their deaths.12 As for the family’s care for the cancer patients before they died, Doctor Hu recalled:

“As the economic condition of the village is better than that of other places, the children took good care of the patients. Before death, whether the Tibetans or Hans, monks are usually invited to their homes to perform Buddhist services (sadhana drubtab). I was not surprised to find myself in this situation.”

Namely, the family members of the cancer patient would light lamps (diandeng 点灯) before and after their death, and invite monks to their homes to recite sutras (nianjing 念经). The original intention is to alleviate the patient’s pain as quickly as possible, reduce the torture from the pain, and release the soul of the patient from the mundane world, allowing them to enter the Pure Land. Due to the religious atmosphere and the power of faith, the patient did not show much fear and reluctance before passing away.

Moreover, depending on their family conditions, some cancer patients are diagnosed at county hospitals, some at provincial and municipal hospitals, while some have their symptoms detected during health check-ups in rural areas (xiangcun jian-kang-ti-jian 乡村健康体检). There are also patients being diagnosed through physical examinations for the elderly and two-cancer screening (liang-ai-shai-cha 两癌筛查, namely, cervical cancer and breast cancer). However, due to limited equipment conditions and doctors’ skills, patients are usually required to go to county hospitals or above for re-examination. For example, during a physical examination, a doctor found a cyst in the abdomen of a villager in Honggeda village. The village doctor and the town hospital doctor suggested that the villager go to a county hospital or above for a re-examination. Unfortunately, the villager refused to get checked again and died soon after. Generally speaking, whether Hans or Tibetans, the hospice care in Honggeda village is the same—a diversified treatment mode. Namely, village doctors often attend to alleviate pain and treat bedsores, and monks recite sutras. After passing away, the family members will ask monks or Taoist priests to perform soul-releasing ceremonies (chaodu yishi 超度仪式). In addition, local Tibetan doctors (mostly monks in monasteries) usually use traditional treatment methods when dealing with patients’ pain, and some cancer patients also take Tibetan medicine to control their disease.

4.3. Ritual Care in End-of-Life Care Models in Rural Gansu

Based on the end-of-life care model observed in the two places, the current Narcotics Card System, and the active participation of village doctors out of benevolence (yizhe renxin 医者仁心)—a feeling upheld in Confucianism—jointly relieve the physical pain of terminal cancer patients in both places. However, such solutions play a limited role due to the limitation of various subjective and objective conditions. Another important finding of this survey is that, because the places are located in cross-ethnic regions, people are simultaneously affected by various ethnic cultures. In the realm of religious medical care, there is a pluralistic and integrated model of end-of-life care. Namely, people in real life are more concerned about addressing their matters of life and death. No matter what kind of faith or which ethnic customs and rituals, as long as they can help solve practical matters, they will be adopted as their own. This has also become the driving force and law of ethnic cultural integration. For example, in our survey in Honggeda village, we found that Tibetan people sometimes invite folk Taoist priests to recite sutras for dying people, while Han people also invite Tibetan Buddhist monks to light lamps for dying people. Meanwhile, in the Yadang area, when Hui people contract an illness, in addition to seeking the guidance of imams, sometimes they will invite folk Taoist priests to their homes to perform rituals. There was even a Han family that invited both Taoist priests and Tibetan Buddhist monks to their home to perform the ceremony of wiping diseases to treat their family member’s cancer.13 This kind of spiritual care model, based on ethnic cultural integration and multi-religious beliefs, has largely solved the spiritual pain of the people, becoming a placebo for the dying, so that they can face death calmly and step into another world with peace of mind.

4.3.1. An Islamic Testimony of Faith Ceremony

The Testimony of Faith Ceremony(gaojie li 告解礼) is mainly for the Hui people in the villages of Yadang and Honggeda as well as for the local Han Chinese residents who have converted to Islam. While the dying person is still conscious, an imam (a-hong 阿訇) will remind him or her to be mindful of Allah and recite al-Shahadah (zuo-zheng-ci 作证词). The recitation goes as follows: “I bear witness that there is no god but Allah, and I bear witness that Muhammad is the Messenger of Allah”. If the dying person is too weak to recite this testimony of belief, a relative may do so on his or her behalf. The idea is to help the dying person to pass away with the belief in the Islamic faith, which helps the soul of the dead find a home. The imam has a set of suggestions for the concerned family to follow. To begin, there should be a quiet and peaceful environment so as to allow the dying person to focus his or her thoughts on Allah. The dying person should be helped by family caregivers to repent of any sins and ask for forgiveness from Allah. Reading or playing audio recordings of passages from the Qur’an is encouraged as a way of bringing blessing and comfort to the dying person. Gratitude to Allah should be expressed through prayers by the relatives of the dying person if he or she is no longer able to do so by himself or herself. In the conversations between an imam and the family of a dying person, the phrase “return to truthfulness” (guizhen 归真) is used as a euphemism for death. “Speaking of Consent” (kouhuan 口唤) is a component of the spiritual care for the dying. Translated from the Arabic word “Izn”, the spoken consent by a dying person is about seeking reconciliation over conflicts that he or she has had with other people.

The Testimony of Faith Ceremony, as described above, is offered to the people of the Hui nationality, as well as to those of the Han nationality who have converted to Islam. According to Chinese laws regarding ethnic identity and religious affiliation, a person’s officially recognized ethnicity must come from his or her parents’ officially recognized ethnicity. If a person’s parents are of the Han ethnicity, he or she cannot become a person of the Hui nationality, even if he or she converts to Islam. Phrased differently, one can convert to Islam and yet cannot change his or her ethnic status. By placing faith above ethnicity, Islamic leaders in many parts of Gansu Province recognize the Han Chinese who have converted to Islam as Muslims by allowing them to participate in Islamic ceremonies, including the Testimony of Faith Ceremony for the dying. We learned in Yadang village that Islamic leaders forbid a family’s wish for further medical intervention if a trusted and experienced physician’s prognosis reveals an incurable illness. A patient suffering from an incurable condition should be brought back home and go through the Testimony of Faith Ceremony, since he or she is deemed to be called by Allah to leave this world. Otherwise, it would be a violation of Allah’s will and judgment. In the Testimony of Faith Ceremony, a dying person testifies and reconfirms his or her Islamic belief with the help of an imam and his or her relatives. The elements of spiritual care in this ceremony are care for one’s faith, one’s relations with others, and one’s thoughts about the meaning of death.

4.3.2. A Buddhist Sutra Ceremony

The Sutra Recitation Ceremony (nianfo li 念佛礼) follows a Tibetan tradition in Honggeda village. When a critically ill person’s terminal stage is determined by a physician, the prognosis is often relayed to the patient’s family caregivers first. Disclosure of the diagnosis to the patient is followed by preparations to invite Tibetan monks to come to the dying person’s home to conduct a Sutra Recitation Ceremony. In preparation for the ceremony, pine branches and leaves, along with fried noodles made of barley and yak butter, are burnt as offerings inside a pagoda-like “pure-smoke furnace” (wei-sang-lu 煨桑炉). In addition, the family of the dying person uses five pieces of cloth with red, yellow, blue, green, and white colors to build a symbolic house for the eventual return of the dead. The family also burns incense as a way of dispersing evil spirits away from the dying person and his or her family. Upon the arrival of Tibetan monks, three bowls of millet, one for the living, one for the dying to take away, and one for the world that the dying is going to enter, are put into the “pure-smoke furnace” to burn along with pine branches and leaves. Additionally, a bowl of Chaohua 炒花 (fried highland barley) is burned as a way of asking the Gods of Heaven and Earth to help the dying and the living find peace and happiness. These ritual procedures are accompanied by prayers in praise of the Gods of Heaven and Earth, who are supposedly responsible for guiding the dying to leave this world and find his or her passage to the Supreme and Perfect Dharmadhatu-Sukhavati (shengyi jile foguo 胜义极乐佛国).

On the second day, the Sutra Recitation Ceremony formally begins and lasts for half a day. The most important procedure of this ritual action is the recitation of the Passage Guidance Sutra, known by the people in Honggeda village as Zhi-Lu-Jing (指路经). This text goes as follows: “Honorable so and so, now is the time for you to seek the passage. You’re going to stop breathing. The Supreme Teacher has helped you see the Clear Light of Reality. You are about to experience the Bardo State as it is in reality. All things in it are like a cloudless sky, and unclouded wisdom is like a transparent vacuum without a border or center. At this point, you should quickly know yourself and settle in this realm. I’m assisting you to use your wisdom to confirm this matter of truth”. The evocation of “the Clear Light of Reality” refers to the transformation of life into death, which leads to different forms of reincarnation, depending on a person’s lifetime virtues, while the “Bardo State” refers to the transitional state between death and rebirth. The final sentence of this Passage Guidance Sutra asks the dying person to acknowledge the fact of death and the beauty of another realm of life as pure as a cloudless sky. During this crucial ritual procedure, we should note that nobody is allowed to shed tears. Not showing sadness so as not to disturb the dying is only a secondary concern. The ultimate concern is to demonstrate calmness in the face of death. Being calm, instead of being sad, for those who will continue to live, is to abide by the Buddhist teaching that death is not the end of life but the beginning of another life cycle. After the formal ceremony is completed, the family of the dying person sends representatives to a nearby Tibetan Buddhist monastery to light lamps. The desirable number of lamps to light starts from 1000 and the more lights, the better. The act of lighting lamps is associated with a variety of purposes, including liturgy, prayers, and reverence. The main purpose, however, is for the dead to avoid hungry ghosts. When the Tibetans in Honggeda village are about to die, their worst fear is that their souls could fall into the realm of the Three Evil Passages (san-e-dao 三恶道). These are the Passage of Hungry Ghosts, the Passage of Wild Beasts, and the Passage to Hell. For this reason, the greatest wish of the dying is to go through the aforementioned ceremony so that they can seek guidance from the Supreme Teacher of the attending monks to find the right passage to reincarnation.

Under the strong influence of Tibetan Buddhism in Honggeda village, it is a common practice among the local Han Chinese families to also invite Tibetan monks to perform the rite of passage for a dying person. In this village, the ritualized spiritual care for the dying is a public event, in the sense that a pending death is known throughout the community because of the burning of offerings, the building of a five-color symbolic house for the eventual return of the dead, and the arrival of Buddhist monks to administer the Sutra Recitation Ceremony. By forbidding overt expressions of sadness, such as crying and emotional despondence, this rite of passage features the sutra-reciting monks in the role of spiritual counselors for the dying. They make it clear, through their reciting of prayers, that one’s faith in Buddhism is intertwined with his or her passage to a new life. In a strict sense, the monks are engaged in an act of supporting the dying person’s belief in the Buddhist views of life and death as a continuum. In this context, the reciting of the Passage Guidance Sutra is of the greatest importance. It formally declares the inevitability of death, while it extols the belief that death is the beginning of a new life.

4.3.3. A Taoist Mantra Ceremony

According to a Taoist priest whom we interviewed during our fieldwork, Taoism also offers spiritual care for the dying, and one of the means for doing so is to recite the Sacred Mantra in Praise of the Heavenly Deities (tianshen baogao 天神宝诰). This prose of praises goes as follows: “The Lord of the Northern Star resides in the Palace of Purple Constellations along with the Lord of the Polaris. Their abode is in the Treasure Garden of Nine Lights, hanging high above the Capital of the Five Diagrams. They came into being when Heaven, Earth, and Mankind became distinguishable. They have governed the mysterious transformations of Heaven, Earth, and Mankind by commanding the existence of these three treasures from the north to the south. They have assisted the Great Jade Emperor in deliberations about war while promoting supreme virtues. They have guided the rotations of the Sun, the Moon, and all the stars without ever making a single mistake. Magnificent in appearance, they possess the vital energy of the true essence in silence. They are as infinitely compassionate in their vows as they are infinitely divine in their mercy.”

In comparison with the Islamic Testimony of Faith Ceremony and the Tibetan Sutra Ceremony which we described above, this Taoist mantra ceremony (baogao li 宝诰礼) for the dying is complicated by inquiries about the Heavenly Stems (tiangan 天干) and the Earthly Branches (dizhi 地支), in connection with the day on which a patient fell to an incurable illness. The Heavenly Stems present a system of ordinals that represent a total of ten days. They are used in combination with the Early Branches, which represent a total of twelve days, therefore producing a compound cycle of sixty days. Four days of the Earthly Branches are governed by “the Gods of Heaven”, while four days are ruled by “the Gods of Earth”. In addition, four days are under the influence of “the Gods of Hell”. If the day on which a patient fell ill due to an incurable illness turned out to be governed by a God of Heaven, it is necessary to burn a stick of incense along with three sheets of yellow paper and offer a bowl of clean water before reciting the Mantra of Praises for the Gods of Heaven. If the day on which the patient fell ill due to an incurable illness was ruled by a God of Earth, it is necessary to take the aforementioned precautions in combination with lighting a five-flower lamp (wu-hua-deng 五花灯). If the day on which the patient was diagnosed with an incurable illness was under the evil influence of a God of Hell, it is necessary to take more precautions, by burning seven sheets of white paper (bai-shao-zhi 白烧纸) and by offering food to the Gods of Hell. These offerings are known in Yadang and Honggeda villages as “ghost food” (guishi 鬼食). All these ritual actions intend to praise the Gods of Heaven, while the act of burning white paper and offering foodstuffs to ghosts is meant to exorcise and appease evil spirits at the command of the Gods of Hell.

5. Discussion

Although the three ceremonies that we described above are associated with different religions, represented by Islam, Tibetan Buddhism, and Taoism, they share many common grounds. They all encourage the dying person not to be afraid of death by consolidating his or her religious faith. They all rely on standardized procedures that make it possible for the dying person to be surrounded by people who care about him or her deeply. They all serve to dispel the discursive taboo about death by turning an approaching reality into a topic of open communication and candid conversations. Above all, they all lead to a clear awareness of dying. In clinical settings, however, a clear awareness of dying is often of an uncertain nature, partly because of medical intervention lasting to the very end and partly because of the incompetence of medical staff in talking about death with a dying person’s family. By contrast, the ceremonies that we described render the awareness of dying a top priority, instead of coping with the inevitability of death in near silence or through evasiveness.

Especially, unlike dying in intensive care units, the dying processes in these two villages where we conducted our fieldwork are similar to what the French historian Philippe Ariès described in 1974 as a forgotten social process leading to the taming of death (Ariès 1977). According to Ariès, the taming of death was a common historical phenomenon, the result of ritualized actions that allowed a dying person to be surrounded by family. Literally, anyone could walk in off the street to attend the deathbed of the person. In comparison, what Ariès described as “forbidden death” in modern society is the result of dying in hospitals, where a ritualized process involving family and community is forbidden, or at least restricted. By using these terms of sharp contrast, Ariès was referring to the transformation of attitudes towards dying and death in many European countries and North America. The historical context of this transformation was the practice of modern medicine in more and more hospitals. From a historical pattern where people usually died at their own homes in times of peace, we transitioned to a situation where the sick wards of modern hospitals are increasingly becoming the sites of death in Europe and North America. Approximately from the 1930s to the 1950s, according to Ariès, the displacement of the site of death from the home to the hospital accelerated changes in people’s attitudes toward death. For most of history, the dying person took his or her last breath at home, surrounded by loved ones. Entering the era of “forbidden death”, people became more likely to end their lives alone in hospitals. Death became a technical cessation, predetermined by a hospital team, and frequently occurring after the dying person had lost consciousness. With this in mind, Ariès wrote pointedly: “No one any longer has the strength or patience to wait over a period of weeks for a moment which has lost its meaning.” Instead, doctors were determined to battle against death as long as possible and when death finally came it was usually considered a failure of medicine rather than a normal occurrence. In the process, spiritual care as practiced in the past now became a taboo while the go-all-out efforts of medical intervention afflicted unnecessary mental and physical pain upon the dying. It was therefore not a coincidence that a hospice movement started in Great Britain in the late 1970s and had spread to many parts of the world by the late 1990s. In Britain, Cicely Saunders, a nurse for cancer patients, founded the first hospice specializing in palliative medicine and, more than anybody else, was responsible for establishing the discipline and the culture of palliative care. In 2014, the first-ever global resolution on palliative care by the World Health Assembly called upon the World Health Organization and its member states to regard palliative care as a core component of health systems.

According to the World Health Organization, 25.7 million people in 2013 needed palliative care, the definition of which was the improvement of the quality of life of patients and that of their families in dealing with the challenges of life-threatening illness, whether physical, psychological, social, or spiritual. In response, the Chinese government launched an experimental initiative of palliative medicine for end-of-life care in 2017 before turning it into a nationwide program in 2019. Throughout the world, however, palliative care at the end of life lacks spiritual care. While physical, psychological, and social care are handled by medical professionals, clinical psychologists, and medical social workers, spiritual care is the weakest link in the delivery of palliative care at the end of life. This dilemma is rooted in medical cultures around the world that place science above faith, while considering psychological, social, and economic factors as being more important and more manageable than spirituality in clinical settings. This is because aspects of spiritual care, in practice, include helping terminally ill patients find meaning, acceptance, peace, empowerment, and reconciliation, which represent a series of highly fluid interpersonal processes and experiences rather than a set of prescribed and proscribed roles. Spiritual care cannot be standardized in the same fashion that medical procedures, psychological interventions, conducts of medical social work, and financial assistance are standardized.

Although it is deemed as one of the four key components of palliative care at the end of life, spiritual care is viewed by many medical institutions as something too complicated to provide. An article by sixteen Canadian researchers specializing in nursing studies, published in 2023, points out: “Despite the centrality of spirituality to healing for many, spiritual care is often sidelined in fast-paced, illness-focused healthcare settings. The religious plurality further complicates spiritual care provision. New approaches are needed to renegotiate these tensions” (Rieger et al. 2023, p. 102027). This problem was pointed out by eight German and Danish researchers in 2020, who had the following to say: “International studies show that healthcare professionals generally find spiritual care as an important aspect of healthcare and providing spiritual care should be included as part of patient-centered and holistic medicine. However, healthcare professionals are rarely trained to identify the spiritual needs or resources of their patients, and consequently, spiritual care is at risk of being neglected or implemented in arbitrary and, more or less, auto-didact ways. Furthermore, existing instruments/approaches (henceforth instruments) to spiritual care derive from many different medical fields and different cultural contexts and may therefore remain unknown across healthcare areas” (Ricko et al. 2020, p. 252). In the United States, according to an article published in the Journal of Religion and Health: “There are two primary stumbling blocks to reaping the financial benefits of spiritual care provision in the US healthcare system. First, spiritual care is not reimbursed from US federal taxes, where the Constitution’s First Amendment requires the separation of church and state. Health facilities therefore have to compensate for this regulatory barrier by funding such un-reimbursable care from less reliable patient, private and public sources. Second, when healthcare costs are a substantial portion of public and private budgetary expenditures, there is an imperative to use validated instruments to generate quantifiable evidence demonstrating the effectiveness, efficacy, appropriateness, and acceptability of spiritual care services. These instruments should include those that can screen people for spiritual distress, assess their needs, and determine the impact of spiritual interventions on patient outcomes. Currently, however, there is a relative lack of such tools, a deficiency that needs to be addressed” (Hall and Powell 2021, pp. 1430–35).

In mainland China, the main challenge to spiritual care in the delivery of palliative care is the exclusion of religion and religious groups from public hospitals, which constitute 90 percent of all large and small hospitals throughout the country. Considering this obstacle, spiritual care associated with end-of-life care in China needs to be delivered differently. One possible approach is linked to the development of Buddhist and Christian nursing homes for seniors. Currently, more than 50 Buddhist nursing homes for seniors are operating in China, while the number of Christian nursing homes for seniors is unknown, and yet it could be in the hundreds. End-of-life care is an integral part of services at the Chinese Buddhist and Christian nursing homes for seniors. Another possible approach is connected to the development of private nursing homes for seniors. At present, there are nearly 30,000 private nursing homes in China, where religious services are legal if they strictly cater to end-of-life care14. A third possible approach is the integration of Confucian ethics and officially extolled social values with spiritual care for critically ill seniors at the last stage of their lives in public hospitals.

The rationality of the aforementioned possible approaches can be explained by a reference to the prominent and late Chinese sociologist Pan Guangdan. He speculated in the 1940s, in a journal article, that Chinese seniors could die with dignity and with a feeling of comfort by relying on four types of strength (Pan 1936, pp. 36–37). These were a religious belief, an ensured bloodline of the family, a high degree of parental authority in the Chinese family system associated with filial piety, and a clear sense of great achievements, leading to spiritual immortality. While the first three types of strength applied to most Chinese seniors, Pan Guangdan argued, the last type of strength, which relied on officially and widely recognized political, intellectual, and moral achievements, could apply to only a few. In the above cases, the elderly in the two villages, whether they believe in Islam, Tibetan Buddhism, folk Taoism, or a mixture of them, can obtain satisfaction and comfort in the sense of religious belief, and envisage entering another “bright world” after death. Additionally, the inheritance of their blood—having many children and grandchildren—makes them feel the continuation of life and the hope of the family, so they can accept the generational change and the transition from the old to the new with peace of mind. The submissive attitude of family members towards the dying, especially their willingness to meet the demands of the dying even if they are unreasonable, makes the elderly people’s life—which may be ordinary and boring—have a “monumental time”. Namely, they have obtained unprecedented attention and a sense of authority. All these enable the elderly people of the two villages to gain spiritual satisfaction and spiritual care. This is also a possible path in which spiritual care can play a role although it cannot be directly included in the medical system. This also highlights the value and significance of the existence of China’s local end-of-life care models.

6. Conclusions

From the current end-of-life care practice in Chinese hospitals, the principle of scientific medical treatment is still the primary focus, while the culture, ethics, and religion of different ethnic groups are given minimum consideration, let alone good communication and practice in this aspect (Yan 2013). On the one hand, for rural patients who are far away from urban hospitals, it is difficult to enjoy high-quality medical resources, let alone hospice care or palliative care. On the other hand, the rich folk religions (minjian zongjiao 民间宗教) and cultural resources in rural areas are hard for urban patients to reach.

In the two villages of this survey, most people follow the concept of “fallen leaves shall return to the roots” (luo-ye-gui-gen 落叶归根) and the idea that people will return home when they die, and all their relatives and friends will also come to say their final goodbyes, expressing their emotions and observing customs. The Confucian values of “fathers being affectionate and children being dutiful” (fu-ci-zi-xiao 父慈子孝), “warmth among neighbors” (ling-li-wen-qing 邻里温情), and even the “benevolence of doctors” continue to exist in the two ethnically interlaced regions, supplemented by spiritual care based on the main beliefs of the subjects, so the dying patients pass away peacefully. The mechanism behind this kind of spiritual care is to strengthen the religious faith of the dying through reciting Buddhist scriptures, so that they can face death calmly and believe in the beauty of the other world. The belief-support ritual of Tibetan Buddhism requires the dying to hold correct mindfulness (正念), namely, giving up obsessions and accepting the Buddhist view of life and death. The belief-support ritual of Taoism requires the dying to make the soul-to-heart conversion (至心皈命), namely, a single-minded glorification of the admonitions and encouragement of the Taoist gods. The belief-support ritual of Islam requires the dying to call to Allah, praising Almighty Allah and asking for his mercy and forgiveness. In fact, the use of religious belief support rituals in end-of-life care is a spiritual form of care for the dying—alleviating or eliminating the extreme mental distress of terminally ill patients and their families. This distress is due to the sense of worthlessness and meaninglessness of life and the confusion about death and future life, as well as relieving a series of spiritual troubles, such as anxiety, sorrow, pain, and depression in both terminal patients and their families (Zheng 2005, p. 4).

Finally, from the perspective of the multicultural attributes of the end-of-life care approach in the two areas, the mutual influence of customs and cultures of various ethnic groups in the ethnically interlaced region, coupled with mutual marriage and gradual integration, has gradually led to the formation of a cultural community. Within this community, the Han, Tibetan, and Hui ethnic groups live in harmony. Especially for the families of the dying, ethnic attributes no longer matter; the important thing is to see the dying pass away in peace. This shows that the motivation and driving force behind end-of-life care, characterized by ethnic integration, come from the actual needs of the people.