Caring for the dying in S’pore: From death houses in Sago Lane to dealing with a super-aged society

SINGAPORE – “I can’t cure you any more, don’t come back,” Mr Christopher So jokingly recalls what his doctor told him about his terminal kidney condition, before referring him to Dover Park Hospice’s day care service.

For the 86-year-old former primary school teacher, the hospice is a less menacing place compared with the hospital. “No needles here,” he explains.

Still, he says he would rather be outside, eating what he wants to eat – even it goes against his diet. “I cheat,” he confesses to this reporter.

Part of the reason he keeps coming back is that the hospice’s day care is free, and he loves the board games that patients play after lunchtime.

Dover Park Hospice’s day care, which runs every weekday from 10am to 3pm, is a service which complements its inpatient and home care services, bringing together people with advanced illnesses for therapy and exercise sessions, while easing the load of their caregivers.

When The Straits Times visits earlier in May, volunteers make and serve kopi before patients partake in a seated group exercise to Hokkien and Zumba music.

One of the attendees is 88-year-old Lily Ng, who has a terminal heart condition. She tells ST that part of the appeal of coming here is being able to raise medical concerns to staff, who can take them to doctors, without the hassle of the revolving door of hospital visits.

While Dover Park Hospice began its day care service in 2019, Singapore’s first was launched in 1997 by Assisi Hospice.

With the Singapore Hospice Council (SHC) reporting more than 12,000 patients referred to specialist palliative care services like these between April 2023 and March 2024, they also form part of a century-long shift in how Singapore cares for the dying.

Death houses

“Long before you reach the buildings, you become aware of the smell of tung oil and the peculiar odour associated with the houses of death,” according to a 1947 report by the Sunday Tribune about Singapore’s “biggest health scandal”, its Chinatown death houses.

Before the first hospices were established in Singapore, their predecessors were licensed sick receiving houses – also colloquially known as “death houses” or “dying houses” – first established in the 19th century to shelter the sick and dying.

In the years leading up to Singapore’s independence, they were concentrated around Sago Lane, Jalan Ampas and Balestier Road.

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.

The Sunday Tribune’s correspondent writes of a 72-year-old woman huddled over a dirty stool, so sick that she could no longer lie down. “I 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.”

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.

In a time when the average hourly wage for non-government workers was 65 cents, these were exorbitant rates. Still, the services proved popular – with an average of six deaths in Sago Lane every day – often because of superstitions surrounding death in the home and the lack of affordable alternatives.

One mourner told the Free Press’ correspondent about why he took his father to a Sago Lane Death House: “I hated to bring him to this strange place, but nothing I said would alter the attitude of my mother and other adult relatives.”

Despite this persistent demand, Singapore’s death houses were places of immense controversy.

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 “giggling, gawking tourists”, according to media reports at the time.

Nearby residents were also outraged over the unsanitary conditions of these death houses and their role in spreading disease. “Sometimes, there are 14 corpses at a time in a room 18ft by 30ft,” notes a 1958 report by ST.

All of this led to a health committee recommendation to stop licensing these houses and to shift them away from the city centre.

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.

In response, councillor Tang Peng Yeu said he and another councillor would accept the challenge and “occupy their rooms and prove that we are representatives of the people and can live with the poorest under any conditions”.

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.

Challenges for first hospices

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.

“But actually, these death houses are the result of an absence of a hospice system,” says Dr Liew. “This is the bad stuff that happens when we’re not here.”

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’s division of palliative care.

“Hospices were a grassroots movement of people who believed we can do more than this,” she adds.

For doctors like Dr Angel Lee, who began working in palliative care in 1992, this meant working with community and voluntary organisations to bring palliative care into the homes of dying Singaporeans.

“Thirty years ago, palliative care was in the community,” says Dr Lee, a board member of the SHC and director of St Andrew’s Community Hospital. “You didn’t have it in the hospitals. And you had only a little of it in the inpatient hospices.”

Singapore’s first hospice opened in 1985 at St Joseph’s 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.

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.

“The 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,” according to an ST report in 1986.

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.

It was a move that sparked bitter debate. In one forum letter response in 1992, an ST reader wrote: “I am amazed that Singapore Polytechnic students and staff should be so vocal in their wish to have the proposed hospice located somewhere else.”

Dover Park Hospice was eventually established in Jalan Tan Tock Seng instead, keeping its original name despite the move.

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.

Hospices today

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.

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.

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.

It was not until 2023 that the Healthcare Services Act was amended to describe hospices as a distinct category of care. Singapore’s hospices are still licensed as nursing homes.

“That is the huge transformation of the last 10 years,” 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.

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.

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.

However, key obstacles remain.

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.

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’s hospice movement.

Super-aged society

As Singapore is set to become a super-aged society in 2026 – meaning that over a fifth of the population is aged 65 and up – the number of people who will need palliative care is likely to exceed that of the country’s inpatient facilities.

This means that Singapore has had to rapidly expand the palliative care ecosystem’s capacity, says Dover Park Hospice’s Dr Liew.

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’s palliative care unit. Home care is the segment where the hospice sees the largest growth in patients.

Associate Professor Melvin Chua, a senior consultant at Sengkang General Hospital’s department of geriatric medicine, says looking ahead, there is a need to break down traditional taboos and normalise conversations about end of life.

“We need broader uptake of Advance Care Planning, greater caregiver support and stronger community capabilities to manage end-of-life care outside the hospital setting,” says Dr Chua.

“With Singapore’s rapidly ageing population, building compassionate, community-based end-of-life care is not just a medical priority, it is a societal one.”

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.

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.

“Sometimes, you have delirious patients saying they saw something, or they’ll say they saw a black image going past,” says Ms Gan. “Especially during my night shifts, they’ll talk like this. If you’re not prepared, it can be a difficult thing.”

Terminal delirium is a condition where patients – in the final weeks of their life – experience confusion, hallucinations and restlessness. For many patients, this also occurs alongside breathlessness and pain.

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.

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. “It’s something unavoidable and will happen to everyone,” she adds. “It gives me comfort to know that we’re here as volunteers to give a proper farewell.”