Effectiveness of End-of-Life Care in the Community in the Asian Context: A Systematic Review

Abstract

Asian countries are prioritizing community and home end-of-life care (EoLC) as populations age and care preferences shift. Asian community-based EoLC’s effectiveness is questionable due to cultural, institutional, and healthcare system challenges that affect access and quality. This systematic review seeks components. This makes EoLC effective in Asia. The disparities in care models, how they combine with healthcare institutions, and cultural and family variables are examined. Systematic review (PROSPERO ID: CRD42025644698). The electronic databases PubMed, CINAHL, Scopus, and ScienceDirect were searched in January 2025, evaluating community- or home-based EoLC programs in Asian countries. Twenty articles (8 qualitative studies, 2 quantitative randomized controlled trials, 3 quantitative non-randomized, 6 quantitative descriptive, and 1 mixed methods) fulfilled the inclusion criteria. The review identified the following key aspects of EoLC in Asian communities: symptom management, advance care planning (ACP), family and professional care, cultural sensitivity and spiritual care, healthcare system integration, education, and training. Although EoLC interventions have contributed substantially to improving care quality, the related evidence is inconclusive. Effective EoLC in Asian communities is related to culturally sensitive approaches, the crucial role of family and caregivers, and collaborative decision-making among patients, families, and healthcare professionals. Limited resource access, especially in rural locations, and inconsistent caregiver training and assistance remain issues. Healthcare, healthcare institutions, community resources, and standardized yet flexible criteria that respect spiritual, emotional, and cultural requirements are critically needed to provide fair, high-quality, and person-centered EoLC.

Introduction

The global population is aging, leading to significant demographic changes that profoundly impact health systems worldwide.^1,2 Concomitantly, there has been a steady increase in the incidence of non-communicable diseases. ³ While advancements in medical technology have improved survival for chronic illnesses.^4,5 Prolonging a patient’s life when there are no chances of recovery may increase the anguish of patients and their caregivers. ⁶ Therefore, it is essential to refocus from curative treatments to palliative care (PC), which concentrates on managing symptoms and providing holistic care, including physical, emotional, psychological, social, and spiritual support. This approach aims to relieve suffering, fulfill the patient’s final wishes, and enhance their quality of life (QoL).^6-8

PC is vital for terminally ill patients and their families, as it provides holistic support during a loved one’s final moments. PC is a multidisciplinary approach to improving patients’ QoL suffering from life-threatening illnesses by addressing their physical, psychological, social, and spiritual needs. ⁶ However, despite its importance, the WHO ⁶ reported that only 14% of terminally ill patients globally have access to PC. EoLC is a key component of PC that focuses on terminally ill patients with a life expectancy of 6 months or less. EoLC should be started early in disease progression to ensure a dignified and compassionate death. ⁹

 The WHO ⁸ reported that community-based EoLC improves the QoL and satisfaction for patients and their families and reduces healthcare costs; however, access to EoLC remains limited, particularly in low- and middle-income countries. ¹⁰ In Asian countries, while the need for EoLC at home and in communities increases, a lack of adequate community health services, inequities in access to care, and insufficient pain management resources hamper the provision of appropriate EoLC^7,11,12 EoLC in the community in the Asian context is not well documented. Therefore, there is an urgent need to explore existing care approaches and guidelines and identify concerns regarding access inequities. The findings from this review might be beneficial for developing effective community-based strategies for improving the QoL of patients in communities in Asian countries.

Methods

Search Strategy and Selection Criteria

We conducted an extensive literature search across the PubMed, CINAHL, Scopus, and ScienceDirect electronic databases to extract full-text articles related to EoLC published between 2014 and 2025. The Boolean operator “OR” was used for a joint set of synonyms, and “AND” was used for conjunctions. Search terms: “End of life in community” AND “Hospice care” OR “Terminal Care” OR “End of life Care” AND “Quality of life” OR “Family satisfaction” OR “Symptom management.”

Inclusion criteria: (1) articles published from 2014 to 2025, (2) availability of full text, (3) English language, (4) conducted in Asia, and (5) community-based/home-based. Exclusion criteria: (1) Review articles and (2) Commentaries.

Search Outcomes

Two researchers independently screened the extracted results based on titles and abstracts using Rayyan. Rayyan is a technology that makes the screening process easier in systematic reviews. Rayyan automatically finds and removes duplicate research after importing search results from several databases. It lets several reviewers independently and quickly looks at titles and abstracts. AI helps them decide which records are most important, but the reviewers make all the decisions on which records to include. The platform makes everything more open and consistent, and any differences are worked out through conversation. This makes sure that the review has a credible and full list of research to consider. Duplicate publications were deleted. For this systematic review, we defined the following results related to EoLC in Asian countries Symptom management, Advance Care Plaining (ACP), Family Caregivers and Professional Care Staff, Cultural Sensitivity and Spiritual Care, Healthcare System Integration. Figure 1 presents the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram depicting the search strategy. ¹³

Figure 1.

PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) flow diagram for study selection.

EoLC = end-of-life care.

*Using Rayyan AI.

Data Extraction

A dedicated Microsoft Excel (for Microsoft 365 MSO, Version 2503 Build 16.0.18623.20116) data extraction form was developed to collect and manage the following data from the included studies: study design and methodology (study purpose, research design, and outcome measures), participant demographics and baseline characteristics, the number of events or measures of effect (as applicable), country of origin, year of publication. The 2 researchers independently extracted data from the included studies to ensure accuracy and reliability (Table 1); duplicate extractions were compared, and any discrepancies or anomalies were discussed and resolved through consensus. If disagreements persisted, a third reviewer was consulted to make the final decision.

Table 1.

Mixed Method Appraisal Tools (MMAT) Scoring Ratio.

First author	Screening question		1. Qualitative					2. Quantitative randomized controlled trials					3. Quantitative non-randomized					4. Quantitative descriptive					5. Mixed methods					Score (%)
	S1	S2	1.1	1.2	1.3	1.4	1.5	2.1	2.2	2.3	2.4	2.5	3.1	3.2	3.3	3.4	3.5	4.1	4.2	4.3	4.4	4.5	5.1	5.2	5.3	5.4	5.5
Cheng	Y	Y	Y	Y	Y	Y	Y																					100
Luk	U	N	Y	N	N	N	N																					20
Kuzuya	N	N	Y	N	N	N	N																					20
Fukui	Y	N						Y	N	N	N	Y																40
Chan	Y	Y						Y	Y	N	Y	Y																80
Teo	Y	Y											Y	Y	Y	Y	Y											100
Tomita	Y	Y											Y	Y	Y	Y	Y											100
Hossain	Y	Y	Y	Y	Y	Y	Y																					100
Haruta	Y	Y	Y	Y	Y	Y	Y																					100
Ho	Y	Y																Y	Y	Y	N	Y						80
Li	Y	Y																					Y	Y	Y	N	Y	80
Tang	Y	Y											Y	Y	Y	Y	Y											100
Huang	Y	Y																Y	Y	Y	Y	Y						100
Lee	Y	Y																Y	N	Y	N	N						40
Lim	Y	Y	Y	Y	Y	Y	Y																					100
Chen	Y	Y																Y	N	Y	N	Y						60
Mon	Y	Y																Y	N	Y	U	Y						60
Jiraphan	Y	Y																Y	N	Y	Y	Y						80
Chung	Y	Y	Y	Y	Y	Y	Y																					100
Leong	Y	Y	Y	Y	Y	Y	Y																					100

Data Synthesis and Integration

To obtain a holistic view of the effectiveness of EoLC in the community and its impact on QoL, we examined the following outcomes: QoL of the patients and their families, satisfaction among the patient and family, symptom management, emotional support, psychosocial support, spiritual support, and the concept of dying with dignity. These outcomes were selected to provide a comprehensive understanding of the characteristics of care contributing to the success of EoLC in community. ¹⁴ For data synthesis, we used Cochrane Methodology for Systematic Reviews. ¹⁵ Because of the heterogeneity among the included studies in terms of samples, methods, interventions (different models of community-based EoLC across Asia), study designs, and outcome measures, a meta-analysis could not be performed. Instead, we conducted a narrative synthesis to integrate and interpret the findings, allowing for a detailed exploration of the diverse evidence base ¹⁶ and providing meaningful insights into the effectiveness of EoLC in the community. For narrative synthesis using a structured approach, we organized the data by grouping studies based on key themes, such as ACP, symptom management, family caregivers and professional care staff, cultural sensitivity and spiritual care, and education and training. Additionally, we explored the characteristics of care and the success of EoLC in communities in Asia.

Results

Characteristics of the Included Studies

Using the aforementioned search strategy, we extracted 225 articles from the databases. After removing duplicates, we screened the study titles and checked for the availability of full texts; finally, 20 relevant articles were selected for review (Figure 1). Eight of these studies were qualitative (Table 2; study no: 1-3, 8, 9,15, 19, and 20), 2 articles were quantitative randomized controlled trials (study no: 4 and 5), 3 articles were quantitative non-randomized (study no: 6, 7, and 12), 6 articles had a quantitative descriptive design (study no: 10, 13, 14, and 16-18), and 1 article used mixed methods (study no: 11). In terms of geographical location, there was 1 study from Thailand (study no: 18), 2 from Malaysia (study no: 19 and 20), 4 from Hong Kong (study no: 1, 2, 5, and 10), 3 from Taiwan (study no: 11,13, and 16), 4 from Japan (study no: 3, 4, 7, and 9), 2 from South Korea (study no: 14 and 15), 2 from Singapore (study no.: 6 and 12), 1 from Myanmar (study no: 17), and 1 article covering Bangladesh, India, and Pakistan (study no: 8). Table 2 presents a summary of the characteristics of the included studies.

Table 2.

Summary of the Articles Included in the Systematic Review (n = 20).

Study and Country	Objective of study	Study Design	Participants	Component Examined	Key findings
Cheng et al. (2023), Hong Kong	- To analyze the nature and types of community palliative and end-of-life care services in Hong Kong	Cross-sectional descriptive design; qualitative content analysis	- No human subjects; study assessed Hong Kong end-of-life care provider websites. - Google searches for end-of-life care found accessible government/NGO sites for local services; single-service, for-profit, or inaccessible sites were excluded. - From 228 websites found (200 via keywords, 8 manually), 16 met criteria and were analyzed.	1. Service Provider Characteristics Provider: Non-profit/Government, Care Type: Palliative/End-of-life, Model: Social-Medical adopted, Target Population: Geriatric, terminally ill adults, children, cancer patients, Access: Referrals/Self-contact, Coverage: Hong Kong-wide, regional, district. 2. Types and Nature of Services Info & Advice, Emotional Support, End-of-life & Grief Support, Spiritual Care, Medical/Nursing Care, Social Activities Practical Help, Resource Referrals, Financial Aid, Caregiver Training	1. Service Provider Characteristics Findings - Dominance of Non-Governmental Organizations (NGOs): NGOs (93.7%) mainly offer community end-of-life care using non-government funding. - Target Population Focus: Half of providers specialize in geriatric care, underscoring its role in end-of-life care. - Limited Geographic Coverage: Services covered 43.8% citywide, 31.3% by region, 25% by district, showing access gaps. - Service Model: 11 of 16 providers offered end-of-life care; 7 used a social-medical model. 2. Types and Nature of Services Findings - Multidimensional Care: Palliative care met physical, mental, social, and spiritual needs holistically. - Most Frequently Provided Services: Info/advice (93.7%) was most common; dying/bereavement, psychological (87.5%), spiritual (75%), and medical care (62.5%) followed. - Less Frequently Provided Services: Fewer received referrals (31.3%) or training/aid (18.8%). - Support for Caregivers: Patient services are prioritized; caregiver support is lacking.
Luk (2018), Hong Kong	1. To highlight the need for quality end-of-life care for elderly with terminal conditions in care homes. 2. To examine barriers stopping older adults from dying in their chosen place, especially in care homes instead of hospitals. 3. To review recent end-of-life care innovations and pilot programs.	Qualitative The establishment of pilot programs, new care pathways, ACP, and regular family engagement	- N = 22 - Aged ≥ 65 years - Multiple co-morbidities, and advanced irreversible chronic medical illnesses characterize this demographic.	1. EoLC program 2. Healthcare utilization 3. Social-medical collaboration 4. Barriers to dying in residential care homes	1. The AED (Ambulatory Emergency Department) Pathway for EoLC in residential care homes for the elderly has been assessed for its feasibility, and the findings indicate that it is indeed a viable option. 2. Improving EoLC in homes 3. Location of death: 41% of residents died in private rooms per Cardiopulmonary Resuscitation order 4. Seniors prefer care homes over hospitals for a dignified EoL experience. 5. Social-medical collaboration improved the effectiveness of EoLC.
3.Kuzuya et al., (2020), Japan	1. To provide Japan’s healthcare workers with concise guidance on promoting the Advanced Care Plan (ACP). 2. To clarify the concept of ACP. 3. To ensure that medical and long-term care for individuals, supporting older adults in Japan by honoring their end-of-life wishes and dignity 4. To support the process of individual wishes in end-of-life decisions, even with reduced capacity or family conflicts.	Qualitative	1. Older adults 2. Family members 3. Multidisciplinary medical and long-term care professionals (exact number of participants not specified)	1. Understanding an individual’s wishes 2. Continuous dialog 3. Community-based integrated care 4. Ethical considerations 5. Cultural sensitivity	1. Urgency and importance of geriatric care in Japan to promote ACP implementation to improve end of life care. 2. Cultural adaptation: ACP requires adaptation to Japanese culture and medicine 3. Facilitator roles: need for ACP facilitators to align healthcare with individual’s values 4. Shared decision-making reflects unvoiced values 5. Recommendations to stress adding ACP to elder care
4.Fukui et al., (2019), Japan	1. To assess the effect of a multidisciplinary end-of-life educational intervention program. 2. To assess collaboration, confidence, and job satisfaction among care professionals.	Randomized controlled trial	- N = 291 (64 nurses, 129 care managers, and 98 care workers.) - Participant lived in an urban area.	1. Multidisciplinary EoLC educational intervention 2. Job satisfaction 3. Interprofessional collaboration	1. Improved interprofessional collaboration: all seven Face-to-Face Cooperative Confidence Questionnaire (FCCQ) subscales showed enhanced confidence, communication, role clarity, and community connections 2. No significant change in job satisfaction among participating healthcare professionals (nurses, care managers, and heads of care workers) 3. Demographic shifts suggest age/experience affect education’s impact on EoLC. Tailored training is vital for diverse health/social care staff.
5.Chan et al. (2018), Hong Kong	1. To examine the effects of a structured, nurse-led post-discharge advance care planning (ACP) program. 2. To assess the congruence between the end-of-life care preferences of patients and their family members. 3. To evaluate the decisional conflicts experienced by patients regarding end-of-life decision-making. 4. To determine the documentation of care preferences	Two-arm parallel-group randomized controlled trial	- 230 Dyads (dyad: patient and their caregiver) - Met one of the three triggers from the Gold Standards Framework Prognostic Indicator Guidance screening tool. - Least 18 years of age. - Were mentally competent. - Could communicate in Cantonese. - Lived at home.	1. Dyadic congruence of the ACP program 2. Decisional conflict 3. Documentation of care preferences 4. Comparison Experimental group nurse-led ACP, 3 weekly home visits, improved EoLC agreement. 5. Control standard self-care	1. Dyadic congruence improved between groups after 6 months of intervention 2. Reduction in decisional conflict: participants felt less conflict in end-of- life care choices, and felt more supported 3. More patients completed advanced directives and “do-not-resuscitate” documentation 4. Effective ACPs for nurses require teamwork: organizations, leaders, teams, educators, policymakers, and families enabling EoL talks.
6.Teo et al. (2014), Singapore	1. To assess the financial effects of the Project CARE (Care at the End-of-Life for Residents in homes for the Elderly) program on nursing home residents. 2. To compare these economic effects to usual end-of-life care costs.	Quasi-experimental	- N = 245 - (48 experimental, 197 controls) - 1-Year mortality risk identified. - At-risk: advanced illness, ≥2 hospitalizations/6 months, Barthel < 30, or positive “surprise question.” 6 to 12 months mortality.	1. Impact of EoLC program (Project CARE) on ACP 2. Cost analysis 3. Health resource utilization	1. Cost Savings: Project CARE achieved savings of SGD 7129 per resident at 3 months and SGD 3703 1 month prior to death (adjusted for baseline differences) 2. Hospitalization dropped to 42% at 3 months and 51% in the last month of life 3. Nursing home stays increased to 94% in the last 3 months and to 90% in the last month of life 4. Significant economic impact
7.Tomita et al. (2021), Japan	To evaluate the specific factors that contribute to older Asian individuals achieving home death while receiving physician-led home healthcare.	Case-control study	- N = 152 - Started physician-led home healthcare - Death occurred Feb 2018–Dec 2019. - Patients had to be at least 40, as long-term care insurance excluded those younger. - Patients ending physician-led home care within 1 week were excluded.	1. Effect of family preferences on home deaths 2. Influence of “filial responsibility” in Asian cultures on decisions about the place of death 3. Impact of physician-led home healthcare on outcomes	1. Family preferences significantly influenced EoLC choices and home deaths 2. Significantly older age, presence of multiple symptoms, and family wishes greatly affected the incidence of home deaths 3. Patient preferences mattered little 4. Cultural context is extremely relevant in Asian families.
8.Hossain et al. (2021), Bangladesh, India, and Pakistan	1. To study South Asian family carers’ dementia experiences. 2. To track dementia experiences from first signs to end-of-life prep. 3. To explore ethnic groups’ dementia experiences, focusing on caregiver views of detection, care, and end-of-life.	Qualitative	1. South Asian countries (Bangladesh, India, and Pakistan) 2. Diverse-aged family carers participated, broadening understanding, offered varied dementia care experiences.	1. Cultural and religious influences 2. Stigma around death in South Asian families 3. Support and EoLC planning for dementia 4. Culturally sensitive support for South Asian dementia caregivers	1. Cultural and religious factors affect caregiving abilities 2. Challenging the dignity of patients: there is a pressing need for culturally sensitive support for South Asian caregivers 3. Address the needs of patients and caregivers from diagnosis to EoL while considering family and faith 4. Limited knowledge of dementia symptoms creates stigma and complicates support for caregivers
9. Haruta et al. (2020), Japan	1. To teach lay people about end-of-life care mechanisms and pathways. 2. To identify participants’ key learnings and perception shifts about end-of-life care from the program.	1. Case Study Approach: Narrative-Centered 2. Learning: Stories enhanced EoL care. 3. Thematic analysis.	-N = 18 - Group qualitative study - Deep EoL care insights, 18 qualitative participants suffice, valuing depth over breadth.	1. Key variables: EoL knowledge & perception; Understanding evolution; Narrative catharsis; Metacognition & perspective; Altruism & support; Mortality reflection & fear reduction. 2. Narrative Engagement: Participant interaction with narrative elements (stories, discussions, reflections). 3. Participant Characteristics: Age and gender can shape learning. 4. Educational Program Components: Learn through structure, content, and assignments.	1. The program improved end-of-life care knowledge and clarified palliative roles. Varied teaching methods and a 3-month break aided learning. 2. Emotional Processing and Catharsis: Stories eased grief, recalling emotions and aiding acceptance. 3. Metacognition and Perspective-Taking: Metacognition fosters empathy, boosting healthcare appreciation. 4. Altruism and Community Engagement: The program fostered altruism, inspiring volunteerism and compassion for families needing end-of-life care. 5. Reflection on Impending Death: Death lessened fear, increased gratitude, and brought peace. Life-framing improves end-of-life care.
10. Ho et al. (2022), Hong Kong	1. To investigate the preferences of older people concerning end-of-life care (EoLC). 2. To compare these preferences specifically in Japan, the Hong Kong Special Administrative Region (SAR), and South Korea.	Cross-sectional study	- N = 417 - 65+ years old - Live in the community. - Japan, Hong Kong, South Korea. - Cognitive Function (Hong Kong SAR), needed a Mini-Mental State Examination score of greater than 20	1. Decision-making preferences 2. Cultural influences 3. Sociodemographic and personal experience variables 4. Role of family members 5. Advance directives	1. Family as preferred decision-makers 2. Regional differences in preferences: Hong Kongers were less keen on family involvement than Japanese patients, while Koreans were less receptive to EoLC talks with doctors 3. Advance directives: >70% of participants in each region chose not to formalize EoLC decisions 4. Cultural influence: older Asians often prioritize family
11. Li et al. (2021), Taiwan	1. To explore older indigenous patients’ views and readiness for ACP, including end-of-life decisions. 2. To use the Transtheoretical Model to assess ACP awareness, intention, and readiness in terminal indigenous cancer. 3. To identify barriers to ACP participation.	Mixed methods	- N = 16 - 70 years or older. - Stage III/IV cancer confirmed with metastasis. - Mandarin or Taiwanese needed for health/end-of-life talks. - Participants needed legal capacity for life-support and ACP decisions. - Lived 3+ years in eastern Taiwan aboriginal areas for local familiarity.	1. ACP Knowledge. Familiarity with ACP terms and concepts. 2. ACP, end-of-life planning, learning, and communication intent. 3. ACP readiness, precontemplation, EOL planning, and advance directive willingness. 4. The study explored how demographics, beliefs, access, and support affect ACP readiness.	1. Older indigenous patients showed low ACP readiness (precontemplation). This stemmed from unawareness of ACP. Most knew ACP was beneficial, yet only (66.66%) intended to start it. 2. Higher education correlated with more ACP completion (44% vs. less). Lower education: ACP confusion, predetermined death beliefs. 3. Indigenous EoLC patients trusted doctors, passively awaiting care. ACP education & Cultural, religious, impacted views. 4. Indigenous patients were largely unready for ACP.
12. Tang (2022), Singapore	1. To evaluate the effectiveness of the End-of-Life Nursing Education Consortium (ELNEC) program. 2. To assess if ELNEC improves nurses’ attitudes and lowers death-related anxiety. 3. To assess if the program lessened nurses’ communication anxiety with dying patients and families. 4. To determine if ELNEC prepared nurses for end-of-life care.	Quantitative single-group pre-post design	- N = 82 - Nurses at a Singapore community hospital. - Nurses of all job grades participated. - Existing and new nurses attended a 2-day workshop.	1. Death Anxiety: This variable is measured using the Frommelt Attitude Toward Care of the Dying (FATCOD) scale. 2. Attitudes Toward Death: The FATCOD scale also evaluates nurses’ attitudes toward caring for dying patients. 3. Communication Apprehension: using the Communication Apprehension Dying Scale (CA-Dying Scale).	1. Improvement in attitudes toward death: FATCOD scores improved from 117.98 to 129.09 2. Reduction in communication apprehension: mean pre-test score = 92.96; mean post-test score = 76.70 3. Clinical experience plays a major role in shaping how nurses perceive and handle EoLC 4. Limited prior education: Nurses’ insufficient palliative care training causes anxiety and poorer care. ELNEC training improves skills, benefiting all. 5. Cultural considerations: must adapt to local culture as sociocultural differences impact communication and views on death
13. Huang et al. (2018), Taiwan	To explore the factors influencing end-of-life care discussions for residents with dementia in long-term care facilities in Taiwan.	Cross-sectional correlational analysis	- N = 478 - Registration nurses (n = 387) - Social workers (n = 68) - Physicians (n = 23) - Work setting: professionals worked in long-term care setting	1. EOL Care Discussions: end of life care, advance direct care, life support. 2. Professional Characteristics: Compare end-of-life care knowledge, attitudes, confidence, and support across disciplines. 3. Factors Influencing Discussions: end-of-life talk factors: education, end-of-life confidence, facility support.	1. EOL care discussions were rare (<10%). Physicians led discussions more than nurses/social workers; AD discussions were similar. Life-sustaining treatment discussions are rare (70% rarely/never). 2. Professional Characteristics and Their Impact. - Physicians knew more about end-of-life care than social workers. - Professionals’ views on decision rights were similar across groups. - More advanced direct discussions are linked to more positive views - Social workers felt less confident in end-of-life care than nurses/doctors. - Confidence predicted more discussions. Support predicted more discussions, regardless of profession. 3. End-of-life care education boosts advanced directives talks. Still, approximately one-third of Taiwanese long-term care staff lack end-of-life care training. Nurses and social workers discuss less than doctors.
14. Lee et al. (2019), Korea	1. To assess the levels of importance and difficulty of multidimensional care needs. 2. To examine these needs across different end-of-life stages. 3. To understand how the patient’s Palliative Performance Scale level influences these care needs. 4. To conduct this investigation from the viewpoint of home healthcare nurse specialists	Retrospective survey: A retrospective survey assessed past home nursing care and the needs of noncancer patients at end-of-life care.	- N = 115 - Age: more than 40 years. - Continuous home care nursing required during stable and final death stages. - Date of Death: Projected lifespan between September 1, 2014, and December 31, 2015. - Diagnosis: Non-cancerous vascular, cardiac, neurological, pulmonary, musculoskeletal, digestive, or urogenital disorders.	1. Patient and Caregiver Characteristics. Patient data: gender, age, vision, hearing, noncancer diagnosis, Palliative Performance Scale (PPS), caregiver type, caregiver age, home care nursing duration. 2. End-of-Life Stages. Stable Stage: Week 2 post-care initiation to 1 week pre-death. Near-Death Stage: Final week of life. 3. Multidimensional Care Needs. Key variables: care need importance/difficulty (basic, symptom, psych/spiritual, death/grief, coordination).	1. Patient and Caregiver Characteristics - Demographics: 115 patients (65% female, mean age 84). Diagnoses: cerebrovascular (33%), cardiovascular (13%), pulmonary (12%). - Functional Status (PPS Level): Lower PPS (10-20%) suggests higher needs, more symptoms than higher PPS (>50%). 2. End-of-Life Stages. Needs: Stable: Family/caregiver health key. Near-death: Grief/loss care vital; anxiety problematic. Fear of death/disease is difficult, always. Difficulty: Symptoms are hardest in both stages (dyspnea)—Dysphagia is worse near death. Death/life management is strict in the stable stage, as well as in daily life. 3. Multidimensional Care Needs. High-needs care, critically ill. Needs: Activities of daily living, bowel/bladder, dyspnea, GI, dysphagia, skin, and pain control.
15. Lim et al. (2020), Korea	To clarify and conceptualize the phenomenon of ego integrity management by nurses in the context of nursing homes. To assess issues related to ego integrity within the nursing home environment. To determine how nurses should play a key role in managing this important life task for older adults.	Qualitative	- N = 8 - Registered nursing home nurses. - Experience Level more than 3 years.	1. Ego Integrity. This study focuses on the near end of life, and how it’s achieved. 2. Management by Nurses. Nurses support residents’ ego integrity via assessment and intervention. 3. Residents of Nursing Homes. Ego integrity is uniquely challenged in nursing home residents. 4. Assessment Components. Nurses assess resident well-being. 5. Intervention Components. Nurse management improves resident well-being.	1. Nurses are essential in supporting the ego integrity of nursing home residents 2. Quality long-term care can be ensured through assessment, intervention, and fostering positive relationships and skills 3. Ego integrity management significantly affected residents’ sociopsychological adaptation to nursing home life 4. Key insights to help develop tools for managing ego integrity 5. Highlights the importance of spiritual comfort and personalized care
16.Chen et al. (2014), Taiwan	1. To a terminally ill cancer patient’s preference for dying at home.	Cross-sectional	- N = 2188 -Terminal Malignancy - Cognitive Competence - Communication Ability	1. Influence of the awareness of prognosis on preferences for home death 2. Functional dependency 3. Symptom distress 4. Family support crucial for decisions home death	1. The majority (54.7%) of participants preferred dying at home 2. Awareness of death preference increased this likelihood (P < .001), especially for those aware of their prognosis (P = .032) 3. Greater functional dependency was linked to a stronger preference for home death (P < .001) 4. Patients with liver/pancreatic cancer (P = .028) or head/neck cancer (P = .012) preferred home death 5. A lack of junior high education was associated with this preference (P < .001)
17. Mon et al. (2020), Myanmar	1. To describe various dimensions of end-of-life experiences among patients with advanced cancer in Myanmar. 2. To assess socioeconomic status (SES) differences in these end-of-life experiences. 3. To provide insights into the challenges faced by advanced cancer patients and identify areas for improvement in the provision of end-of-life care.	Quantitative: cross-sectional study	- N = 195 - More than 21 years. - Stage IV solid cancer. - Patients must know their diagnosis. - Cognitively intact per referral.	1. Sociodemographics 2. Socioeconomic Status (SES) 3. QoL Assessment 4. Pain Management 5. Desire for Hastened Death 6. Quality of Care	1. Poor QOL in terminally ill patients with cancer 2. Severe pain and limited pain management 3. Desire for hastened death: 41% of patients desired an earlier end to their suffering. 4. Not euthanasia, low use of PC services 5. Low SES patients had poorer QOL, less care coordination, and more pain, showing disparities in EoLC
18. Jiraphan et al. (2022), Thailand	1. To investigate the end-of-life care preferences of the general Thai population, specific southern region 2. To identify any factors associated with these preferences.	Cross-sectional	- N = 1037 - Aged 20 years or above - Use the Thai language well.	1. Experiences with End-of-Life Care for Relatives 2. End-of-Life Care Preferences	1. Patient Experiences: Coping: emotions & acceptance. 2. Patient Preferences: It covers end-of-life care preferences and planning. 3. Spiritual and Cultural Factors: Spirituality and culture significantly shape end-of-life care. 4. Family Involvement: Family strongly affects Advance Care Plan.
19. Chung et al. (2025), Malaysia	To explore the experiences and preferences of Malaysian patients with advanced cancer regarding end-of-life care.	Qualitative	- N = 19 - Stage 4 cancer - 18 years old or above - Use English or Malasia	Patient Experiences Patient Preferences Demographic Characteristics Spiritual and Cultural Factors Family Involvement	1. Dealing with Poor Prognosis: Fear, then acceptance. Life over cure. 2. Spirituality as a Source of Strength: Faith gave meaning, eased death fears. Family helped. 3. Enablers of Advance Care Planning: Tailor prognosis talks; include family in end-of-life care; honor home death wishes.
20. Leong et al. (2022), Malaysia	1.To illustrate the Importance of PC care; symptom relief, family care in terminal illness 2. To Home terminal care injections may cause caregiver distress. 3. To EoLC challenges in Malaysian communities	Qualitative	- Age 72-year - Old woman metastatic lung cancer spread to her bones and brain.	1. Patient and Caregiver Needs 2. Access to Palliative Care Services 3. Resource and Personnel Limitations 4. Integration with Healthcare System	1. Skilled family caregivers can manage complex pain at home, enabling comfortable EoLC in familiar settings 2. Role of ongoing community PC services vital for family caregivers to manage symptoms and facilitate home death 3. Importance of providing guidance and emotional support to patients and families 4. Training and support for caregivers improves home care success.

Symptom Management

Symptom management in EoLC is primarily aimed at reducing distress in terminally ill patients. Six studies specifically addressed symptom management in EoLC (study no. 14-17, 19, and 20). In Malaysia, subcutaneous infusions and family care were primarily used to enhance home pain management, reduce emergency visits, and increase comfort. ¹⁷ A study from Myanmar reported that tools such as Functional Assessment of Cancer Therapy General (FACT-G) and pain scales were used for structured symptom control. ¹⁸ A Korean study highlighted the need to address the physical, psychological, social, and spiritual needs of patients with chronic illness and stated that lower Palliative Performance Scale scores reflect a greater need for support. ¹⁹ Another Malaysian study described that spirituality aided in offering peace to patients, highlighting the need for culturally sensitive care such as respecting religious beliefs, facilitating traditional healing practices, accommodating rituals related to EoL, and supporting family involvement in decision-making ²⁰ In Taiwan, family caregivers play a key role in symptom management and preferences for home death; accordingly, providing adequate support to caregivers through training reduces anxiety and enhances care quality for the patient is essential. ²¹

Leong et al also stated that community services were essential for aiding caregivers and facilitating home EoLC in Malaysia. Patients with low-income struggle to access pain medication, leading to poor pain management. ¹⁷ Notably, rural areas often lack PC services, worsening symptom management. ¹⁸ Caregivers usually struggle to manage complex symptoms without adequate support, leading to emotional distress. ²⁰ Huang et al ²² noted that barriers within healthcare systems include low participation levels in professional discussions related to EoLC, which limit the effective integration of symptom management. Similarly, in Japan, healthcare professionals found it difficult to adopt ACP due to language-related challenges, which also influenced the low effectiveness of symptom management. ²³ Additionally, cultural and communication barriers cause complicated discussions about care planning and decision-making. ²⁰ These issues indicate a significant need for improved education and communication strategies within healthcare systems to support EoLC. This is a region-specific problem. In Taiwan, hospice services are frequently overlooked, restricting the scope of symptom management and creating gaps in healthcare delivery. ²¹ Such limitations reflect broader regional trends within parts of Asia, where disparities in access to EoLC resources are evident. Rural areas, in particular, face significant resource shortages compared to urban areas, accentuating the need for systemic improvements to equitable care delivery. Symptom management at the EoL remains a substantial challenge, especially in home and community settings, where caregivers often struggle with complex pain crises and must administer anticipatory subcutaneous injections with limited support. The lack of easily accessible palliative care services, inadequate training, ²⁴ and concerns about medication safety can contribute to distress among both patients and family caregivers, highlighting the urgent need for comprehensive support systems and education to ensure effective and dignified symptom control at home.^17,24

Advance Care Plaining (ACP)

ACP is an essential process in PC that allows individuals to indicate their preferences for EoLC in advance. Six studies specifically addressed ACP in EoLC (study no: 3, 5, 8, 10, 11, 19). It comprises the following key components: (1) shared decision-making, (2) documentation of preferences, (3) advance directives, (4) cultural and contextual influences, and (5) predictors of discussion frequency. The success of EoLC depends heavily on effective communication between patients, families, and healthcare professionals.^23-26 Shared decision-making is a crucial step that reflects the values of patients and their families through open conversations.^23-26 It emphasizes aligning healthcare decisions with the patients’ and their families’ unique cultural, ethical, and personal values. Preference documentation involves writing or recording a person’s specific preferences for their desired treatment and care options during EoLC. ²⁷ Over recent years, there has been an increase in the completion of advance directives and “do-not-attempt cardiopulmonary resuscitation” documentation in Asia. This trend indicates a shift toward formalizing patients’ wishes regarding EoLC.

Advance directives ²⁶ refer to legal documents that specify future healthcare wishes if patients cannot decide for themselves. These ensure that the patient’s treatment preferences are respected. However, Ho et al reported that over 70% of participants from some regions in Asia—for example, Hong Kong, Japan, and Korea—opted not to formalize their EoLC decisions, raising concerns about the understanding and utilizing ACP. Cultural and contextual influences^23,26,28 affect patients’ EoLC-related decisions. These findings indicate the importance of tailoring ACP approaches to incorporate individual values and beliefs ²⁰ Studying factors influencing advance directive discussion helps us understand how crucial conversations between patients, families, and providers can be improved. Increased patient confidence in EoLC has led to more discussions about advanced directives among caregivers and residents with dementia. ²⁵ However, many healthcare providers report infrequent engagement in these discussions, ²⁷ highlighting a communication gap. This gap reflects differences in ACP understanding and treatment-related decision-making.^27,28 Furthermore, different age groups showed varying participation levels in treatment decisions. Many individuals desire to be informed about their condition and avoid burdening their families, a preference underscoring the need for clarification and inclusive communication in ACP.^23,27 These findings illustrate the complexities associated with ACP, emphasizing the need for effective communication, cultural sensitivity. ²⁵ Healthcare providers work closely with patients, taking time to listen and understand their values and preferences, so that every aspect of care truly reflects what matters most to each individual.

Family Caregivers and Professional Care Staff

Family caregivers (study no: 5, 7, 8, 10, 14, and 20) and healthcare staff (study no: 1, 7, 12,13, 15, and 19) play a crucial role in delivering effective EoLC in community settings. Several studies have emphasized the importance of collaborative approaches that empower families^17,19,29,30 respect cultural values^25,26,31 and improve communication between family members and healthcare providers.^21,22,32 Addressing these aspects can significantly enhance the QoL and support during EoLC. ³³

Furthermore, collaboration among different sectors—such as healthcare systems, community organizations, and social services—was identified as vital for meeting caregiver and staff needs and enhancing service integration. ³³ Notably, many patients rely on non-governmental organizations (NGOs) due to inconsistent public healthcare funding and limited governmental resources. ³³ NGOs often provide vital psychological support, spirituality, and social activity programs, which fill the gaps left by public healthcare systems. The combination of public healthcare services and NGO support creates a more comprehensive care network, addressing both medical and emotional needs for patients and their families. ³³ Family preferences^25,26 and cultural contexts play a significant role in EoLC decision-making by influencing how families engage in care processes.^25,26,31 Hence, culturally sensitive support is essential for diverse families in EoLC planning. ²⁶ Some authors have also described the importance of effective communication between families and healthcare providers to enhance care quality.^20,29 Hossain et al ²⁵ reported that a lack of knowledge about dementia hinders the provision of support for families and staff. Therefore, empowering caregivers by providing training can improve EoLC experiences at home and aid nurses in better supporting the patient.^19,32 Healthcare professionals should regularly visit such patients to provide consistent support, even if families may overlook the importance of professional care.

Cultural Sensitivity and Spiritual Care

EoLC should address the patient’s and families’ emotional, psychological, and spiritual needs. Moreover, key components of EoLC in Asia are influenced by cultural and religious values. Eight studies highlighted the importance of cultural sensitivity and spiritual care in community-based EoLC in Asia (study no: 3, 8-10, 11, 15, 18, and 19). Chung et al described that spirituality aided Malaysian patients in finding peace during their final moments, especially in culturally diverse settings; they also stated that holistic care addresses emotional and existential concerns. ²⁰ Lim and Chang ³² noted that spiritual care helps patients accept their mortality and maintain dignity. Likewise, patients from Bangladesh, India, and Pakistan stated that religious practices like prayer provided them comfort and helped maintain their cultural identity. ²⁵

Family involvement is crucial in EoLC decisions in some Asian cultures.^18,31 In Japan, family preferences often overshadow the patient’s, highlighting the need to ensure collective decision-making. ³¹ In Malaysia, involving families in care planning was associated with fostering trust and helped align the expectations of EoLC. ¹⁷ Haruta et al. ³⁴ concluded that community engagement in Japan through narrative-based education promotes reflection on mortality and a community-focused approach to EoLC. In summary, despite communication barriers and cultural stigma related to EoLC, integrating spiritual care, and fostering sensitivity can enhance the quality of EoL and ensure compassionate and dignified support for patients and their families. ³⁴

Healthcare System Integration

Healthcare systems in Asia differ widely in terms of resources, policies, and cultural contexts, making healthcare system integration crucial for enhancing the quality and equity of EoLC. Twelve of the 20 studies (study numbers 1-9, 13, 16, and 20) discussed the challenges and strategies of integrating EoLC into community settings, identifying key focus areas such as cost-effectiveness and resource optimization. For instance, Singapore’s national frameworks support the incorporation of EoLC into healthcare systems by offering funding, training, and guidelines. A report on Singapore’s Project CARE on nursing home residents showed significant economic benefits by reducing hospital admissions and healthcare costs while improving the quality of care in nursing homes during patients’ final months. ³⁵ Integration ensures better resource allocation and patient outcomes while improving access to EoLC in communities. In Malaysia, integrating EoLC initiatives at the community level allowed patients to receive care at home, easing pressure on hospital systems. ¹⁷ Similarly, community programs in Hong Kong provide comprehensive EoLC by reducing service fragmentation and collaborating with social services to offer holistic support tailored to patients’ diverse needs.^33,36 These efforts to build better-integrated systems are pivotal for addressing the gaps in EoLC service provisions, particularly in community settings.

Discussion

Success of EoLC in Communities in Asia

The effectiveness of community-based EoLC in Asia fundamentally depends on the successful integration of healthcare systems. Multiple studies included in this review highlight that gaps in coordination between hospitals, primary care providers, community health resources, and specialist PC services often result in fragmented care and suboptimal outcomes.^17,33,35,36 For integration to work, there need to be clear roles for interdisciplinary teams, efficient referral paths, and accessible health records.^35,36 Initiatives such as integrated care networks and community-based palliative outreach demonstrate potential to bridge these divisions and ensure continuity of care for patients in their preferred settings.^17,35 Furthermore, coordinated funding mechanisms and unified training standards across sectors may help standardize quality and access across diverse geographic and organizational contexts.^30,33 Beyond system-level organization, cultural considerations have a significant influence on EoLC delivery in Asian communities. Many Asian societies place a high value on family-led decision-making and collective approaches to care, which shapes not only treatment preferences but also communication patterns between care teams and families. Respecting these cultural norms—such as involving family members in discussions about prognosis and care planning—is essential for ensuring satisfaction and minimizing distress at the EoL. ¹⁷ However, healthcare systems must find ways to respectfully engage with these cultural expectations while upholding ethical principles of autonomy and informed consent.^17,23

Another critical finding from this review is the essential role of caregiver support. Most EoLC in the community rely heavily on family caregivers, who frequently experience significant physical, emotional, and financial burdens.^17,20,25 Several studies reported inadequate access to respite care, insufficient caregiver training, and limited psychosocial support networks.^17,25 Without targeted interventions—such as structured caregiving education, psychological counseling, and financial assistance, caregiver strain can jeopardize both patient outcomes and the sustainability of community-based EoLC. Policymakers and healthcare providers should prioritize the development of accessible, flexible caregiver support services embedded in EoLC models.^17,25

Finally, disparities in resource access continue to be a substantial barrier to effective EoLC in Asian communities. Rural areas, in particular, often lack specialist PC teams, essential medications, and reliable transport for home visits. Economic constraints and uneven resource allocation within health systems further exacerbate these disparities. Innovative solutions, such as telehealth and regional resource-sharing initiatives, have shown promise but require greater investment and policy support to be widely sustainable. Achieving equitable resource distribution is crucial for ensuring that all communities—regardless of location or socioeconomic status—have access to dignified, high-quality EoLC.

In summary, advancing EoLC in Asia requires not only better-integrated healthcare systems but also culturally responsive care, enhanced support for caregivers, and improved access to resources. Addressing these interconnected challenges holistically will help close existing gaps and move toward more equitable, person-centered EoLC throughout the region.

Conclusion

The effectiveness of Asian EoLC is related to cultural beliefs, family roles, system efficiency, and professional support. This study suggests that EoLC quality depends on collaboration and adaptability among healthcare facilities, families, and professionals to meet patients’ needs and address their diverse beliefs. Group and family decision-making in Asian cultures affects patient treatment. Family, patients, and medical professionals must collaborate on EoL decisions and preparation to honor dignity. Limited resources, access, especially in rural regions, and caregiver education and support remain challenges. The systematic review suggests that standardized yet flexible solutions for the diverse spiritual, emotional, and social needs of different groups are urgently needed. To empower families and professionals, public healthcare, NGOs, and community networks must collaborate on caregiver training, psychological support, and symptom management. Develop evidence-based recommendations for equitable and high-quality EoLC in Asian communities, considering patient and caregiver perspectives. Develop and train family caregivers and healthcare staff to enhance their skills and support. Healthcare providers, community groups, and legislators should collaborate to strengthen access and organization. Managing these complex concerns will make EoLC more person-centered, respectful, and effective for Asians.