A Qualitative Study on Rural Chinese Residents’ Perceptions and Demands for Palliative Care within the Framework of “Rural Good Death Belief”

A Qualitative Study on Rural Chinese Residents’ Perceptions and Demands for Palliative Care within the Framework of “Rural Good Death Belief” | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Study on Rural Chinese Residents’ Perceptions and Demands for Palliative Care within the Framework of “Rural Good Death Belief” Shenglong Sun, Shuai Yuan, Yunling Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8846419/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background The development of palliative care in China exhibits a pattern of “urban priority and rural lag”. Older adults in rural areas face low quality of life and a lack of professional care during the end-of-life stage. Objective This study aims to explore rural Chinese residents’ awareness of and demands for palliative care, along with their underlying decision-making logic. The objective is not only to provide theoretical insights for formulating localized development strategies in rural China but also to contribute Chinese perspectives and experiences to addressing palliative care accessibility challenges in similar resource-limited settings worldwide. Methods Purposive sampling was used to select 43 rural residents for semi-structured in-depth interviews. Thirty-nine interview transcripts were ultimately obtained and analyzed using grounded theory. Results Eight axial codes were extracted: “Views on Life and Death” “Awareness of Quality of Life and Dignity” “Perceptions of Medical Care” “Customs for Handling Post-Death Matters” “Attitudes Toward Palliative Care” “Influence of Economic Status on Acceptance of Palliative Care” “Demands for Palliative Care Services” and “Expectations for Government Support and Promotion Policies”. The selective coding was identified as “Rural Chinese Residents’ Perceptions and Demands Regarding Palliative Care within the ‘Rural Good Death Belief’ Framework”. Conclusion Rural Chinese residents’ perceptions and demands regarding palliative care are deeply embedded in the logical framework of “Rural Good Death Belief”. They demonstrate a strong need to maintain quality of life and dignity, emphasize the economic accessibility of services and the vital role of families as informal caregivers, and express high expectations for government leadership and involvement. Palliative care Rural residents Older adults Perceptions Figures Figure 1 Introduction Since 2017, three batches of palliative care pilot projects have been launched nationwide in China, yet these efforts have primarily focused on secondary and tertiary hospitals in urban areas, with insufficient attention paid to rural regions. This has resulted in a development pattern characterized by “urban priority and rural lag” in the provision of palliative and palliative care in China [ 1 – 4 ]. In rural areas, the proportion of residents aged 60 and above and 65 and above is 23.81% and 17.72%, respectively, which is 7.99 and 6.61 percentage points higher than that in urban areas [ 5 ], indicating substantial care needs. However, the development of palliative care in rural China remains exploratory [ 4 ], and many issues require further investigation. Notably, the accessibility challenges of rural palliative care constitute a global issue. A systematic international review points out that nearly half of the world’s population resides in rural areas, yet access to palliative care is generally limited due to constrained resources, a shortage of specialized teams, and population dispersion [ 6 ]; in the United States, rural communities similarly face multiple complex challenges, including accelerated population aging, scarcity of specialized medical resources, geographic isolation, and adverse social determinants of health[ 7 ]. Therefore, exploring effective pathways for palliative care in rural settings with limited resources holds broad international practical significance. As a developing country with vast rural areas and a profound traditional culture, China’s development of rural palliative care not only faces challenges common to rural regions worldwide but also encompasses unique cultural and social dynamics. Adopting a localized perspective, this study seeks to empirically explore rural Chinese residents’ perceptions and demands regarding palliative care. The findings reveal that rural residents’ understandings and expectations of palliative care are deeply embedded in the structure and ethics of what Xiaotong Fei [ 8 ] described as the “rural society”. To better understand rural residents’ end-of-life decision-making behaviors, this study attempts to construct a “Rural Good Death Belief” framework, which not only describes the phenomena but also explains the cultural logic underlying these perceptions and demands, thereby providing theoretical insights for developing a localized model of palliative care in rural China. Furthermore, this theoretical exploration rooted in the Chinese context can also serve as a reference for understanding the life-and-death perspectives of rural residents in other cultural settings, the role of families in caregiving and decision-making, and their expectations for services. Meanwhile, it will enrich the global scholarly dialogue on palliative care practices and contribute an analytical lens and practical insights to rural areas in countries with similar resource and cultural contexts. Methods 1. Research Setting and Design This study was conducted across nine provinces (Shandong, Shanxi, Hebei, Henan, Hubei, Hunan, Guizhou, Sichuan, Fujian) and one municipality (Beijing) in the eastern, central, and western regions of mainland China. Adopting a qualitative research design, it selected rural residents from the aforementioned areas as the study participants. Data were collected using semi-structured interviews and analyzed via the grounded theory method to explore rural Chinese residents’ perceptions and demands regarding palliative care. 2. Study Participants Using purposive sampling, researchers contacted potential participants through two approaches. The first approach was to contact staff at local village committees, either in person or by phone, to introduce the study. Once they agreed to assist, these staff members helped connect the researchers with potential participants by providing a brief explanation to foster initial trust. The second approach involved contacting the respondents through family members or acquaintances of the researchers who live in rural areas. All participants in this study volunteered for the interviews and provided either written informed consent or verbal consent recorded during the interview. The inclusion criteria for participants were as follows: (1) age ≥ 40 years old; (2) possession of a rural household registration ; (3) continuous residence in a rural area for at least three years; (4) full consciousness and absence of diagnosed psychiatric disorders; (5) capacity for independent verbal communication; (6) ownership of a legally registered rural homestead; and (7) no urban residential property holdings. A total of 52 completed interview transcripts were collected. After quality screening (excluding records with excessively short duration or where participants were uncooperative with the researchers), a total of 39 high-quality interview transcripts were retained. These comprised 36 individual interviews and 3 focus group interviews (involving 3, 2, and 2 participants respectively), involving a total of 43 rural residents 3. Interview Guide Based on relevant literature on palliative care and the practical context of rural end-of-life care, a semi-structured in-depth interview outline was developed (Supplementary 1). The outline covered topics including participants’ personal experiences or knowledge of death events, caregiving experiences, views on life and death, and perceptions of palliative care. Techniques such as clarification, focusing, and probing were employed to elicit in-depth responses and ensure the collection of rich qualitative data. 4. Data Collection Data collection was from July to September 2024. The research team consisted of university professors, medical professionals, social workers, and graduate and undergraduate students recruited from multiple universities across the country, with experience in qualitative research and/or palliative care. Their disciplines covered medicine, nursing, sociology, and social work. Before data collection, all team members completed a four-day training on the fundamentals of palliative care and qualitative interview techniques. Before each interview, the research purpose and the participant’s right to withdraw were clearly explained. Upon obtaining consent, interviews were audio-recorded using mobile phones or voice recorders, while handwritten notes captured non-verbal expressions such as gestures and facial expressions. Interviews were conducted in quiet, undisturbed settings, lasting no less than 30 minutes, with an average duration of approximately 57 minutes. Transcripts were produced within 24 hours post-interview. As data collection was conducted simultaneously across the nine provinces and one municipality, data collection and analysis were treated as separate sequential phases; therefore, the principle of data saturation was not applied during the collection stage. During the analysis phase, thematic saturation was reached upon analyzing the 21st transcript. However, considering potential significant differences in economic conditions, cultural concepts, and customs among China’s eastern, central, and western regions, the research team chose to analyze all 39 transcripts to capture more nuanced perspectives and details. 5. Research Method and Quality Control This study employed the grounded theory research method. The Nvivo15 software was used for open coding of the interview data, extracting initial concepts grounded in the data. Subsequently, connections among these initial concepts were identified, leading to the formation of main categories through summarization and condensation. Finally, a systematic synthesis was performed to derive the core category. During the research process, to ensure research reliability and minimize bias, one researcher performed preliminary coding on the de-identified transcripts to establish an initial coding framework. Subsequently, another researcher systematically reviewed the initial coding results. Through iterative discussions, comparisons, and revisions, consensus was reached on the naming, categorization, and attribution of the codes. For codes where disagreements arose, a third researcher joined the discussion until consensus was achieved. Additionally, the accuracy of the coding was continuously reviewed throughout the process, and participants were consulted regarding their intended meanings to enhance the credibility and validity of the study. Research Results 1. Demographic Characteristics The median age of the 43 participants was 62 (range 42–82). There were 27 female participants (62.8%) and 16 male participants (37.2%). In terms of education, 23 (53.5%) had primary schooling or less, while 20 (46.5%) had attended junior high school or above. 2. Research Findings The 39 interview transcripts were labeled “C1-C39” and imported into Nvivo15 software. Open codes were extracted from the raw text, with the number of reference points annotated based on the frequency and variation of expressions [ 9 ]. Ultimately, 32 open codes were derived, comprising a total of 476 reference points (Table 1 ). Table 1 Axial Coding Axial Codes (Reference Points) Open Codes Text Examples(Data sources) Reference Points Views on Life and Death (89) 1) Cherishing life and fearing death The older you get, the more you fear death, the more you want to live. (C15) 32 2) Falling leaves returning to the roots For folks in rural China, they still hold the belief that they ought to be buried in their ancestral hometown when they pass away. (C17) 20 3) Life and death as natural Well, that’s life—everyone goes through birth, old age, sickness and death. It’s just the natural order of things; you can’t fight it; it’s bound to happen. (C11) 17 4) Fearlessness towards death I’m not afraid. Everyone has to walk this path eventually. On the road to death, there’s no young or old. (C16) 8 5) Dying peacefully of old age When your time’s up, you pass away just like falling asleep, without any pain whatsoever. (C11) 5 6) Fate not being in one's own hands You can’t call the shots on the fate of your life, and no one can ever really figure out what fate’s all about. (C32) 4 7) Death as liberation Once dead, all worries are gone. (C23) 3 Awareness of Quality of Life and Dignity (118) 1) Family harmony Family harmony is what brings happiness. (C2) 39 2) Physical and mental well-being Good health is the real foundation of a happy and comfortable life. (C37) 35 3) Dying without pain When it really comes to the end, what matters is to pass away painlessly and with dignity. For an elderly person, that’s the greatest fortune and their heart’s deepest desire. (C17) 14 4) No lack of material resources Of course, material things are indispensable. If you can’t even put food on the table or fill your stomach, you certainly can’t talk about happiness. (C18) 12 5) Avoiding futile treatment When it truly comes to the final moments of life, they certainly don’t want to lose their dignity—being attached to tubes all over, spending all their money on the hospital for nothing, and still having to leave in the end. (C17) 9 6) Longevity We say anyone who lives a long life is blessed. (C11) 5 7) Not being a burden to family and children Truth be told, not being a burden to your children is the true blessing. (C17) 4 Perceptions of Medical Care (85) 1) Patient care relying on the family I believe the biggest strength of rural people is their strong family bonds, and family members take excellent care of one another. (C37) 55 2) Treating to the end to fulfill filial piety In rural areas now, rural families won’t easily give up on treatment. Because living conditions have improved compared to the past, their children are financially capable now and also very filial. Even when a patient is in the advanced stage of illness and doctors say treatment is no longer effective, the children will still insist on continuing it. (C6) 19 3) Patient care through neighborhood mutual assistance When the children get tired from their caregiving sometimes, you can ask the neighbors to come over to accompany the patient and chat a bit together. (C13) 8 4) Prioritizing treatment for the young over the elderly Nowadays, most people spare no effort to treat sick kids no matter what. Their attitude toward the elderly is different, though. Fewer spare no effort to treat them. This is human instinct. (C32) 3 Customs for Handling Post-Death Matters (20) 1) Dying at home It’s almost always at their own home for rural families—passing away outside is considered bad luck. (C14) 8 2) Family members staying by the dying person’s side In our rural areas, we must stay by their side, no matter when they pass, someone must be there with them. (C13) 4 3) Being laid to rest in peace The deceased finds peace only when interred in the earth. (C22) 3 4) Purchasing burial items and dressing the deceased in burial clothes Once he passed away, we helped buy those things, we went to town to buy the plain clothes, all the clothes for the dead, and the joss money. (C13) 3 5) Not disturbing the deceased Don’t move them when they are dying; they are already in great pain, the soul is separating from the body. If you cry and move them then, they suffer more. Right after death, you shouldn't cry; if you cry, they can’t let go and won’t depart peacefully. (C15) 2 Attitudes Toward Palliative Care (64) 1) Positive acceptance of palliative care This matter of palliative care, now that the state is promoting it, I think it’s a good thing and should be strongly supported. (C6) 47 2) Rejection of palliative care Not very useful, a superficial project, just do some practical action. (C2) 17 Influence of Economic Conditions on Acceptance of Palliative Care (23) 1) Poverty hindering rural residents from accepting palliative care Rural folks have no money in hand, the key is having no money. (C33) 13 2) Accepting palliative care only if costs are low A small amount of money is acceptable, but none of us are willing or able to afford a large sum, right? (C32) 10 Demands for Palliative Care Services (40) 1) Hoping for professional service support I think because it’s in rural areas, nearby corresponding palliative care facilities are relatively few. Places that actually implement palliative care are almost non-existent. (C20) 35 2) Expecting home-based care I think palliative care in a hospital is not as convenient as at home. (C35) 5 Expectations for Government Support and Promotion Policies (37) 1) Strengthening policy support Looking forward to government policies coming through, so there can be professional teams, and we can enjoy this kind of care—this is also an expectation of ours. (C32) 17 2) Government increasing financial investment Palliative care is good, but it simply won’t work out without government funding. (C4) 12 3) Hoping for life-and-death education and palliative care publicity I think the government needs to step up publicity, such as playing promotional videos in the villages and holding awareness sessions like they did before, so that everyone can understand what hospice care is all about. (C19) 8 Based on the connections among the open codes, eight axial codes were inductively formed: “Views on Life and Death” “Awareness of Quality of Life and Dignity” “Perceptions of Medical Care” “Customs for Handling Post-Death Matters” “Attitudes Toward Palliative Care” “Influence of Economic Status on Acceptance of Palliative Care” “Demands for Palliative Care Services” and “Expectations for Government Support and Promotion Policies”. Through a systematic analysis of the intrinsic relationships among these eight axial codes, it was found that participants’ understanding, attitudes, and expectations regarding palliative care revolved around a logical framework characterized by “the core principle of ‘familism’, the life sentiment of ‘attachment to native soil’, the ethical norm of ‘traditional filial piety’, and the bottom-line consideration of ‘family economic security’”. We termed this framework the “Rural Good Death Belief” framework. Consequently, the final selective coding was determined as “Rural Chinese Residents’ Perceptions and Demands Regarding Palliative Care within the ‘Rural Good Death Belief’ Framework” (Table 2 ). Table 2 Selective Coding Axial Codes (Number of Reference Points) Selective Coding (Total Reference Points) Views on Life and Death (89) Chinese Rural Residents’ Perceptions and Demands Regarding Palliative Care within the “Rural Good Death Belief” Framework (476) Awareness of Quality of Life and Dignity (118) Perceptions of Medical Care (85) Customs for Handling Post-Death Matters (20) Attitudes Toward Palliative Care (64) Influence of Economic Conditions on Acceptance of Palliative Care (23) Demands for Palliative Care Services (40) Expectations for Government Support and Promotion Policies (37) (*Note: Table 1 and Table 2 are presented at the end of this article for clarity. These two tables are located between the end of the second paragraph of “2. Research Findings” and the heading “(1) Views on Life and Death” in the “Research Results” section.) (1) Views on Life and Death The interview data indicate that the prevailing views on life and death among rural Chinese residents are characterized by “cherishing life and fearing death” and “falling leaves return to the root (the desire to return to one’s ancestral homeland)”. The former manifests as a strong attachment to life and an instinctive aversion to death (C18: “People fear death. Death is a great dread for everyone. It’s quite natural to fear death.”). The latter emphasizes that death should occur in one’s homeland, reflecting a traditional perception of the place of death (C13: “In rural thinking, it’s not good to die outside. One must die at home.”). Attaching importance to the connection with a specific place at the end of life is a cross-cultural phenomenon of growing interest in the field of palliative care [ 10 ]. The concept of "returning to one’s roots" among rural Chinese residents is a localized embodiment of this cultural pursuit of the wholeness of life, familial belonging, and spiritual homecoming. Some rural residents expressed a more accepting and philosophical attitude toward death, viewing it as an inevitable outcome of life that requires no fear, citing notions such as “dying peacefully of old age” “fate not being in one’s own hands” and “death as liberation”. However, these perspectives were mentioned less frequently, suggesting that such open and accepting views on life and death are not mainstream among rural residents. (2) Awareness of Quality of Life and Dignity Rural residents hold a straightforward yet clear understanding of quality of life and dignity. They place high value on family harmony, filial children, and physical and mental well-being (C2: “Having filial children is a blessing. Follow the elderly’s wishes and don't upset them—this is happiness.”; C25: “What is a blessing? Being healthy and free of illness is the true blessing.”). The notion of “no lack of material resources” indicates they view economic security as the foundation for ensuring quality of life and dignity. “Dying without pain” “avoiding futile treatment” and “not being a burden to family and children” demonstrate that rural residents wish neither to endure unnecessary suffering nor to become a burden on their families. The concept of “longevity” appeared relatively infrequently. Considering the rejection of palliative care due to economic reasons under the code “Attitudes Toward Palliative Care” and the influence of economic conditions within the code “Influence of Economic Status on Acceptance of Palliative Care”, it can be reasonably inferred that rural residents may perceive longevity as a luxury due to constrained living conditions. Of course, it’s also possible that some prioritize life quality over mere longevity without quality. Clearly, both quality of life and dignity of life are values recognized by rural residents. However, when realizing these values entails significant economic costs, they may withdraw, indicating the vulnerability of these values for rural residents. (3) Perceptions of Medical Care The care of patients in rural areas relies primarily on the family, with “family-collaborative care” being the dominant model. When there is no hope for a patient’s recovery, persisting with treatment to demonstrate filial piety remains the primary choice for some rural families (C4: “Even if treatment might lead to his death, we cannot just let him stay at home untreated.”). However, this behavior is not entirely driven by hope for recovery but rather stems from fulfilling a cultural obligation of filial piety to avoid moral condemnation as “unfilial” within the close-knit rural community, reflecting the strong influence of social opinion on medical decision-making (C14: “If parents themselves have no hope of recovery, reviving them merely prolongs their life by a few days. But if you don’t attempt resuscitation, when this gets out, the neighbor will say this son is most unfilial. They fear being called unfilial.”). “Patient care relying on neighborly mutual assistance” was mentioned less frequently, likely related to what Xiaotong Fei described as “graded love”: who would provide bedside filial piety if not one’s own kin? “Prioritizing treatment for the young over the elderly” was not frequently mentioned, possibly indicating that while this situation exists in rural society, it is not widespread, as deaths among the young due to illness are far less common than among the elderly. Nevertheless, its existence may still suggest a potential intergenerational bias in resource allocation when family resources are limited. (4) Customs for Handling Post-Death Matters Rural residents exhibit a strong preference for “dying at home” and hope to “be laid to rest in peace”, which can be seen as their preferred place of death, reflecting traditional funeral beliefs and aligning with the “returning to one's roots” “view of life and death”. “Family members staying by the dying person’s side” emphasizes family reunion at the moment of death, which not only mitigates the dying person’s loneliness and fear but also safeguards the integrity of life (C8: “When all the children are by their side, it’s quite lively, so the dying elderly won’t feel terrified or lonely. For life and death are the most important moments in life.”). This companionship serves as both emotional support and a ritual farewell. “Not disturbing the deceased” and “purchasing burial items and dressing the deceased in burial clothes” represent meticulous care and dignity preservation within rural funeral culture, reflecting rural Chinese residents' adherence to traditional funeral customs. Overall, rural residents’ handling of post-death matters demonstrates strong familism and local sentiment. (5) Attitudes Toward Palliative Care Rural residents’ attitudes toward palliative care are primarily positive acceptance, yet notable reservations exist. They acknowledge the function, value, and service orientation of palliative care, believing it can effectively alleviate the physical and mental suffering of patients and families and is worthy of support. Reservations mainly center on economic and trust aspects, viewing it as meaningless financial waste or a superficial project (C35: “Palliative care is acceptable, but it wastes money. It’s not that rural folks are short the money on it, but that the money simply isn’t worth wasting on it.”). Some respondents also expressed resistance to non-family members being involved in care, believing that only family care is reassuring and that outsiders are difficult to trust (C8: “If an outsider comes to take care of the elder, we’ll feel uneasy. We think outsiders can’t do this job, because it’s something only their own children should do.”; C3: “When outsiders come over, no matter how well they speak, they just can’t create that genuine spiritual resonance.”). This stems firstly from wariness and trust barriers regarding non-family involvement, fearing “outsiders” may not be as dedicated or might breach family privacy. Secondly, it stems from the inherent reliance on and emotional identification with family care influenced by the aforementioned views, considering caring for a dying family member an inescapable duty of children and a crucial way to express familial love. Entrusting this to outsiders can generate feelings of emotional deficit and discomfort. (6) Influence of Economic Status on Acceptance of Palliative Care Interview data show that “poverty hinders rural residents from accepting palliative care”, indicating economic conditions are a key constraining factor. For rural residents with limited income, medical expenditures are often prioritized for curative treatments; their willingness to pay for palliative care services that primarily provide comfort is not high (C37: “Long-term treatment and care costs are difficult for many rural families to bear.”). “Only accepting palliative care if costs are low” demonstrates rural residents’ high sensitivity to palliative care expenses; they weigh the cost-effectiveness of different treatment options (C15: “As long as palliative care costs less than that conventional treatment, I think it should be acceptable.”). Therefore, service affordability is a crucial prerequisite for rural residents to accept palliative care. (7) Demands for Palliative Care Services Based on rural customs, rural residents expect to receive palliative care services at home (C14: “It’s a common custom in rural areas for people to recover from illness and spend their last days at home.”). Their primary demands focus on eight aspects: “pain control”, “professional knowledge”, “personnel supply”, “medical resources”, “respite services”, “companionship services”, “home-visit services”, and “spiritual care”. The root of their preference for home-based services is twofold. Firstly, patients feel more secure in a familiar environment (C5: “Elderly people prefer being at home more, where they feel safe and have someone to rely on.”), making it easier to maintain daily habits and social networks, which helps reduce physical and mental stress. Secondly, home care offers convenience (C12: “Oh, I think it’s more convenient at home than in an institution. You know, going to the hospital is just like being in prison; even a healthy person would be worn out after just a few days there.”), eliminating the hassle of traveling to and from hospitals. (8) Expectations for Government Support and Promotion Policies Medical resources are scarce in rural areas, and palliative care resources are particularly lacking. Rural residents have fragile economic conditions, making it difficult to afford palliative care costs. They hope the government will introduce policies, strengthen financial investment, ensure the implementation and promotion of palliative care in rural areas, and simultaneously strive to lessen the individual economic burden on villagers (C4: “In my view, if rural areas want to have such palliative care conditions, the government must invest real funds in it.”). They also emphasize the need to enhance rural residents’ understanding and awareness of life through publicity and education, thereby clearing obstacles for the popularization of palliative care in rural areas (C19: “I think the government needs to step up publicity, such as playing promotional videos in the villages and holding awareness sessions like they did before, so that everyone can understand what hospice care is all about.”). This essentially reflects an expectation for the government to play a leading role in promoting rural palliative care development. Above all, the perceptions and demands of rural residents towards palliative care present a complex picture interwoven with traditional concepts and current conditions. Their views on life and death are mainly characterized by “cherishing life and fearing death” and “falling leaves returning to the roots”. They attach great importance to family harmony and filial piety of their children. In terms of care, they strongly rely on their families and are deeply influenced by the ethics and obligations of filial piety. This has led to a certain recognition of the value of palliative care, believing that it can alleviate pain and maintain dignity. However, there are also significant concerns: on the one hand, economic vulnerability makes cost a key constraint, and the willingness to pay often gives way to the priority consideration of survival medical care; On the other hand, the trust barriers towards caregivers outside the family, the sensitivity to the cultural pressure of “filial piety”, and the preference for places to “pass away at home” all reflect a deep family-oriented tradition and a strong sense of nostalgia for one’s native land. On this basis, the demands of rural residents clearly point to home-based palliative care services and they strongly expect government intervention. Overall, the process of rural residents’ acceptance of palliative care is essentially a process of collision and adjustment among their traditional bioethics, real economic rationality and modern palliative care concepts. To promote the development of rural palliative care, it is necessary to deeply respect and integrate the internal logic of the “Rural Good Death Belief” framework, and strive to break through the dual constraints of economic feasibility and social trust. Only in this way can the vision of a “good death” in the final stage of life be truly realized. Discussion This study adopts the perspective of rural residents and employs a qualitative research method through semi-structured in-depth interviews. Using grounded theory analysis, it attempts to clarify the perceptions and demands of rural Chinese residents regarding palliative care and the underlying reasons behind them. The perceptions and demands of rural residents towards palliative care are not isolated; rather, they form an organic cognitive system closely interconnected by a fundamental underlying logic. This logic is constructed with “familism” as the core principle, “attachment to native soil” as the life sentiment, “traditional filial piety” as the ethical norm, and “family economic security” as the bottom-line consideration, thereby forming the framework of the “Rural Good Death Belief”. This framework reveals the realistic constraints shaping perceptions of palliative care in rural China and provides an important factual basis for constructing the rural palliative care system (see Fig. 1 ). 1. “Familism” as the Core Principle The core principle of “familism” within the “Rural Good Death Belief” framework profoundly shapes rural residents’ cognitive pathways and service preferences regarding palliative care. Under this principle, the family is not only the unit of daily life but also the fundamental unit responsible for caregiving and medical decision-making. Analysis of the interview data reveals that the “good death” and “dignity” pursued by rural residents are essentially a form of “dignity within the family” - fulfilling family responsibilities and avoiding becoming a heavy burden to one’s children. That is, for rural residents, dignity is achieved by raising children to adulthood, helping them establish families and careers, and then aging and dying without becoming a financial or caregiving burden to other family members, especially one’s children. Clearly, this sense of dignity among rural residents inherently involves a reverse care for their family members [ 11 ]. However, from the caregivers’ perspective, whether driven by traditional filial piety or concern for social opinion, caring for an ill family member is an inescapable duty, at least in form. The aforementioned care logic and value orientation jointly determine the unshakable core position of the family in the rural care system and profoundly influence the integration path of palliative care services. On one hand, the family is the core bearer of care responsibility and emotional comfort. Rural residents generally hold a cautious attitude towards the involvement of non-family members in care and prefer home-based care. This care preference is deeply bound to ethical responsibility, demonstrating the profound influence of Confucian familism in rural areas [ 12 ]. Therefore, developing a home-based palliative care model holds greater cultural affinity for rural residents and is more likely to gain their psychological acceptance, while also compensating for the shortage of formal care resources. In fact, this aligns with the global trend where palliative care is predominantly home-based [ 13 , 14 ], representing an important experience and consensus in worldwide palliative care development: a study based on national data in the United States indicates that decedents who received palliative care at home during the last month of life had significantly higher quality of care ratings than those who died in other settings such as hospitals or inpatient hospice units [ 15 ]; a study in Kazakhstan also indicates that the family is the primary and most sustainable source of care provision in contexts where formal care resources are lacking [ 16 ]; a cross-sectional study of adult cancer patients in Iran showed that 69.9% of patients preferred home as their primary place for end-of-life care, and 75.2% chose home as their preferred place of death [ 17 ]; a discrete choice experiment in Germany indicated that terminally ill patients and their families were more inclined to choose home as the preferred care location, with families willing to bear higher costs than for institutional care to ensure their ill family member received the highest level of home care [ 18 ]; an international systematic review on place of death in rural palliative care further confirms that home is universally preferred by rural residents as the location of death, although in reality the majority of deaths still occur in hospitals, highlighting the global gap between preferences and the accessibility of services in reality [ 19 ]. On the other hand, this family-dependent care model also brings corresponding pressure to family members. Therefore, to alleviate family caregiving pressure and improve care quality, future system construction must seek to transcend the sole reliance on the family. Given the current situation where rural social networks have not been fully transformed into effective care resources and considering the concept of public health palliative care [ 20 ], inherent social capital in rural areas should be converted into effective care resources, with efforts focused on building rural neighborhood mutual assistance networks. However, simply introducing the Western concept of “community” or advocating for universal neighborhood mutual assistance may encounter deep-seated socio-psychological and cultural barriers in practical implementation. Therefore, the building blocks of the mutual assistance network can be positioned within kinship-based family networks and quasi-kinship neighborhood acquaintances, rather than the abstract “community”. In villages severely affected by the outflow of young and middle-aged adults, efforts should focus on identifying and training potential local forces such as left-behind middle-aged individuals, healthy low-age elderly, and returnees. Through systematic training and support, informal community mutual assistance forces can be transformed into professional auxiliary care resources, ultimately building a new model of home-based palliative care with Chinese characteristics, featuring “family self-care as the mainstay, supplemented effectively by neighborhood mutual assistance”. 2. “Attachment to Native Soil” as the Life Sentiment “Attachment to native soil” as the core embodiment of rural residents’ life sentiment, profoundly influences their understanding of life’s belonging and their choice of place of death. This emotion manifests not only as a spatial attachment to one’s homeland and family but is also internalized as a cultural psychology that pursues the integrity of life and the realization of social and spatial return. “Cherishing life and fearing death” and “falling leaves returning to the roots” together constitute the dual dimensions of this sentiment: the former reflects a strong attachment to the continuation of life, while the latter points to the cultural persistence of belonging to the homeland and returning to the family. Cai et al. (2017) [ 21 ] believe that, influenced by the traditional Chinese culture of “returning to the roots” and the physical/emotional comfort, security, and sense of belonging that “home” brings to the dying, the majority of elderly people prefer to pass away at home. In China, the family is the core of social life. Influenced by the traditional Chinese agricultural culture centered on the family unit, people’s birth, aging, illness, death, and the inheritance of life cannot be separated from family interdependence, emphasizing the companionship of family, relatives and friends at life's end [ 22 , 23 ]. Therefore, in traditional funeral customs, “home” or “native land” holds extremely high symbolic significance as an end-of-life setting: “family members staying by the dying person’s side” is seen as safeguarding life’s integrity, “dying at home” is endowed with special symbolic meaning, and “being laid to rest in peace” is considered the ultimate ideal destination of life. Higginson et al (2013) [ 24 ] also propose that the family, as a familiar environment for patients, allows them to maintain autonomy and greater freedom and enables them to face death calmly. This suggests that when promoting palliative care in rural areas, it is necessary to fully consider rural residents’ cultural preferences regarding the place of death and their life sentiment of “attachment to native soil”, embedding service scenarios into contexts related to family and hometown to achieve “a peaceful farewell in a familiar place”. However, “attachment to native soil” also carries a certain cultural tension. The notion of “cherishing life and fearing death” can easily lead rural residents to simplistically view death as a malignant event that ends life rather than the natural conclusion of the life process. Furthermore, palliative care emphasizes not treating the patient’s primary disease. This concept may cause some rural residents to misunderstand palliative care as giving up treatment, which they may find difficult to accept, leading to resistance. The traditional concept of “valuing life over death” still holds considerable cultural influence in today’s society. People’s taboo and avoidance of death reduce their initiative to understand and approach it from a rational, scientific perspective [ 25 ]. Confucius’s saying, “If you cannot serve people, how can you serve ghosts?” originally meant to pursue the meaning and value of life and temporarily not consider the issue of death; however, in the course of its transmission, this concept of being cautious about death after valuing life gradually evolved into the cultural root of the Chinese people’s taboo and fear of death [ 26 ]. This reflects, on one hand, a deficiency in life education in rural areas and, on the other hand, insufficient awareness of palliative care among rural residents, constituting a cultural obstacle to the promotion of palliative care in rural areas. Nonetheless, rural residents also hold an open-minded view that death is a natural law of life and thus need not be feared. Rural residents holding this view may be more likely to understand that palliative care is not a denial of life but an important way to help patients spend their final days with quality and dignity. This lays a potential foundation of acceptance for promoting palliative care in rural areas. The seemingly contradictory cognitive phenomena mentioned above precisely reveal the complexity and key entry point for promoting rural palliative care. That is, promotional efforts should not simply adopt a “cultural substitution” strategy but should seek “cultural translation”, transforming the professional concepts of palliative care into local concepts easily understood by rural residents and connecting them with traditional end-of-life pursuits such as “returning to the roots”. On the basis of respecting “attachment to native soil”, a gradual adjustment of life-and-death concepts should be achieved, thereby transforming rural residents’ cultural and practical pursuit of a “good death” into the internal driving force for accepting professional palliative care services. Furthermore, while respecting the life sentiment of “attachment to homeland” and embedding services within families and native soil, it is essential to acknowledge the heterogeneity within rural communities. International research indicates that one of the core principles of successful rural palliative care networks is the recognition of the unique differences among various rural communities in terms of social structures, cultural practices, and resource endowments. Such networks should adopt participatory approaches—such as collaborating with experienced elders and knowledge bearers—to co-create service programs that align with the spiritual and cultural practices of each community [ 27 ]. Therefore, in promoting rural palliative care in China, it is also necessary to guard against oversimplifying and universally applying “rural culture”. Instead, based on personalized in-depth assessments, diverse and localized service embedding models should be developed. 3. “Traditional Filial Piety” as the Ethical Norm Traditional filial piety, as an important ethical norm in rural society, profoundly influences the medical decisions and behavioral choices of rural residents. The research finds that the concept of “treating to the end to fulfill filial piety” among rural residents is not merely a medical decision but rather a strategy to cope with the public opinion pressure of traditional “filial piety” : Under the influence of traditional filial piety, when family members make decisions for terminal-stage patients, driven by moral responsibility, they often believe that active treatment is the right choice; therefore, they frequently choose to do their utmost to save the patient’s life, disregarding the patient’s quality of life [ 28 – 30 ]. This decision-making model derived from filial piety ethics has formed a powerful informal normative system within the rural social environment. In the context of a rural acquaintance society, “filial piety” is not only a personal virtue and family ethic but also an important form of moral capital and a criterion for social evaluation. This external moral pressure often causes medical decisions to deviate from the patient-centered principle of palliative care, instead serving the cultural performance of “filial piety” and the maintenance of community identity. The perception of “continuing treatment at all costs” identified in this study within Chinese rural contexts stems primarily from the ethics of filial piety and the moral pressures inherent to rural society, often manifesting as a preference for extending aggressive treatment. In contrast, a systematic review by Marshall et al. (2024) [ 31 ] focusing on rural palliative care models in countries such as Australia and Canada indicates that patients and families there generally desire earlier and more timely access to strategically integrated specialist palliative care teams, recognizing that this helps alleviate caregiving burdens and enhance quality of life in the terminal phase. This discrepancy underscores how socio‑cultural contexts and healthcare‑system frameworks profoundly shape end‑of‑life decision‑making patterns. From this perspective, there is an obvious ethical tension between traditional filial piety and palliative care. To alleviate this tension, on one hand, the ethical legitimacy of palliative care can be explained using the discourse of “filial piety”, emphasizing that “allowing a loved one to pass away peacefully” is also an expression of filial piety. On the other hand, through life-and-death education and publicity, promote the transformation of the concept of filial piety from “treating to the end to fulfill filial piety” to “providing comfort to the patient is filial piety” in modern times, advocate new concepts such as “alleviating a loved one’s pain is a higher level of filial piety”, and create a favorable ethical environment for promoting palliative care in rural areas. 4. “Family Economic Security” as the Bottom-Line Consideration In end-of-life decision-making choices regarding palliative care, rural residents take “family economic security” as the fundamental consideration. This consideration is reflected not only in high sensitivity to the cost of palliative care but also in the economic rationality of their medical decision-making. However, this rational choice exhibits a certain complexity: on one hand, some families, driven by filial piety ethics, will “treat to the end”, often sparing no expense for active treatment; on the other hand, they show obvious concerns about the cost of palliative care services. This seemingly contradictory behavior precisely reflects insufficient understanding of palliative care among rural residents. The concept of “financial toxicity” proposed by Zafar et al (2013) [ 32 ] describes the dual burden that high medical expenses impose on patients and their families. Some studies point out that high financial toxicity is significantly associated with low quality of life [ 33 – 35 ]. Palliative care can reduce hospitalization costs for terminal-stage patients and is the most important factor in lowering financial toxicity for advanced patients [ 36 – 39 ]. Due to lower income, lower education levels, and information isolation, rural residents tend to be more conservative in medical consumption. When illness occurs, they are unable to make the most economical and effective medical choices, leading to aggravated health problems, higher medical expenses [ 40 ], and further exacerbation of their economic vulnerability. Fragile economic affordability and scarce medical resources together constitute a dual structural bottleneck restricting the development of rural palliative care. Specifically, economic pressure is the core factor hindering rural residents from accepting palliative care services. Therefore, the “affordability” of service fees is a prerequisite for the long-term development of rural palliative care. Due to lower income and limited conditions, rural residents often face a higher risk of catastrophic health expenditure compared to urban residents. With limited income, rural residents’ medical expenditures are primarily based on cost-effectiveness considerations. The cost of receiving palliative care services is unaffordable for many rural families, meaning that even if they recognize the value of palliative care services, the “economic pressure” may outweigh positive willingness. Economic pressure is a universal bottleneck constraining the development of palliative care in rural areas. A study on rural palliative care in the United States indicates that flexible reimbursement mechanisms and financial support are key drivers for implementing palliative care in rural communities [ 41 ]. Resource shortage is another constraining factor. Rural residents have clear demands and expectations for professional palliative care services. However, due to insufficient medical resources in rural areas, a lack of professional palliative care talent, and limited home-visit service capacity, the accessibility and professionalism of services are further restricted. This dual constraint of economy and resources objectively requires that rural palliative care must follow a development path of “low cost and strong adaptability”. This path aligns with Cheng Yu’s concept of “inclusive palliative care”, which emphasizes meeting the needs of terminal patients at low cost, wide coverage, and high quality, as well as service fairness, accessibility, and universal welfare, to achieve attention to the entire life cycle and health process [ 42 , 43 ]. However, we must recognize that under the premise of limited resources, emphasizing “low cost” makes it difficult to achieve “high quality”, and promoting “high quality” makes it difficult to achieve “low cost”. To date, how to effectively balance the two, truly transform palliative care into a livelihood service within reach of rural residents, and achieve a virtuous cycle of “economic accessibility - resource matching - demand satisfaction” remains a topic worthy of in-depth exploration and continuous optimization. A study from South Africa indicates that under resource-constrained conditions, training community health workers, integrating existing non-governmental organization networks, and leveraging collaborative services from primary health clinics can effectively enhance the accessibility and sustainability of palliative care services [ 44 ]. This offers a reference for developing “well-adapted” and inclusive palliative care in rural China—that is, making good use of existing rural health human resources (such as village doctors) and systematically enhancing their core competencies in palliative care, rather than relying solely on establishing new specialized institutions. It should be noted here that rural residents' strong expectation for government support is not a denial of the familism approach. In essence, it reflects the internal logic within their cognitive system of care responsibility gradually spilling over from the family to the state. It is a rational demand for a higher-level “quasi-familial” support system when family resources and capabilities are insufficient. Therefore, the government should assume the primary responsibility for the promotion and implementation of palliative care. In this process, government leadership and support are the key mechanisms to break the dual constraints and achieve the goal of universal benefit. The enjoyment of palliative care services has human rights legitimacy [ 45 ]. Rural residents’ emphasis on the government's leading responsibility in promotion and implementation confirms the proposition of “government-led” within a universal palliative care service system and is an inherent component of a modern health governance system. An international review study points out that government policy support and funding investment, as well as partnerships established with non-governmental organizations (NGOs) and other stakeholders, are key strategies for promoting the sustainable development of rural palliative care [ 46 ]. Currently, rural palliative care lacks complete policy regulations and sustained financial input. Therefore, the government urgently needs to conduct systematic empowerment and functional supplementation through institutional intervention. The ultimate goal is to build a universal palliative care service system led by the government, with families as the main body and rural neighborhoods as important participants, so that it truly becomes a livelihood undertaking safeguarding the dignity of rural residents’ lives. Conclusion The “Rural Good Death Belief” framework constructed in this study is an organic whole comprising “familism” as the core principle, “attachment to native soil” as the life sentiment, “traditional filial piety” as the ethical norm, and “family economic security” as the bottom-line consideration. This belief framework reveals that the development of rural palliative care cannot be a simple transplantation of urban models or Western experiences, but must be deeply rooted in China’s rural social culture. The perceptions and demands of rural residents regarding palliative care, as revealed by this framework, indicate that promoting rural palliative care is a systematic project. It should be grounded in rural traditional views on life and death and the family-centered ethical structure. Through cultural translation and ethical concept transformation, acceptance should be enhanced, and a “family-neighborhood” collaborative home-based care model should be developed. Relying on government leadership to build an inclusive service system, and using institutional empowerment to address the dual constraints of economy and resources, a palliative care system that aligns with rural realities and meets rural residents’ needs for maintaining quality of life and dignity will be gradually established, enabling rural residents to complete their final journey with true dignity. Limitations This study has several limitations. Given China’s vast geographical expanse, large population, and numerous ethnic groups, significant cultural differences exist across regions and ethnicities. Furthermore, uneven economic development leads to a certain degree of heterogeneity among different provinces and regions. Consequently, the findings of this study may only be applicable to some provinces and regions in China and may not generalize to all areas. Declarations Ethical Approval and Informed Consent Ethical approval was granted by the ethics committee of University of Jinan. The research adhered to all research ethics principles stipulated in the Declaration of Helsinki. Before data collection, the researchers explained the study purpose and methods to all participants and assured confidentiality. All participants were informed that they could withdraw from the interview at any time without any consequences. Each participant provided informed consent for the interview in different forms. To protect privacy, participant identities and their villages have been anonymized. Consent for Publication Not applicable. Availability of Data and Materials The data generated during this study are available from the corresponding author upon reasonable request. Competing Interests The authors declare that they have no competing interests. Funding The research was supported by the Talent Introduction Project (Academic Leader Project) in University of Jinan, titled “Exploration of the Construction of Rural Hospice Care in China under the Background of ‘Healthy China’”. Contributions S.S. conducted the data analysis and drafted the manuscript. S.Y. participated in data analysis and manuscript revision. Y.W. designed the overall study, conceptualized the research, and led the data collection, manuscript revision, and finalization. All authors reviewed and approved the final manuscript. Acknowledgements We sincerely thank all research team members and participants for their assistance during the data collection and analysis process. Additionally, we extend our sincere gratitude to Dr. Changhui Song and Dr. Yixi Yang for their valuable insights and constructive feedback throughout this study. References Department of Aging and Health of National Health Commission of the People’s Republic of China. Notice of the General Office of the National Health Commission on carrying out the second palliative pilot project. https://www.nhc.gov.cn/lljks/c100158/201912/511c6cddc8ab4afa850c8fe1b203d1ca.shtml . Accessed August 9 2025. Department of Aging and Health of National Health Commission of the People’s Republic of China. Notice of the General Office of the National Health Commission on carrying out the third palliative pilot project. https://www.nhc.gov.cn/lljks/c100158/202307/709d1b1220914f1f8f1750a63bbfebf8.shtml . Accessed August 9 2025. Lu Y, Gu Y, Yu W. Hospice and Palliative Care in China: Development and Challenges. Asia Pac J Oncol Nurs. 2018;5(1):26–32. Lin H, Huang Y, Wang Y. Facilitators and barriers to palliative care delivery in rural China: a qualitative study of the perceptions and experiences of rural healthcare professionals. BMC Palliat Care. 2025;24(1):211. Council The Office of the Leading Group for the Seventh National Population Census of the State. Key Data from the 2020 Seventh National Population Census. Beijing: China Statistics; 2021. Marshall C, Virdun C, Phillips JL. Evidence-based models of rural palliative care: A systematic review. Palliat Med. 2023;37(8):1129–43. Fasolino T, Mayfield ME, Valentine K, Rosa WE, Koci A. Palliative Care in Rural Communities. Am J Nurs. 2024;124(8):50–5. Xiaotong Fei. From the Soil: The Foundations of Chinese Society. Beijing: People’s Publishing House; 2008. Xiangming Chen. Grounded theory: its train of thought and methods. Educational Res Exp. 1999(04):58–63. Racine L, Fowler-Kerry S, Aiyer H. Integrative review of the needs and challenges of indigenous palliative care in rural and remote settings. J Adv Nurs. 2022;78(9):2693–712. Jing J, Song M. Cuiwen Fa. End-of-Life Reverse Care. CHINESE LIFE AND DEATH STUDIES. 2024(1):19–29. Ruiping Fan. Contemporary Confucian Bioethics. Beijing: Peking University; 2011. Yun YH, Lee MK, Kim SY, Lee WJ, Jung KH, Do YR, et al. Impact of awareness of terminal illness and use of palliative care or intensive care unit on the survival of terminally ill patients with cancer: prospective cohort study. J Clin Oncol. 2011;29(18):2474–80. Dexter KL. Know your community resources. Hospice care at home: an alternative. J Gerontol Nurs. 1980;6(7):410–1. Zhu E, McCreedy E, Teno JM. Bereaved Respondent Perceptions of Quality of Care by Inpatient Palliative Care Utilization in the Last Month of Life. J Gen Intern Med. 2024;39(6):893–901. Salikhanov I, Katapodi MC, Kunirova G, Crape BL. Improving palliative care outcomes in remote and rural areas of LMICs through family caregivers: lessons from Kazakhstan. Front Public Health. 2023;11:1186107. Fereidouni A, Salesi M, Rassouli M, Hosseinzadegan F, Javid M, Karami M, et al. Preferred place of death and end-of-life care for adult cancer patients in Iran: A cross-sectional study. Front Oncol. 2022;12:911397. Apolinarski B, de Jong L, Herbst FA, Huperz C, Röwer HAA, Schneider N, et al. Patients' and Relatives' Preferences for Outpatient and Day Care Services Within End-of-Life Care in Germany - A Discrete Choice Experiment. Patient Prefer Adherence. 2024;18:519–29. Rainsford S, MacLeod RD, Glasgow NJ. Place of death in rural palliative care: A systematic review. Palliat Med. 2016;30(8):745–63. Yuxin Zhou M, Zhou. Guangwei Ji. Death Literacy: A New Public Health Perspective on Hospice and Palliative Care. Med Philos. 2024;45(04):1–5. Cai J, Zhao H, Coyte PC. Socioeconomic Differences and Trends in the Place of Death among Elderly People in China. Int J Environ Res Public Health. 2017;14(10). Wang Z, Zhou N, Lu G. Hospice Care with Chinese Characteristics from the Perspective of Comparison between Chinese and Western Cultures. Chin Med Ethics. 2022;35(02):222–9. Shuming Liang. Essentials of Chinese Culture. Shanghai: Shanghai People’s Publishing House; 2005. Higginson IJ, Sarmento VP, Calanzani N, Benalia H, Gomes B. Dying at home–is it better: a narrative appraisal of the state of the science. Palliat Med. 2013;27(10):918–24. Liangjun, Song. Congwen Su. Studies on the Quality of Death among the Elderly in China:Current Status and Countermeasures. Social Sci Beijing. 2021(06):119–28. Mu M, Ji M. Analysis of the Current State of Palliative Care in China from the Perspective of Sino-Western Cultural Differences. Chin Gen Pract Nurs. 2024;22(17):3220–2. Vargas-Escobar LM, Hernández-Rincón EH, León-Delgado MX, Muñoz-Medina SE, Mantilla-Manoslava N, Correa-Morales JE, et al. Enhancing rural community engagement through palliative care networks: A scoping review. Health Policy. 2024;149:105165. Lei L, Xu X, Lin L, Zhang S, Luo Y. Research progress on quality of death and dying in end of life patients: implication for clinical practice. J Nurs Sci. 2018;33(18):107–10. Ling M, Wang X, Ma Y, Long Y. A Review of the Current State of Hospice Care in China. Curr Oncol Rep. 2020;22(10):99. Zijing Yang X, Shu Y, Zhou Q, Chen. Study on family caregiver’s choice preference of elderly patients death place and its related factors. J Nurses Train. 2023;38(03):193–8. Marshall C, Virdun C, Phillips JL. Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis. Palliat Med. 2024;38(9):935–50. Zafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncol (Williston Park). 2013;27(2):80–1. Zafar SY. Financial Toxicity of Cancer Care: It's Time to Intervene. J Natl Cancer Inst. 2016;108(5). Ting CY, Teh GC, Yu KL, Alias H, Tan HM, Wong LP. Financial toxicity and its associations with health-related quality of life among urologic cancer patients in an upper middle-income country. Support Care Cancer. 2020;28(4):1703–15. Casilla-Lennon MM, Choi SK, Deal AM, Bensen JT, Narang G, Filippou P, et al. Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life. J Urol. 2018;199(5):1166–73. Wang JP, Wu CY, Hwang IH, Kao CH, Hung YP, Hwang SJ, et al. How different is the care of terminal pancreatic cancer patients in inpatient palliative care units and acute hospital wards? A nationwide population-based study. BMC Palliat Care. 2016;15:1. Hung YN, Wen FH, Liu TW, Chen JS, Tang ST. Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage. 2018;55(3):755–e655. Li S, Zhang X, Lv Y, Shen L. A Comparative Study on the Level of Medical Cost Burden between Palliative Care and Non-palliative Care. Med Philos. 2022;43(18):43–6. Yanru Guo Y, Yuan H, Cui X, Ren X, Ji. Zhijing Liu. Possible Measures to Alleviate Financial Toxicity in the Treatment of Critically Ill Patients. Med Philos. 2023;44(14):1–6. Li H, Chen Z, Huangfu H. Study on the Impact of Critical Illness Insurance on Catastrophic Medical Expenditure of Residents. Health Econ Res. 2025;42(03):28–32. Weng K, Shearer J, Grangaard Johnson L. Developing Successful Palliative Care Teams in Rural Communities: A Facilitated Process. J Palliat Med. 2022;25(5):734–41. Cheng Y. Longwen Fu. Building a Universally Accessible Hospice Care System with Chinese Characteristic. 2021-03-17. Cheng Y. Research on the Professional Advantages of Medical Social Work in the Construction of Inclusive Hospice Care System from the Whole Person Care. Social Work Manage. 2024;24(03):1–11. Hamilton-Baillie A, Jenkins LS, Munnings M, Bruinders E, Bekker A. Palliative care in a rural subdistrict in South Africa: A 4-year critical review. Afr J Prim Health Care Fam Med. 2024;16(1):e1–9. Ma Y, Wang J. On the Legitimacy of Promoting Hospice Care in China. J Inner Mongolia Univ (Philosophy Social Sciences). 2024;56(03):66–71. Aregay A, O'Connor M, Stow J, Ayers N, Lee S. Strategies used to establish palliative care in rural low- and middle-income countries: an integrative review. Health Policy Plan. 2020;35(8):1110–29. Additional Declarations No competing interests reported. Supplementary Files Supplementary1.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 02 Apr, 2026 Reviews received at journal 30 Mar, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers agreed at journal 29 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers invited by journal 25 Feb, 2026 Editor invited by journal 13 Feb, 2026 Editor assigned by journal 11 Feb, 2026 Submission checks completed at journal 11 Feb, 2026 First submitted to journal 10 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8846419","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":598671761,"identity":"a3df5eb1-cc9d-4b93-bfaf-49163d26f689","order_by":0,"name":"Shenglong Sun","email":"","orcid":"","institution":"University of Jinan","correspondingAuthor":false,"prefix":"","firstName":"Shenglong","middleName":"","lastName":"Sun","suffix":""},{"id":598671762,"identity":"4e30bc98-eda6-4810-bf09-e1c58a4e0beb","order_by":1,"name":"Shuai Yuan","email":"","orcid":"","institution":"University of Jinan","correspondingAuthor":false,"prefix":"","firstName":"Shuai","middleName":"","lastName":"Yuan","suffix":""},{"id":598671763,"identity":"354af022-37c8-4bdc-b958-22abced18601","order_by":2,"name":"Yunling Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYFADduYDDBIgxgGitTCzJZCshccAwiCkRb7/+ANmnpo7dhsO83yTsNzBIMd3I4HxcwEeLQY3cgyYeY49S95wmHebhOQZBmPJGwnM0jPwaZHgYWDOYTucbADW0saQuOFGAhszDyGH5fwDaeF5BtJST1ALw4EEA+bctsN2QC1sIC0JBoS0gP3yt+9wguRhNmMLyTYJw5lnHjZLE3IY44xvh+35jjc/vC3ZZiPPdzz54Ge8DgNG+w8gkbjgADBqJMCRydiAXwMU2MsD1TF+IErtKBgFo2AUjDQAAA9PSZWwa4lOAAAAAElFTkSuQmCC","orcid":"","institution":"University of Jinan","correspondingAuthor":true,"prefix":"","firstName":"Yunling","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-02-11 02:53:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8846419/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8846419/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103758976,"identity":"5625e1b0-8567-435c-a32a-2095045adcd4","added_by":"auto","created_at":"2026-03-02 14:43:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":395659,"visible":true,"origin":"","legend":"\u003cp\u003eThe “Rural Good Death Belief” Framework\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8846419/v1/dbab6b4b05010d4aae971b9d.jpg"},{"id":104400495,"identity":"8c945747-ddae-4e83-8d64-a5f9442e1ecd","added_by":"auto","created_at":"2026-03-11 12:10:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1440149,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8846419/v1/73d81e7a-8d8e-412f-8914-7c7993a7a6ef.pdf"},{"id":103758977,"identity":"e401fe0a-3409-4d4d-8b30-743dba812a03","added_by":"auto","created_at":"2026-03-02 14:43:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":78778,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8846419/v1/560ebb8dac9c2e59c4ddefac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Study on Rural Chinese Residents’ Perceptions and Demands for Palliative Care within the Framework of “Rural Good Death Belief”","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince 2017, three batches of palliative care pilot projects have been launched nationwide in China, yet these efforts have primarily focused on secondary and tertiary hospitals in urban areas, with insufficient attention paid to rural regions. This has resulted in a development pattern characterized by \u0026ldquo;urban priority and rural lag\u0026rdquo; in the provision of palliative and palliative care in China [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In rural areas, the proportion of residents aged 60 and above and 65 and above is 23.81% and 17.72%, respectively, which is 7.99 and 6.61 percentage points higher than that in urban areas [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], indicating substantial care needs. However, the development of palliative care in rural China remains exploratory [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and many issues require further investigation. Notably, the accessibility challenges of rural palliative care constitute a global issue. A systematic international review points out that nearly half of the world\u0026rsquo;s population resides in rural areas, yet access to palliative care is generally limited due to constrained resources, a shortage of specialized teams, and population dispersion [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; in the United States, rural communities similarly face multiple complex challenges, including accelerated population aging, scarcity of specialized medical resources, geographic isolation, and adverse social determinants of health[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, exploring effective pathways for palliative care in rural settings with limited resources holds broad international practical significance.\u003c/p\u003e \u003cp\u003eAs a developing country with vast rural areas and a profound traditional culture, China\u0026rsquo;s development of rural palliative care not only faces challenges common to rural regions worldwide but also encompasses unique cultural and social dynamics. Adopting a localized perspective, this study seeks to empirically explore rural Chinese residents\u0026rsquo; perceptions and demands regarding palliative care. The findings reveal that rural residents\u0026rsquo; understandings and expectations of palliative care are deeply embedded in the structure and ethics of what Xiaotong Fei [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] described as the \u0026ldquo;rural society\u0026rdquo;. To better understand rural residents\u0026rsquo; end-of-life decision-making behaviors, this study attempts to construct a \u0026ldquo;Rural Good Death Belief\u0026rdquo; framework, which not only describes the phenomena but also explains the cultural logic underlying these perceptions and demands, thereby providing theoretical insights for developing a localized model of palliative care in rural China. Furthermore, this theoretical exploration rooted in the Chinese context can also serve as a reference for understanding the life-and-death perspectives of rural residents in other cultural settings, the role of families in caregiving and decision-making, and their expectations for services. Meanwhile, it will enrich the global scholarly dialogue on palliative care practices and contribute an analytical lens and practical insights to rural areas in countries with similar resource and cultural contexts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003e1. Research Setting and Design\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study was conducted across nine provinces (Shandong, Shanxi, Hebei, Henan, Hubei, Hunan, Guizhou, Sichuan, Fujian) and one municipality (Beijing) in the eastern, central, and western regions of mainland China. Adopting a qualitative research design, it selected rural residents from the aforementioned areas as the study participants. Data were collected using semi-structured interviews and analyzed via the grounded theory method to explore rural Chinese residents\u0026rsquo; perceptions and demands regarding palliative care.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Study Participants\u003c/b\u003e \u003c/p\u003e \u003cp\u003eUsing purposive sampling, researchers contacted potential participants through two approaches. The first approach was to contact staff at local village committees, either in person or by phone, to introduce the study. Once they agreed to assist, these staff members helped connect the researchers with potential participants by providing a brief explanation to foster initial trust. The second approach involved contacting the respondents through family members or acquaintances of the researchers who live in rural areas.\u003c/p\u003e \u003cp\u003e All participants in this study volunteered for the interviews and provided either written informed consent or verbal consent recorded during the interview. The inclusion criteria for participants were as follows: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;40 years old; (2) possession of a rural household registration ; (3) continuous residence in a rural area for at least three years; (4) full consciousness and absence of diagnosed psychiatric disorders; (5) capacity for independent verbal communication; (6) ownership of a legally registered rural homestead; and (7) no urban residential property holdings. A total of 52 completed interview transcripts were collected. After quality screening (excluding records with excessively short duration or where participants were uncooperative with the researchers), a total of 39 high-quality interview transcripts were retained. These comprised 36 individual interviews and 3 focus group interviews (involving 3, 2, and 2 participants respectively), involving a total of 43 rural residents\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Interview Guide\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBased on relevant literature on palliative care and the practical context of rural end-of-life care, a semi-structured in-depth interview outline was developed (Supplementary 1). The outline covered topics including participants\u0026rsquo; personal experiences or knowledge of death events, caregiving experiences, views on life and death, and perceptions of palliative care. Techniques such as clarification, focusing, and probing were employed to elicit in-depth responses and ensure the collection of rich qualitative data.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Data Collection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData collection was from July to September 2024. The research team consisted of university professors, medical professionals, social workers, and graduate and undergraduate students recruited from multiple universities across the country, with experience in qualitative research and/or palliative care. Their disciplines covered medicine, nursing, sociology, and social work. Before data collection, all team members completed a four-day training on the fundamentals of palliative care and qualitative interview techniques.\u003c/p\u003e \u003cp\u003eBefore each interview, the research purpose and the participant\u0026rsquo;s right to withdraw were clearly explained. Upon obtaining consent, interviews were audio-recorded using mobile phones or voice recorders, while handwritten notes captured non-verbal expressions such as gestures and facial expressions. Interviews were conducted in quiet, undisturbed settings, lasting no less than 30 minutes, with an average duration of approximately 57 minutes. Transcripts were produced within 24 hours post-interview. As data collection was conducted simultaneously across the nine provinces and one municipality, data collection and analysis were treated as separate sequential phases; therefore, the principle of data saturation was not applied during the collection stage. During the analysis phase, thematic saturation was reached upon analyzing the 21st transcript. However, considering potential significant differences in economic conditions, cultural concepts, and customs among China\u0026rsquo;s eastern, central, and western regions, the research team chose to analyze all 39 transcripts to capture more nuanced perspectives and details.\u003c/p\u003e \u003cp\u003e \u003cb\u003e5. Research Method and Quality Control\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study employed the grounded theory research method. The Nvivo15 software was used for open coding of the interview data, extracting initial concepts grounded in the data. Subsequently, connections among these initial concepts were identified, leading to the formation of main categories through summarization and condensation. Finally, a systematic synthesis was performed to derive the core category.\u003c/p\u003e \u003cp\u003eDuring the research process, to ensure research reliability and minimize bias, one researcher performed preliminary coding on the de-identified transcripts to establish an initial coding framework. Subsequently, another researcher systematically reviewed the initial coding results. Through iterative discussions, comparisons, and revisions, consensus was reached on the naming, categorization, and attribution of the codes. For codes where disagreements arose, a third researcher joined the discussion until consensus was achieved. Additionally, the accuracy of the coding was continuously reviewed throughout the process, and participants were consulted regarding their intended meanings to enhance the credibility and validity of the study.\u003c/p\u003e "},{"header":"Research Results","content":"\u003cp\u003e \u003cb\u003e1. Demographic Characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe median age of the 43 participants was 62 (range 42\u0026ndash;82). There were 27 female participants (62.8%) and 16 male participants (37.2%). In terms of education, 23 (53.5%) had primary schooling or less, while 20 (46.5%) had attended junior high school or above.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Research Findings\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe 39 interview transcripts were labeled \u0026ldquo;C1-C39\u0026rdquo; and imported into Nvivo15 software. Open codes were extracted from the raw text, with the number of reference points annotated based on the frequency and variation of expressions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Ultimately, 32 open codes were derived, comprising a total of 476 reference points (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAxial Coding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxial Codes (Reference Points)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen Codes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eText Examples(Data sources)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference Points\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViews on Life and Death (89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Cherishing life and fearing death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe older you get, the more you fear death, the more you want to live. (C15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Falling leaves returning to the roots\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFor folks in rural China, they still hold the belief that they ought to be buried in their ancestral hometown when they pass away. (C17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) Life and death as natural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWell, that\u0026rsquo;s life\u0026mdash;everyone goes through birth, old age, sickness and death. It\u0026rsquo;s just the natural order of things; you can\u0026rsquo;t fight it; it\u0026rsquo;s bound to happen. (C11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4) Fearlessness towards death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u0026rsquo;m not afraid. Everyone has to walk this path eventually. On the road to death, there\u0026rsquo;s no young or old. (C16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5) Dying peacefully of old age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhen your time\u0026rsquo;s up, you pass away just like falling asleep, without any pain whatsoever. (C11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6) Fate not being in one's own hands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYou can\u0026rsquo;t call the shots on the fate of your life, and no one can ever really figure out what fate\u0026rsquo;s all about. (C32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7) Death as liberation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce dead, all worries are gone. (C23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of Quality of Life and Dignity (118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Family harmony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily harmony is what brings happiness. (C2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Physical and mental well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood health is the real foundation of a happy and comfortable life. (C37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) Dying without pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhen it really comes to the end, what matters is to pass away painlessly and with dignity. For an elderly person, that\u0026rsquo;s the greatest fortune and their heart\u0026rsquo;s deepest desire. (C17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4) No lack of material resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOf course, material things are indispensable. If you can\u0026rsquo;t even put food on the table or fill your stomach, you certainly can\u0026rsquo;t talk about happiness. (C18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5) Avoiding futile treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhen it truly comes to the final moments of life, they certainly don\u0026rsquo;t want to lose their dignity\u0026mdash;being attached to tubes all over, spending all their money on the hospital for nothing, and still having to leave in the end. (C17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6) Longevity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWe say anyone who lives a long life is blessed. (C11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7) Not being a burden to family and children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTruth be told, not being a burden to your children is the true blessing. (C17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of Medical Care (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Patient care relying on the family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI believe the biggest strength of rural people is their strong family bonds, and family members take excellent care of one another. (C37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Treating to the end to fulfill filial piety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn rural areas now, rural families won\u0026rsquo;t easily give up on treatment. Because living conditions have improved compared to the past, their children are financially capable now and also very filial. Even when a patient is in the advanced stage of illness and doctors say treatment is no longer effective, the children will still insist on continuing it. (C6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) Patient care through neighborhood mutual assistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhen the children get tired from their caregiving sometimes, you can ask the neighbors to come over to accompany the patient and chat a bit together. (C13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4) Prioritizing treatment for the young over the elderly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNowadays, most people spare no effort to treat sick kids no matter what. Their attitude toward the elderly is different, though. Fewer spare no effort to treat them. This is human instinct. (C32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCustoms for Handling Post-Death Matters (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Dying at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt\u0026rsquo;s almost always at their own home for rural families\u0026mdash;passing away outside is considered bad luck. (C14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Family members staying by the dying person\u0026rsquo;s side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn our rural areas, we must stay by their side, no matter when they pass, someone must be there with them. (C13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) Being laid to rest in peace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe deceased finds peace only when interred in the earth. (C22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4) Purchasing burial items and dressing the deceased in burial clothes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce he passed away, we helped buy those things, we went to town to buy the plain clothes, all the clothes for the dead, and the joss money. (C13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5) Not disturbing the deceased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDon\u0026rsquo;t move them when they are dying; they are already in great pain, the soul is separating from the body. If you cry and move them then, they suffer more. Right after death, you shouldn't cry; if you cry, they can\u0026rsquo;t let go and won\u0026rsquo;t depart peacefully. (C15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitudes Toward Palliative Care (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Positive acceptance of palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThis matter of palliative care, now that the state is promoting it, I think it\u0026rsquo;s a good thing and should be strongly supported. (C6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Rejection of palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot very useful, a superficial project, just do some practical action. (C2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfluence of Economic Conditions on Acceptance of Palliative Care (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Poverty hindering rural residents from accepting palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRural folks have no money in hand, the key is having no money. (C33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Accepting palliative care only if costs are low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA small amount of money is acceptable, but none of us are willing or able to afford a large sum, right? (C32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemands for Palliative Care Services (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Hoping for professional service support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think because it\u0026rsquo;s in rural areas, nearby corresponding palliative care facilities are relatively few. Places that actually implement palliative care are almost non-existent. (C20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Expecting home-based care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think palliative care in a hospital is not as convenient as at home. (C35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectations for Government Support and Promotion Policies (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Strengthening policy support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLooking forward to government policies coming through, so there can be professional teams, and we can enjoy this kind of care\u0026mdash;this is also an expectation of ours. (C32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2) Government increasing financial investment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalliative care is good, but it simply won\u0026rsquo;t work out without government funding. (C4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3) Hoping for life-and-death education and palliative care publicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think the government needs to step up publicity, such as playing promotional videos in the villages and holding awareness sessions like they did before, so that everyone can understand what hospice care is all about. (C19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on the connections among the open codes, eight axial codes were inductively formed: \u0026ldquo;Views on Life and Death\u0026rdquo; \u0026ldquo;Awareness of Quality of Life and Dignity\u0026rdquo; \u0026ldquo;Perceptions of Medical Care\u0026rdquo; \u0026ldquo;Customs for Handling Post-Death Matters\u0026rdquo; \u0026ldquo;Attitudes Toward Palliative Care\u0026rdquo; \u0026ldquo;Influence of Economic Status on Acceptance of Palliative Care\u0026rdquo; \u0026ldquo;Demands for Palliative Care Services\u0026rdquo; and \u0026ldquo;Expectations for Government Support and Promotion Policies\u0026rdquo;. Through a systematic analysis of the intrinsic relationships among these eight axial codes, it was found that participants\u0026rsquo; understanding, attitudes, and expectations regarding palliative care revolved around a logical framework characterized by \u0026ldquo;the core principle of \u0026lsquo;familism\u0026rsquo;, the life sentiment of \u0026lsquo;attachment to native soil\u0026rsquo;, the ethical norm of \u0026lsquo;traditional filial piety\u0026rsquo;, and the bottom-line consideration of \u0026lsquo;family economic security\u0026rsquo;\u0026rdquo;. We termed this framework the \u0026ldquo;Rural Good Death Belief\u0026rdquo; framework. Consequently, the final selective coding was determined as \u0026ldquo;Rural Chinese Residents\u0026rsquo; Perceptions and Demands Regarding Palliative Care within the \u0026lsquo;Rural Good Death Belief\u0026rsquo; Framework\u0026rdquo; (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelective Coding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxial Codes (Number of Reference Points)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelective Coding (Total Reference Points)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViews on Life and Death (89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eChinese Rural Residents\u0026rsquo; Perceptions and Demands Regarding Palliative Care within the \u0026ldquo;Rural Good Death Belief\u0026rdquo; Framework (476)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of Quality of Life and Dignity (118)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of Medical Care (85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCustoms for Handling Post-Death Matters (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitudes Toward Palliative Care (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfluence of Economic Conditions on Acceptance of Palliative Care (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemands for Palliative Care Services (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectations for Government Support and Promotion Policies (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(*Note: Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e are presented at the end of this article for clarity. These two tables are located between the end of the second paragraph of \u0026ldquo;2. Research Findings\u0026rdquo; and the heading \u0026ldquo;(1) Views on Life and Death\u0026rdquo; in the \u0026ldquo;Research Results\u0026rdquo; section.)\u003c/p\u003e\n\u003ch3\u003e(1) Views on Life and Death\u003c/h3\u003e\n\u003cp\u003eThe interview data indicate that the prevailing views on life and death among rural Chinese residents are characterized by \u0026ldquo;cherishing life and fearing death\u0026rdquo; and \u0026ldquo;falling leaves return to the root (the desire to return to one\u0026rsquo;s ancestral homeland)\u0026rdquo;. The former manifests as a strong attachment to life and an instinctive aversion to death (C18: \u0026ldquo;People fear death. Death is a great dread for everyone. It\u0026rsquo;s quite natural to fear death.\u0026rdquo;). The latter emphasizes that death should occur in one\u0026rsquo;s homeland, reflecting a traditional perception of the place of death (C13: \u0026ldquo;In rural thinking, it\u0026rsquo;s not good to die outside. One must die at home.\u0026rdquo;). Attaching importance to the connection with a specific place at the end of life is a cross-cultural phenomenon of growing interest in the field of palliative care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The concept of \"returning to one\u0026rsquo;s roots\" among rural Chinese residents is a localized embodiment of this cultural pursuit of the wholeness of life, familial belonging, and spiritual homecoming. Some rural residents expressed a more accepting and philosophical attitude toward death, viewing it as an inevitable outcome of life that requires no fear, citing notions such as \u0026ldquo;dying peacefully of old age\u0026rdquo; \u0026ldquo;fate not being in one\u0026rsquo;s own hands\u0026rdquo; and \u0026ldquo;death as liberation\u0026rdquo;. However, these perspectives were mentioned less frequently, suggesting that such open and accepting views on life and death are not mainstream among rural residents.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e(2) Awareness of Quality of Life and Dignity\u003c/h2\u003e \u003cp\u003eRural residents hold a straightforward yet clear understanding of quality of life and dignity. They place high value on family harmony, filial children, and physical and mental well-being (C2: \u0026ldquo;Having filial children is a blessing. Follow the elderly\u0026rsquo;s wishes and don't upset them\u0026mdash;this is happiness.\u0026rdquo;; C25: \u0026ldquo;What is a blessing? Being healthy and free of illness is the true blessing.\u0026rdquo;). The notion of \u0026ldquo;no lack of material resources\u0026rdquo; indicates they view economic security as the foundation for ensuring quality of life and dignity. \u0026ldquo;Dying without pain\u0026rdquo; \u0026ldquo;avoiding futile treatment\u0026rdquo; and \u0026ldquo;not being a burden to family and children\u0026rdquo; demonstrate that rural residents wish neither to endure unnecessary suffering nor to become a burden on their families. The concept of \u0026ldquo;longevity\u0026rdquo; appeared relatively infrequently. Considering the rejection of palliative care due to economic reasons under the code \u0026ldquo;Attitudes Toward Palliative Care\u0026rdquo; and the influence of economic conditions within the code \u0026ldquo;Influence of Economic Status on Acceptance of Palliative Care\u0026rdquo;, it can be reasonably inferred that rural residents may perceive longevity as a luxury due to constrained living conditions. Of course, it\u0026rsquo;s also possible that some prioritize life quality over mere longevity without quality. Clearly, both quality of life and dignity of life are values recognized by rural residents. However, when realizing these values entails significant economic costs, they may withdraw, indicating the vulnerability of these values for rural residents.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e(3) Perceptions of Medical Care\u003c/h3\u003e\n\u003cp\u003eThe care of patients in rural areas relies primarily on the family, with \u0026ldquo;family-collaborative care\u0026rdquo; being the dominant model. When there is no hope for a patient\u0026rsquo;s recovery, persisting with treatment to demonstrate filial piety remains the primary choice for some rural families (C4: \u0026ldquo;Even if treatment might lead to his death, we cannot just let him stay at home untreated.\u0026rdquo;). However, this behavior is not entirely driven by hope for recovery but rather stems from fulfilling a cultural obligation of filial piety to avoid moral condemnation as \u0026ldquo;unfilial\u0026rdquo; within the close-knit rural community, reflecting the strong influence of social opinion on medical decision-making (C14: \u0026ldquo;If parents themselves have no hope of recovery, reviving them merely prolongs their life by a few days. But if you don\u0026rsquo;t attempt resuscitation, when this gets out, the neighbor will say this son is most unfilial. They fear being called unfilial.\u0026rdquo;). \u0026ldquo;Patient care relying on neighborly mutual assistance\u0026rdquo; was mentioned less frequently, likely related to what Xiaotong Fei described as \u0026ldquo;graded love\u0026rdquo;: who would provide bedside filial piety if not one\u0026rsquo;s own kin? \u0026ldquo;Prioritizing treatment for the young over the elderly\u0026rdquo; was not frequently mentioned, possibly indicating that while this situation exists in rural society, it is not widespread, as deaths among the young due to illness are far less common than among the elderly. Nevertheless, its existence may still suggest a potential intergenerational bias in resource allocation when family resources are limited.\u003c/p\u003e\n\u003ch3\u003e(4) Customs for Handling Post-Death Matters\u003c/h3\u003e\n\u003cp\u003eRural residents exhibit a strong preference for \u0026ldquo;dying at home\u0026rdquo; and hope to \u0026ldquo;be laid to rest in peace\u0026rdquo;, which can be seen as their preferred place of death, reflecting traditional funeral beliefs and aligning with the \u0026ldquo;returning to one's roots\u0026rdquo; \u0026ldquo;view of life and death\u0026rdquo;. \u0026ldquo;Family members staying by the dying person\u0026rsquo;s side\u0026rdquo; emphasizes family reunion at the moment of death, which not only mitigates the dying person\u0026rsquo;s loneliness and fear but also safeguards the integrity of life (C8: \u0026ldquo;When all the children are by their side, it\u0026rsquo;s quite lively, so the dying elderly won\u0026rsquo;t feel terrified or lonely. For life and death are the most important moments in life.\u0026rdquo;). This companionship serves as both emotional support and a ritual farewell. \u0026ldquo;Not disturbing the deceased\u0026rdquo; and \u0026ldquo;purchasing burial items and dressing the deceased in burial clothes\u0026rdquo; represent meticulous care and dignity preservation within rural funeral culture, reflecting rural Chinese residents' adherence to traditional funeral customs. Overall, rural residents\u0026rsquo; handling of post-death matters demonstrates strong familism and local sentiment.\u003c/p\u003e\n\u003ch3\u003e(5) Attitudes Toward Palliative Care\u003c/h3\u003e\n\u003cp\u003eRural residents\u0026rsquo; attitudes toward palliative care are primarily positive acceptance, yet notable reservations exist. They acknowledge the function, value, and service orientation of palliative care, believing it can effectively alleviate the physical and mental suffering of patients and families and is worthy of support. Reservations mainly center on economic and trust aspects, viewing it as meaningless financial waste or a superficial project (C35: \u0026ldquo;Palliative care is acceptable, but it wastes money. It\u0026rsquo;s not that rural folks are short the money on it, but that the money simply isn\u0026rsquo;t worth wasting on it.\u0026rdquo;). Some respondents also expressed resistance to non-family members being involved in care, believing that only family care is reassuring and that outsiders are difficult to trust (C8: \u0026ldquo;If an outsider comes to take care of the elder, we\u0026rsquo;ll feel uneasy. We think outsiders can\u0026rsquo;t do this job, because it\u0026rsquo;s something only their own children should do.\u0026rdquo;; C3: \u0026ldquo;When outsiders come over, no matter how well they speak, they just can\u0026rsquo;t create that genuine spiritual resonance.\u0026rdquo;). This stems firstly from wariness and trust barriers regarding non-family involvement, fearing \u0026ldquo;outsiders\u0026rdquo; may not be as dedicated or might breach family privacy. Secondly, it stems from the inherent reliance on and emotional identification with family care influenced by the aforementioned views, considering caring for a dying family member an inescapable duty of children and a crucial way to express familial love. Entrusting this to outsiders can generate feelings of emotional deficit and discomfort.\u003c/p\u003e\n\u003ch3\u003e(6) Influence of Economic Status on Acceptance of Palliative Care\u003c/h3\u003e\n\u003cp\u003eInterview data show that \u0026ldquo;poverty hinders rural residents from accepting palliative care\u0026rdquo;, indicating economic conditions are a key constraining factor. For rural residents with limited income, medical expenditures are often prioritized for curative treatments; their willingness to pay for palliative care services that primarily provide comfort is not high (C37: \u0026ldquo;Long-term treatment and care costs are difficult for many rural families to bear.\u0026rdquo;). \u0026ldquo;Only accepting palliative care if costs are low\u0026rdquo; demonstrates rural residents\u0026rsquo; high sensitivity to palliative care expenses; they weigh the cost-effectiveness of different treatment options (C15: \u0026ldquo;As long as palliative care costs less than that conventional treatment, I think it should be acceptable.\u0026rdquo;). Therefore, service affordability is a crucial prerequisite for rural residents to accept palliative care.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e(7) Demands for Palliative Care Services\u003c/h2\u003e \u003cp\u003eBased on rural customs, rural residents expect to receive palliative care services at home (C14: \u0026ldquo;It\u0026rsquo;s a common custom in rural areas for people to recover from illness and spend their last days at home.\u0026rdquo;). Their primary demands focus on eight aspects: \u0026ldquo;pain control\u0026rdquo;, \u0026ldquo;professional knowledge\u0026rdquo;, \u0026ldquo;personnel supply\u0026rdquo;, \u0026ldquo;medical resources\u0026rdquo;, \u0026ldquo;respite services\u0026rdquo;, \u0026ldquo;companionship services\u0026rdquo;, \u0026ldquo;home-visit services\u0026rdquo;, and \u0026ldquo;spiritual care\u0026rdquo;. The root of their preference for home-based services is twofold. Firstly, patients feel more secure in a familiar environment (C5: \u0026ldquo;Elderly people prefer being at home more, where they feel safe and have someone to rely on.\u0026rdquo;), making it easier to maintain daily habits and social networks, which helps reduce physical and mental stress. Secondly, home care offers convenience (C12: \u0026ldquo;Oh, I think it\u0026rsquo;s more convenient at home than in an institution. You know, going to the hospital is just like being in prison; even a healthy person would be worn out after just a few days there.\u0026rdquo;), eliminating the hassle of traveling to and from hospitals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e(8) Expectations for Government Support and Promotion Policies\u003c/h3\u003e\n\u003cp\u003eMedical resources are scarce in rural areas, and palliative care resources are particularly lacking. Rural residents have fragile economic conditions, making it difficult to afford palliative care costs. They hope the government will introduce policies, strengthen financial investment, ensure the implementation and promotion of palliative care in rural areas, and simultaneously strive to lessen the individual economic burden on villagers (C4: \u0026ldquo;In my view, if rural areas want to have such palliative care conditions, the government must invest real funds in it.\u0026rdquo;). They also emphasize the need to enhance rural residents\u0026rsquo; understanding and awareness of life through publicity and education, thereby clearing obstacles for the popularization of palliative care in rural areas (C19: \u0026ldquo;I think the government needs to step up publicity, such as playing promotional videos in the villages and holding awareness sessions like they did before, so that everyone can understand what hospice care is all about.\u0026rdquo;). This essentially reflects an expectation for the government to play a leading role in promoting rural palliative care development.\u003c/p\u003e \u003cp\u003eAbove all, the perceptions and demands of rural residents towards palliative care present a complex picture interwoven with traditional concepts and current conditions. Their views on life and death are mainly characterized by \u0026ldquo;cherishing life and fearing death\u0026rdquo; and \u0026ldquo;falling leaves returning to the roots\u0026rdquo;. They attach great importance to family harmony and filial piety of their children. In terms of care, they strongly rely on their families and are deeply influenced by the ethics and obligations of filial piety. This has led to a certain recognition of the value of palliative care, believing that it can alleviate pain and maintain dignity. However, there are also significant concerns: on the one hand, economic vulnerability makes cost a key constraint, and the willingness to pay often gives way to the priority consideration of survival medical care; On the other hand, the trust barriers towards caregivers outside the family, the sensitivity to the cultural pressure of \u0026ldquo;filial piety\u0026rdquo;, and the preference for places to \u0026ldquo;pass away at home\u0026rdquo; all reflect a deep family-oriented tradition and a strong sense of nostalgia for one\u0026rsquo;s native land. On this basis, the demands of rural residents clearly point to home-based palliative care services and they strongly expect government intervention. Overall, the process of rural residents\u0026rsquo; acceptance of palliative care is essentially a process of collision and adjustment among their traditional bioethics, real economic rationality and modern palliative care concepts. To promote the development of rural palliative care, it is necessary to deeply respect and integrate the internal logic of the \u0026ldquo;Rural Good Death Belief\u0026rdquo; framework, and strive to break through the dual constraints of economic feasibility and social trust. Only in this way can the vision of a \u0026ldquo;good death\u0026rdquo; in the final stage of life be truly realized.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study adopts the perspective of rural residents and employs a qualitative research method through semi-structured in-depth interviews. Using grounded theory analysis, it attempts to clarify the perceptions and demands of rural Chinese residents regarding palliative care and the underlying reasons behind them. The perceptions and demands of rural residents towards palliative care are not isolated; rather, they form an organic cognitive system closely interconnected by a fundamental underlying logic. This logic is constructed with \u0026ldquo;familism\u0026rdquo; as the core principle, \u0026ldquo;attachment to native soil\u0026rdquo; as the life sentiment, \u0026ldquo;traditional filial piety\u0026rdquo; as the ethical norm, and \u0026ldquo;family economic security\u0026rdquo; as the bottom-line consideration, thereby forming the framework of the \u0026ldquo;Rural Good Death Belief\u0026rdquo;. This framework reveals the realistic constraints shaping perceptions of palliative care in rural China and provides an important factual basis for constructing the rural palliative care system (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e1. \u0026ldquo;Familism\u0026rdquo; as the Core Principle\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe core principle of \u0026ldquo;familism\u0026rdquo; within the \u0026ldquo;Rural Good Death Belief\u0026rdquo; framework profoundly shapes rural residents\u0026rsquo; cognitive pathways and service preferences regarding palliative care. Under this principle, the family is not only the unit of daily life but also the fundamental unit responsible for caregiving and medical decision-making. Analysis of the interview data reveals that the \u0026ldquo;good death\u0026rdquo; and \u0026ldquo;dignity\u0026rdquo; pursued by rural residents are essentially a form of \u0026ldquo;dignity within the family\u0026rdquo; - fulfilling family responsibilities and avoiding becoming a heavy burden to one\u0026rsquo;s children. That is, for rural residents, dignity is achieved by raising children to adulthood, helping them establish families and careers, and then aging and dying without becoming a financial or caregiving burden to other family members, especially one\u0026rsquo;s children. Clearly, this sense of dignity among rural residents inherently involves a reverse care for their family members [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, from the caregivers\u0026rsquo; perspective, whether driven by traditional filial piety or concern for social opinion, caring for an ill family member is an inescapable duty, at least in form.\u003c/p\u003e \u003cp\u003eThe aforementioned care logic and value orientation jointly determine the unshakable core position of the family in the rural care system and profoundly influence the integration path of palliative care services. On one hand, the family is the core bearer of care responsibility and emotional comfort. Rural residents generally hold a cautious attitude towards the involvement of non-family members in care and prefer home-based care. This care preference is deeply bound to ethical responsibility, demonstrating the profound influence of Confucian familism in rural areas [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, developing a home-based palliative care model holds greater cultural affinity for rural residents and is more likely to gain their psychological acceptance, while also compensating for the shortage of formal care resources. In fact, this aligns with the global trend where palliative care is predominantly home-based [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], representing an important experience and consensus in worldwide palliative care development: a study based on national data in the United States indicates that decedents who received palliative care at home during the last month of life had significantly higher quality of care ratings than those who died in other settings such as hospitals or inpatient hospice units [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]; a study in Kazakhstan also indicates that the family is the primary and most sustainable source of care provision in contexts where formal care resources are lacking [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]; a cross-sectional study of adult cancer patients in Iran showed that 69.9% of patients preferred home as their primary place for end-of-life care, and 75.2% chose home as their preferred place of death [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]; a discrete choice experiment in Germany indicated that terminally ill patients and their families were more inclined to choose home as the preferred care location, with families willing to bear higher costs than for institutional care to ensure their ill family member received the highest level of home care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]; an international systematic review on place of death in rural palliative care further confirms that home is universally preferred by rural residents as the location of death, although in reality the majority of deaths still occur in hospitals, highlighting the global gap between preferences and the accessibility of services in reality [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, this family-dependent care model also brings corresponding pressure to family members. Therefore, to alleviate family caregiving pressure and improve care quality, future system construction must seek to transcend the sole reliance on the family. Given the current situation where rural social networks have not been fully transformed into effective care resources and considering the concept of public health palliative care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], inherent social capital in rural areas should be converted into effective care resources, with efforts focused on building rural neighborhood mutual assistance networks. However, simply introducing the Western concept of \u0026ldquo;community\u0026rdquo; or advocating for universal neighborhood mutual assistance may encounter deep-seated socio-psychological and cultural barriers in practical implementation. Therefore, the building blocks of the mutual assistance network can be positioned within kinship-based family networks and quasi-kinship neighborhood acquaintances, rather than the abstract \u0026ldquo;community\u0026rdquo;. In villages severely affected by the outflow of young and middle-aged adults, efforts should focus on identifying and training potential local forces such as left-behind middle-aged individuals, healthy low-age elderly, and returnees. Through systematic training and support, informal community mutual assistance forces can be transformed into professional auxiliary care resources, ultimately building a new model of home-based palliative care with Chinese characteristics, featuring \u0026ldquo;family self-care as the mainstay, supplemented effectively by neighborhood mutual assistance\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. \u0026ldquo;Attachment to Native Soil\u0026rdquo; as the Life Sentiment\u003c/b\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;Attachment to native soil\u0026rdquo; as the core embodiment of rural residents\u0026rsquo; life sentiment, profoundly influences their understanding of life\u0026rsquo;s belonging and their choice of place of death. This emotion manifests not only as a spatial attachment to one\u0026rsquo;s homeland and family but is also internalized as a cultural psychology that pursues the integrity of life and the realization of social and spatial return. \u0026ldquo;Cherishing life and fearing death\u0026rdquo; and \u0026ldquo;falling leaves returning to the roots\u0026rdquo; together constitute the dual dimensions of this sentiment: the former reflects a strong attachment to the continuation of life, while the latter points to the cultural persistence of belonging to the homeland and returning to the family. Cai et al. (2017) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] believe that, influenced by the traditional Chinese culture of \u0026ldquo;returning to the roots\u0026rdquo; and the physical/emotional comfort, security, and sense of belonging that \u0026ldquo;home\u0026rdquo; brings to the dying, the majority of elderly people prefer to pass away at home. In China, the family is the core of social life. Influenced by the traditional Chinese agricultural culture centered on the family unit, people\u0026rsquo;s birth, aging, illness, death, and the inheritance of life cannot be separated from family interdependence, emphasizing the companionship of family, relatives and friends at life's end [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, in traditional funeral customs, \u0026ldquo;home\u0026rdquo; or \u0026ldquo;native land\u0026rdquo; holds extremely high symbolic significance as an end-of-life setting: \u0026ldquo;family members staying by the dying person\u0026rsquo;s side\u0026rdquo; is seen as safeguarding life\u0026rsquo;s integrity, \u0026ldquo;dying at home\u0026rdquo; is endowed with special symbolic meaning, and \u0026ldquo;being laid to rest in peace\u0026rdquo; is considered the ultimate ideal destination of life. Higginson et al (2013) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] also propose that the family, as a familiar environment for patients, allows them to maintain autonomy and greater freedom and enables them to face death calmly. This suggests that when promoting palliative care in rural areas, it is necessary to fully consider rural residents\u0026rsquo; cultural preferences regarding the place of death and their life sentiment of \u0026ldquo;attachment to native soil\u0026rdquo;, embedding service scenarios into contexts related to family and hometown to achieve \u0026ldquo;a peaceful farewell in a familiar place\u0026rdquo;.\u003c/p\u003e \u003cp\u003eHowever, \u0026ldquo;attachment to native soil\u0026rdquo; also carries a certain cultural tension. The notion of \u0026ldquo;cherishing life and fearing death\u0026rdquo; can easily lead rural residents to simplistically view death as a malignant event that ends life rather than the natural conclusion of the life process. Furthermore, palliative care emphasizes not treating the patient\u0026rsquo;s primary disease. This concept may cause some rural residents to misunderstand palliative care as giving up treatment, which they may find difficult to accept, leading to resistance. The traditional concept of \u0026ldquo;valuing life over death\u0026rdquo; still holds considerable cultural influence in today\u0026rsquo;s society. People\u0026rsquo;s taboo and avoidance of death reduce their initiative to understand and approach it from a rational, scientific perspective [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Confucius\u0026rsquo;s saying, \u0026ldquo;If you cannot serve people, how can you serve ghosts?\u0026rdquo; originally meant to pursue the meaning and value of life and temporarily not consider the issue of death; however, in the course of its transmission, this concept of being cautious about death after valuing life gradually evolved into the cultural root of the Chinese people\u0026rsquo;s taboo and fear of death [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This reflects, on one hand, a deficiency in life education in rural areas and, on the other hand, insufficient awareness of palliative care among rural residents, constituting a cultural obstacle to the promotion of palliative care in rural areas. Nonetheless, rural residents also hold an open-minded view that death is a natural law of life and thus need not be feared. Rural residents holding this view may be more likely to understand that palliative care is not a denial of life but an important way to help patients spend their final days with quality and dignity. This lays a potential foundation of acceptance for promoting palliative care in rural areas.\u003c/p\u003e \u003cp\u003eThe seemingly contradictory cognitive phenomena mentioned above precisely reveal the complexity and key entry point for promoting rural palliative care. That is, promotional efforts should not simply adopt a \u0026ldquo;cultural substitution\u0026rdquo; strategy but should seek \u0026ldquo;cultural translation\u0026rdquo;, transforming the professional concepts of palliative care into local concepts easily understood by rural residents and connecting them with traditional end-of-life pursuits such as \u0026ldquo;returning to the roots\u0026rdquo;. On the basis of respecting \u0026ldquo;attachment to native soil\u0026rdquo;, a gradual adjustment of life-and-death concepts should be achieved, thereby transforming rural residents\u0026rsquo; cultural and practical pursuit of a \u0026ldquo;good death\u0026rdquo; into the internal driving force for accepting professional palliative care services. Furthermore, while respecting the life sentiment of \u0026ldquo;attachment to homeland\u0026rdquo; and embedding services within families and native soil, it is essential to acknowledge the heterogeneity within rural communities. International research indicates that one of the core principles of successful rural palliative care networks is the recognition of the unique differences among various rural communities in terms of social structures, cultural practices, and resource endowments. Such networks should adopt participatory approaches\u0026mdash;such as collaborating with experienced elders and knowledge bearers\u0026mdash;to co-create service programs that align with the spiritual and cultural practices of each community [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Therefore, in promoting rural palliative care in China, it is also necessary to guard against oversimplifying and universally applying \u0026ldquo;rural culture\u0026rdquo;. Instead, based on personalized in-depth assessments, diverse and localized service embedding models should be developed.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. \u0026ldquo;Traditional Filial Piety\u0026rdquo; as the Ethical Norm\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTraditional filial piety, as an important ethical norm in rural society, profoundly influences the medical decisions and behavioral choices of rural residents. The research finds that the concept of \u0026ldquo;treating to the end to fulfill filial piety\u0026rdquo; among rural residents is not merely a medical decision but rather a strategy to cope with the public opinion pressure of traditional \u0026ldquo;filial piety\u0026rdquo; : Under the influence of traditional filial piety, when family members make decisions for terminal-stage patients, driven by moral responsibility, they often believe that active treatment is the right choice; therefore, they frequently choose to do their utmost to save the patient\u0026rsquo;s life, disregarding the patient\u0026rsquo;s quality of life [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This decision-making model derived from filial piety ethics has formed a powerful informal normative system within the rural social environment. In the context of a rural acquaintance society, \u0026ldquo;filial piety\u0026rdquo; is not only a personal virtue and family ethic but also an important form of moral capital and a criterion for social evaluation. This external moral pressure often causes medical decisions to deviate from the patient-centered principle of palliative care, instead serving the cultural performance of \u0026ldquo;filial piety\u0026rdquo; and the maintenance of community identity.\u003c/p\u003e \u003cp\u003eThe perception of \u0026ldquo;continuing treatment at all costs\u0026rdquo; identified in this study within Chinese rural contexts stems primarily from the ethics of filial piety and the moral pressures inherent to rural society, often manifesting as a preference for extending aggressive treatment. In contrast, a systematic review by Marshall et al. (2024) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] focusing on rural palliative care models in countries such as Australia and Canada indicates that patients and families there generally desire earlier and more timely access to strategically integrated specialist palliative care teams, recognizing that this helps alleviate caregiving burdens and enhance quality of life in the terminal phase. This discrepancy underscores how socio‑cultural contexts and healthcare‑system frameworks profoundly shape end‑of‑life decision‑making patterns. From this perspective, there is an obvious ethical tension between traditional filial piety and palliative care. To alleviate this tension, on one hand, the ethical legitimacy of palliative care can be explained using the discourse of \u0026ldquo;filial piety\u0026rdquo;, emphasizing that \u0026ldquo;allowing a loved one to pass away peacefully\u0026rdquo; is also an expression of filial piety. On the other hand, through life-and-death education and publicity, promote the transformation of the concept of filial piety from \u0026ldquo;treating to the end to fulfill filial piety\u0026rdquo; to \u0026ldquo;providing comfort to the patient is filial piety\u0026rdquo; in modern times, advocate new concepts such as \u0026ldquo;alleviating a loved one\u0026rsquo;s pain is a higher level of filial piety\u0026rdquo;, and create a favorable ethical environment for promoting palliative care in rural areas.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. \u0026ldquo;Family Economic Security\u0026rdquo; as the Bottom-Line Consideration\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn end-of-life decision-making choices regarding palliative care, rural residents take \u0026ldquo;family economic security\u0026rdquo; as the fundamental consideration. This consideration is reflected not only in high sensitivity to the cost of palliative care but also in the economic rationality of their medical decision-making. However, this rational choice exhibits a certain complexity: on one hand, some families, driven by filial piety ethics, will \u0026ldquo;treat to the end\u0026rdquo;, often sparing no expense for active treatment; on the other hand, they show obvious concerns about the cost of palliative care services. This seemingly contradictory behavior precisely reflects insufficient understanding of palliative care among rural residents. The concept of \u0026ldquo;financial toxicity\u0026rdquo; proposed by Zafar et al (2013) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] describes the dual burden that high medical expenses impose on patients and their families. Some studies point out that high financial toxicity is significantly associated with low quality of life [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Palliative care can reduce hospitalization costs for terminal-stage patients and is the most important factor in lowering financial toxicity for advanced patients [\u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Due to lower income, lower education levels, and information isolation, rural residents tend to be more conservative in medical consumption. When illness occurs, they are unable to make the most economical and effective medical choices, leading to aggravated health problems, higher medical expenses [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and further exacerbation of their economic vulnerability.\u003c/p\u003e \u003cp\u003eFragile economic affordability and scarce medical resources together constitute a dual structural bottleneck restricting the development of rural palliative care. Specifically, economic pressure is the core factor hindering rural residents from accepting palliative care services. Therefore, the \u0026ldquo;affordability\u0026rdquo; of service fees is a prerequisite for the long-term development of rural palliative care. Due to lower income and limited conditions, rural residents often face a higher risk of catastrophic health expenditure compared to urban residents. With limited income, rural residents\u0026rsquo; medical expenditures are primarily based on cost-effectiveness considerations. The cost of receiving palliative care services is unaffordable for many rural families, meaning that even if they recognize the value of palliative care services, the \u0026ldquo;economic pressure\u0026rdquo; may outweigh positive willingness. Economic pressure is a universal bottleneck constraining the development of palliative care in rural areas. A study on rural palliative care in the United States indicates that flexible reimbursement mechanisms and financial support are key drivers for implementing palliative care in rural communities [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Resource shortage is another constraining factor. Rural residents have clear demands and expectations for professional palliative care services. However, due to insufficient medical resources in rural areas, a lack of professional palliative care talent, and limited home-visit service capacity, the accessibility and professionalism of services are further restricted. This dual constraint of economy and resources objectively requires that rural palliative care must follow a development path of \u0026ldquo;low cost and strong adaptability\u0026rdquo;. This path aligns with Cheng Yu\u0026rsquo;s concept of \u0026ldquo;inclusive palliative care\u0026rdquo;, which emphasizes meeting the needs of terminal patients at low cost, wide coverage, and high quality, as well as service fairness, accessibility, and universal welfare, to achieve attention to the entire life cycle and health process [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, we must recognize that under the premise of limited resources, emphasizing \u0026ldquo;low cost\u0026rdquo; makes it difficult to achieve \u0026ldquo;high quality\u0026rdquo;, and promoting \u0026ldquo;high quality\u0026rdquo; makes it difficult to achieve \u0026ldquo;low cost\u0026rdquo;. To date, how to effectively balance the two, truly transform palliative care into a livelihood service within reach of rural residents, and achieve a virtuous cycle of \u0026ldquo;economic accessibility - resource matching - demand satisfaction\u0026rdquo; remains a topic worthy of in-depth exploration and continuous optimization. A study from South Africa indicates that under resource-constrained conditions, training community health workers, integrating existing non-governmental organization networks, and leveraging collaborative services from primary health clinics can effectively enhance the accessibility and sustainability of palliative care services [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This offers a reference for developing \u0026ldquo;well-adapted\u0026rdquo; and inclusive palliative care in rural China\u0026mdash;that is, making good use of existing rural health human resources (such as village doctors) and systematically enhancing their core competencies in palliative care, rather than relying solely on establishing new specialized institutions.\u003c/p\u003e \u003cp\u003eIt should be noted here that rural residents' strong expectation for government support is not a denial of the familism approach. In essence, it reflects the internal logic within their cognitive system of care responsibility gradually spilling over from the family to the state. It is a rational demand for a higher-level \u0026ldquo;quasi-familial\u0026rdquo; support system when family resources and capabilities are insufficient. Therefore, the government should assume the primary responsibility for the promotion and implementation of palliative care. In this process, government leadership and support are the key mechanisms to break the dual constraints and achieve the goal of universal benefit. The enjoyment of palliative care services has human rights legitimacy [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Rural residents\u0026rsquo; emphasis on the government's leading responsibility in promotion and implementation confirms the proposition of \u0026ldquo;government-led\u0026rdquo; within a universal palliative care service system and is an inherent component of a modern health governance system. An international review study points out that government policy support and funding investment, as well as partnerships established with non-governmental organizations (NGOs) and other stakeholders, are key strategies for promoting the sustainable development of rural palliative care [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Currently, rural palliative care lacks complete policy regulations and sustained financial input. Therefore, the government urgently needs to conduct systematic empowerment and functional supplementation through institutional intervention. The ultimate goal is to build a universal palliative care service system led by the government, with families as the main body and rural neighborhoods as important participants, so that it truly becomes a livelihood undertaking safeguarding the dignity of rural residents\u0026rsquo; lives.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The \u0026ldquo;Rural Good Death Belief\u0026rdquo; framework constructed in this study is an organic whole comprising \u0026ldquo;familism\u0026rdquo; as the core principle, \u0026ldquo;attachment to native soil\u0026rdquo; as the life sentiment, \u0026ldquo;traditional filial piety\u0026rdquo; as the ethical norm, and \u0026ldquo;family economic security\u0026rdquo; as the bottom-line consideration. This belief framework reveals that the development of rural palliative care cannot be a simple transplantation of urban models or Western experiences, but must be deeply rooted in China\u0026rsquo;s rural social culture. The perceptions and demands of rural residents regarding palliative care, as revealed by this framework, indicate that promoting rural palliative care is a systematic project. It should be grounded in rural traditional views on life and death and the family-centered ethical structure. Through cultural translation and ethical concept transformation, acceptance should be enhanced, and a \u0026ldquo;family-neighborhood\u0026rdquo; collaborative home-based care model should be developed. Relying on government leadership to build an inclusive service system, and using institutional empowerment to address the dual constraints of economy and resources, a palliative care system that aligns with rural realities and meets rural residents\u0026rsquo; needs for maintaining quality of life and dignity will be gradually established, enabling rural residents to complete their final journey with true dignity.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. Given China\u0026rsquo;s vast geographical expanse, large population, and numerous ethnic groups, significant cultural differences exist across regions and ethnicities. Furthermore, uneven economic development leads to a certain degree of heterogeneity among different provinces and regions. Consequently, the findings of this study may only be applicable to some provinces and regions in China and may not generalize to all areas.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Informed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the ethics committee of University of Jinan. The research adhered to all research ethics principles stipulated in the Declaration of Helsinki. Before data collection, the researchers explained the study purpose and methods to all participants and assured confidentiality. All participants were informed that they could withdraw from the interview at any time without any consequences. Each participant provided informed consent for the interview in different forms. To protect privacy, participant identities and their villages have been anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was supported by the Talent Introduction Project (Academic Leader Project) in University of Jinan, titled \u0026ldquo;Exploration of the Construction of Rural Hospice Care in China under the Background of \u0026lsquo;Healthy China\u0026rsquo;\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.S. conducted the data analysis and drafted the manuscript. S.Y. participated in data analysis and manuscript revision. Y.W. designed the overall study, conceptualized the research, and led the data collection, manuscript revision, and finalization. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all research team members and participants for their assistance during the data collection and analysis process. Additionally, we extend our sincere gratitude to Dr. Changhui Song and Dr. Yixi Yang for their valuable insights and constructive feedback throughout this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDepartment of Aging and Health of National Health Commission of the People\u0026rsquo;s Republic of China. Notice of the General Office of the National Health Commission on carrying out the second palliative pilot project. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nhc.gov.cn/lljks/c100158/201912/511c6cddc8ab4afa850c8fe1b203d1ca.shtml\u003c/span\u003e\u003cspan address=\"https://www.nhc.gov.cn/lljks/c100158/201912/511c6cddc8ab4afa850c8fe1b203d1ca.shtml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed August 9 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Aging and Health of National Health Commission of the People\u0026rsquo;s Republic of China. Notice of the General Office of the National Health Commission on carrying out the third palliative pilot project. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nhc.gov.cn/lljks/c100158/202307/709d1b1220914f1f8f1750a63bbfebf8.shtml\u003c/span\u003e\u003cspan address=\"https://www.nhc.gov.cn/lljks/c100158/202307/709d1b1220914f1f8f1750a63bbfebf8.shtml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed August 9 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu Y, Gu Y, Yu W. Hospice and Palliative Care in China: Development and Challenges. Asia Pac J Oncol Nurs. 2018;5(1):26\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin H, Huang Y, Wang Y. Facilitators and barriers to palliative care delivery in rural China: a qualitative study of the perceptions and experiences of rural healthcare professionals. BMC Palliat Care. 2025;24(1):211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCouncil The Office of the Leading Group for the Seventh National Population Census of the State. Key Data from the 2020 Seventh National Population Census. Beijing: China Statistics; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarshall C, Virdun C, Phillips JL. Evidence-based models of rural palliative care: A systematic review. Palliat Med. 2023;37(8):1129\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFasolino T, Mayfield ME, Valentine K, Rosa WE, Koci A. Palliative Care in Rural Communities. Am J Nurs. 2024;124(8):50\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiaotong Fei. From the Soil: The Foundations of Chinese Society. Beijing: People\u0026rsquo;s Publishing House; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiangming Chen. Grounded theory: its train of thought and methods. Educational Res Exp. 1999(04):58\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRacine L, Fowler-Kerry S, Aiyer H. Integrative review of the needs and challenges of indigenous palliative care in rural and remote settings. J Adv Nurs. 2022;78(9):2693\u0026ndash;712.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJing J, Song M. Cuiwen Fa. End-of-Life Reverse Care. CHINESE LIFE AND DEATH STUDIES. 2024(1):19\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuiping Fan. Contemporary Confucian Bioethics. Beijing: Peking University; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYun YH, Lee MK, Kim SY, Lee WJ, Jung KH, Do YR, et al. Impact of awareness of terminal illness and use of palliative care or intensive care unit on the survival of terminally ill patients with cancer: prospective cohort study. J Clin Oncol. 2011;29(18):2474\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDexter KL. Know your community resources. Hospice care at home: an alternative. J Gerontol Nurs. 1980;6(7):410\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu E, McCreedy E, Teno JM. Bereaved Respondent Perceptions of Quality of Care by Inpatient Palliative Care Utilization in the Last Month of Life. J Gen Intern Med. 2024;39(6):893\u0026ndash;901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalikhanov I, Katapodi MC, Kunirova G, Crape BL. Improving palliative care outcomes in remote and rural areas of LMICs through family caregivers: lessons from Kazakhstan. Front Public Health. 2023;11:1186107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFereidouni A, Salesi M, Rassouli M, Hosseinzadegan F, Javid M, Karami M, et al. Preferred place of death and end-of-life care for adult cancer patients in Iran: A cross-sectional study. Front Oncol. 2022;12:911397.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApolinarski B, de Jong L, Herbst FA, Huperz C, R\u0026ouml;wer HAA, Schneider N, et al. Patients' and Relatives' Preferences for Outpatient and Day Care Services Within End-of-Life Care in Germany - A Discrete Choice Experiment. Patient Prefer Adherence. 2024;18:519\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRainsford S, MacLeod RD, Glasgow NJ. Place of death in rural palliative care: A systematic review. Palliat Med. 2016;30(8):745\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuxin Zhou M, Zhou. Guangwei Ji. Death Literacy: A New Public Health Perspective on Hospice and Palliative Care. Med Philos. 2024;45(04):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai J, Zhao H, Coyte PC. Socioeconomic Differences and Trends in the Place of Death among Elderly People in China. Int J Environ Res Public Health. 2017;14(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z, Zhou N, Lu G. Hospice Care with Chinese Characteristics from the Perspective of Comparison between Chinese and Western Cultures. Chin Med Ethics. 2022;35(02):222\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShuming Liang. Essentials of Chinese Culture. Shanghai: Shanghai People\u0026rsquo;s Publishing House; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHigginson IJ, Sarmento VP, Calanzani N, Benalia H, Gomes B. Dying at home\u0026ndash;is it better: a narrative appraisal of the state of the science. Palliat Med. 2013;27(10):918\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiangjun, Song. Congwen Su. Studies on the Quality of Death among the Elderly in China:Current Status and Countermeasures. Social Sci Beijing. 2021(06):119\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMu M, Ji M. Analysis of the Current State of Palliative Care in China from the Perspective of Sino-Western Cultural Differences. Chin Gen Pract Nurs. 2024;22(17):3220\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVargas-Escobar LM, Hern\u0026aacute;ndez-Rinc\u0026oacute;n EH, Le\u0026oacute;n-Delgado MX, Mu\u0026ntilde;oz-Medina SE, Mantilla-Manoslava N, Correa-Morales JE, et al. Enhancing rural community engagement through palliative care networks: A scoping review. Health Policy. 2024;149:105165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLei L, Xu X, Lin L, Zhang S, Luo Y. Research progress on quality of death and dying in end of life patients: implication for clinical practice. J Nurs Sci. 2018;33(18):107\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLing M, Wang X, Ma Y, Long Y. A Review of the Current State of Hospice Care in China. Curr Oncol Rep. 2020;22(10):99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZijing Yang X, Shu Y, Zhou Q, Chen. Study on family caregiver\u0026rsquo;s choice preference of elderly patients death place and its related factors. J Nurses Train. 2023;38(03):193\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarshall C, Virdun C, Phillips JL. Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis. Palliat Med. 2024;38(9):935\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncol (Williston Park). 2013;27(2):80\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZafar SY. Financial Toxicity of Cancer Care: It's Time to Intervene. J Natl Cancer Inst. 2016;108(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTing CY, Teh GC, Yu KL, Alias H, Tan HM, Wong LP. Financial toxicity and its associations with health-related quality of life among urologic cancer patients in an upper middle-income country. Support Care Cancer. 2020;28(4):1703\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasilla-Lennon MM, Choi SK, Deal AM, Bensen JT, Narang G, Filippou P, et al. Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life. J Urol. 2018;199(5):1166\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang JP, Wu CY, Hwang IH, Kao CH, Hung YP, Hwang SJ, et al. How different is the care of terminal pancreatic cancer patients in inpatient palliative care units and acute hospital wards? A nationwide population-based study. BMC Palliat Care. 2016;15:1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHung YN, Wen FH, Liu TW, Chen JS, Tang ST. Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage. 2018;55(3):755\u0026ndash;e655.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi S, Zhang X, Lv Y, Shen L. A Comparative Study on the Level of Medical Cost Burden between Palliative Care and Non-palliative Care. Med Philos. 2022;43(18):43\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYanru Guo Y, Yuan H, Cui X, Ren X, Ji. Zhijing Liu. Possible Measures to Alleviate Financial Toxicity in the Treatment of Critically Ill Patients. Med Philos. 2023;44(14):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi H, Chen Z, Huangfu H. Study on the Impact of Critical Illness Insurance on Catastrophic Medical Expenditure of Residents. Health Econ Res. 2025;42(03):28\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeng K, Shearer J, Grangaard Johnson L. Developing Successful Palliative Care Teams in Rural Communities: A Facilitated Process. J Palliat Med. 2022;25(5):734\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng Y. Longwen Fu. Building a Universally Accessible Hospice Care System with Chinese Characteristic. 2021-03-17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng Y. Research on the Professional Advantages of Medical Social Work in the Construction of Inclusive Hospice Care System from the Whole Person Care. Social Work Manage. 2024;24(03):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamilton-Baillie A, Jenkins LS, Munnings M, Bruinders E, Bekker A. Palliative care in a rural subdistrict in South Africa: A 4-year critical review. Afr J Prim Health Care Fam Med. 2024;16(1):e1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa Y, Wang J. On the Legitimacy of Promoting Hospice Care in China. J Inner Mongolia Univ (Philosophy Social Sciences). 2024;56(03):66\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAregay A, O'Connor M, Stow J, Ayers N, Lee S. Strategies used to establish palliative care in rural low- and middle-income countries: an integrative review. Health Policy Plan. 2020;35(8):1110\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Palliative care, Rural residents, Older adults, Perceptions","lastPublishedDoi":"10.21203/rs.3.rs-8846419/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8846419/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe development of palliative care in China exhibits a pattern of \u0026ldquo;urban priority and rural lag\u0026rdquo;. Older adults in rural areas face low quality of life and a lack of professional care during the end-of-life stage.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aims to explore rural Chinese residents\u0026rsquo; awareness of and demands for palliative care, along with their underlying decision-making logic. The objective is not only to provide theoretical insights for formulating localized development strategies in rural China but also to contribute Chinese perspectives and experiences to addressing palliative care accessibility challenges in similar resource-limited settings worldwide.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePurposive sampling was used to select 43 rural residents for semi-structured in-depth interviews. Thirty-nine interview transcripts were ultimately obtained and analyzed using grounded theory.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEight axial codes were extracted: \u0026ldquo;Views on Life and Death\u0026rdquo; \u0026ldquo;Awareness of Quality of Life and Dignity\u0026rdquo; \u0026ldquo;Perceptions of Medical Care\u0026rdquo; \u0026ldquo;Customs for Handling Post-Death Matters\u0026rdquo; \u0026ldquo;Attitudes Toward Palliative Care\u0026rdquo; \u0026ldquo;Influence of Economic Status on Acceptance of Palliative Care\u0026rdquo; \u0026ldquo;Demands for Palliative Care Services\u0026rdquo; and \u0026ldquo;Expectations for Government Support and Promotion Policies\u0026rdquo;. The selective coding was identified as \u0026ldquo;Rural Chinese Residents\u0026rsquo; Perceptions and Demands Regarding Palliative Care within the \u0026lsquo;Rural Good Death Belief\u0026rsquo; Framework\u0026rdquo;.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRural Chinese residents\u0026rsquo; perceptions and demands regarding palliative care are deeply embedded in the logical framework of \u0026ldquo;Rural Good Death Belief\u0026rdquo;. They demonstrate a strong need to maintain quality of life and dignity, emphasize the economic accessibility of services and the vital role of families as informal caregivers, and express high expectations for government leadership and involvement.\u003c/p\u003e","manuscriptTitle":"A Qualitative Study on Rural Chinese Residents’ Perceptions and Demands for Palliative Care within the Framework of “Rural Good Death Belief”","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 14:43:19","doi":"10.21203/rs.3.rs-8846419/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-02T07:54:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T16:36:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51337783048964366933825572010363498205","date":"2026-03-30T16:14:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230920030691505605783144428386475114684","date":"2026-03-29T23:20:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T02:11:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327640614094324844037133197490483068773","date":"2026-03-06T01:11:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-26T02:58:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-13T12:50:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-11T22:58:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-11T22:57:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2026-02-11T02:39:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"599a1d72-d448-46e2-913f-cd3ecea771da","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T10:23:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 14:43:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8846419","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8846419","identity":"rs-8846419","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}