How we die: Inside New Zealand’s looming crisis in palliative care
As New Zealand’s population ages, the number of people dying each year will rise rapidly. With hospices already experiencing funding shortages, who will care for us at the end of our lives?
One day, Bev Evans will notice a pain burrowing into the side of her back. Here, she leans forward slightly from her couch, bends her arm at the elbow and lays her palm on the approximate site of that expected pain. It will signify that the aneurysm in her aorta, formed in the place from which years ago she had another surgically removed, has burst. She’ll be overwhelmed by tiredness. She will fall asleep. In that sleep she will die. “I’ve gotten used to that fact,” Evans, 83, says in her small, inhibited and slightly croaky voice, her still-sharp eyes shining brightly. Next to her is an open book of crosswords, and her walking frame is within easy reach. On the walls of her immaculately tidy Mount Wellington apartment hangs a selection of her own artwork, which commemorates important moments of her life: family holidays in Whitianga, the births of grandchildren. “There’s nothing I can do about that.”
About three years ago, Evans’ GP noticed she was beginning to struggle on her own – she also suffers from chronic obstructive pulmonary disease, described as “holes in my lungs” – and recommended a palliative approach to Evans’ remaining time. It was difficult for Evans to hear there was nothing more doctors could do to cure her, that she should try to accept that her life had reached its terminal phase – that she should, in effect, prepare herself for death.
She was referred to Mercy Hospice, and a friend who was already engaged with the team there strongly encouraged her to take advantage of the services it offers. She is very glad she listened. “If I hadn’t had that palliative care, I probably would have been dead by now,” she says.
I first met Evans at Mercy Hospice on the fringe of the Auckland CBD on a sunny, breezy morning in early spring. Years ago, when I had first moved to Auckland, I used to walk past the hospice on my way to and from work; I hardly ever did so without my imagination travelling down the long driveway, past the pretty gardens glimpsed from the street, and inside the cheery, peach-coloured walls. Then, I’d thought of the building as the site of dreary and depressing final days, a place to be avoided until the very end. But when I met Evans, with a breeze blowing the scent of that garden through the building’s open windows, spring sunlight spilling across the floor, and a succession of 70s and then 80s pop hits energising the wellness session she frequently attends, it had a much different air, something like the seniors’ exercise classes you’d expect to find at any retirement village.
Half a dozen or so people followed an instructor, lifting half-kilogram dumbbells at an intensity low enough to allow for plenty of group-wide chatter about what constituted the ideal breakfast and which country served the best coffee: far from being merely a place one comes to die, hospice had become a hub of Evans’ life. On the floor above, in the eight-bed in-patient unit, someone at that instant may have been expelling their very last breath; but here, death seemed a much-distant concept as, with a tinkling of its porcelain, the morning-tea trolley was wheeled in.
If there is a minor irony in Evans’ belief that a branch of medicine primarily concerned with easing one’s final days and years had prolonged her own, it is one confirmed by the literature, which consistently finds that patients engaged with hospice services benefit from more effective pain management, that they are happier, more fulfilled, and more at peace with the end to which every life travels. Likewise, society benefits: a 2024 report compiled by advisory firm Martin Jenkins found that in New Zealand hospice services take the pressure off many other aspects of a national healthcare system often stretched beyond its capacity, that those engaged with hospice are less likely to require hospital admission, visits to emergency departments or ambulance callouts. Hospice reduces the burden on stressed and exhausted family caregivers, and offers bereavement support for those left behind. That report conservatively estimated that every dollar the government invests in hospices generates $1.59 in health benefits for the country’s taxpayers.
Yet, as that same report also makes clear, it is a sector that is “fragmented, complex, and at risk of collapse”. In 2024, according to official numbers 37,722 New Zealanders died, but with the population of the nation rapidly ageing, that number is forecast to increase to nearly 54,000 by 2043. And if the proportion of dying New Zealanders engaging with hospice was to remain the same, that timeframe would see demand for the service rise by 53 percent – a looming catastrophe for a sector of the country’s healthcare system already struggling to make ends meet.
For years, as Hospice New Zealand CEO Wayne Naylor told me, funding shortages have meant cost-cutting measures at the 28 publicly contracted hospices across the nation, with administrative and executive staff often having to be let go in an attempt to keep overheads low and the shortfall from impacting on those, like Evans, under their care. That, however, is no longer possible – and will become increasingly less so unless the financial pressure is eased. “Some hospices are making cuts, which is impacting on patient care… That’s happening around the country, and unless something changes, more hospices will be moving to the point where they have to start cutting clinical staff,” Naylor says.
Once ranked by the World Map of Palliative Care Development report as the third best country in which to die, New Zealand had slipped to 15th by the 2025 report. Minister of Health Simeon Brown told The Spinoff that hospices play “a critically important role in the healthcare system in New Zealand”, but that importance has never been adequately acknowledged in funding – by his or any previous government. In 2024, for instance, it cost $226 million to run the country’s hospice services, with the government providing roughly half of that amount. The balance was made up by charity and the proceeds from the network of second-hand stores that Hospice NZ operates around the country, not to mention the many, many hours of labour given by volunteers.
It is an “always fragile” model, Naylor says – and one whose fragility was demonstrated by Covid-19 and the lockdowns that eliminated for a time the income from its more than 120 op shops. He argues that hospices, if they are indeed the critically important pieces of infrastructure politicians assure us they are, should be funded with the same inevitability as the more established pillars of health care in New Zealand. “We see hospice and palliative care as a key part of the healthcare system,” Naylor says. “The same way you fund general surgery or maternity services, hospice should be funded as a core part of the healthcare system.” Increasingly, the current way of doing things will become untenable: the Martin Jenkins report estimated that, by 2043, the cost of running the country’s hospice services would climb to over $530 million – far beyond the capacity of the current funding model, and a stark indication, experts warn, that it needs to change.
That it hasn’t already could be, according to Dr Carol McAllum, who leads both Mercy Hospice’s community action and its medical team, partly a result of societal uneasiness around the subject at the core of palliative medicine: dying and death. We spoke in a disused downstairs function room, the furniture pushed to the wall. The escaped strands of her tied-up grey hair were highlighted against a bouquet of white flowers resting on the sideboard behind her, the remnant of a Scottish accent – her family moved to the Antipodes when she was 12 – detectable in her speech.
When McAllum was a student — she qualified as a doctor in 1979, the year New Zealand’s first hospice opened in Wellington — she remembers a culture of discomfort around dying so persistent that even patients imminently close to death were shielded from that knowledge. A leukaemia patient, who had been just a few years older than her when she was a student in the late 70s, came to mind: “He asked me, ‘Am I dying?’” McAllum, of course, knew that he was. “So how could I say no? So I didn’t say no, we had a conversation.”
That wasn’t appreciated by the senior consultants who, McAllum says, stuck closely to the prevailing theory that even with patients that close to the end, death was a subject to be avoided. That was an idea that chafed against McAllum’s growing belief that the least she owed her patients was honesty – even, or perhaps particularly, when the news wasn’t good.
Another formative experience occurred early in her career. It involved a nine-year-old boy suffering from a fatal hematological condition – to guard against infection, McAllum remembers, he was kept insulated and spent much of his time “being looked at through a window”. He was exhausted, McAllum says, aware that he was dying and ready to do so. “He was just done,” she says her conversations with the child had taught her.
So she was furious when she later learned he had been encouraged to undergo what was then, in the early 1980s, the experimental treatment of a bone-marrow transplant – an experiment that ultimately proved futile. “You wouldn’t just let that young man die a natural death,” she remembers thinking. “You had to keep subjecting him to tests, to reverse-barrier nursing.”
Those early lessons guided her into a career in small-town general practice, during which she often found herself caring for dying patients in the community, and later into the hospice system. Over the course of her career, she says, as hospices have become more established in New Zealand’s healthcare system, she has seen a more enlightened, a more honest, approach to dying develop, even if she believes there is still far to go. Western medicine, she says, has long been predicated on a “treat treat treat treat” philosophy, driven relentlessly by the development of new drugs and a “drive for longevity”. Palliative care, in her view, was born out of “protest” against a view of medicine that seemed to reduce the measure of its success almost to a single metric: how long one could prolong a life.
“It’s so much easier to write a prescription, do an intervention, drain a lung; but knowing when not to do it, that’s an art.”
Palliative care, of the kind offered by hospices, takes a broader view, she says, always guided by what a patient desires from their remaining time, whether that be fighting for every extra hour of life or mere pain management as death is left to run its unrestricted course. McAllum calls it “an art and a science”. “It’s so much easier to write a prescription, do an intervention, drain a lung; but knowing when not to do it, that’s an art.” And one, she says, that can put it at philosophical odds with a prevailing medical culture that places finding a cure at the apex of its ambition. “It’s seen as a bit soft, you know, as just looking after someone… [but] it is a damned hard speciality.”
A 2025 survey of this country’s medical workforce by the Medical Council of New Zealand found that of the country’s roughly 20,000 doctors, only 135 worked in palliative medicine, about the same number who specialised in urological surgery. Within Health New Zealand’s Planning, Funding and Outcomes Directorate, the palliative care team consists of 1.8 full-time equivalent positions; there are 4.5 full-time equivalent roles dedicated to the assisted dying programme.
McAllum says that illustrates a slightly “weird” inversion of priorities, given that only a tiny proportion of New Zealanders will make use of the assisted dying programme – 344 people had an assisted death between April 1, 2023 and March 31, 2024 – but that a huge majority of people would benefit from some form of palliative care. Almost nine out of ten New Zealanders die natural deaths, most after an illness of variable length, and thus we all have an interest in making the process of death as pain- and fear-free as possible. That those naked statistics aren’t reflected in funding, McAllum says, leaves those in the hospice sector feeling forgotten. And vulnerable people bear the brunt.
She recalled the weekend that she had just spent on duty, some hours of which she worked with a family whose father and husband was dying and had elected to do so at home. His condition had deteriorated faster than expected, and his adult children and his wife, who were his primary carers, were struggling to cope — fighting exhaustion, uncertainty, fear, second-guessing all of their decisions.
Before the funding crisis had really begun to bite, McAllum says, Hospice NZ had had the resources to put a nurse into people’s homes for what was expected to be the last three nights of someone’s life. And that is all this family needed, McAllum says: someone to be there as a constant, calming presence through the night, to reassure the family through the final stages of their father’s life – his delirium, his laboured, noisy breathing – and to ease the situation for everyone by keeping him comfortable throughout his last days and hours. But no one was available. The children’s last memories of their father, she says, will forever be of a “really hard night”. She worries about the legacy of those memories. “What’s that going to do for them when their mother dies? They’re going to be apprehensive that the same thing is going to happen.
“All they wanted was a nurse.”
The last time Kim Stephen, a clinical nurse specialist of Māori health at Mercy Hospice, stepped into Margy Tawhi’s home – a small second-storey flat on a scruffy Ōtāhuhu backstreet – the curtains were drawn, the door was closed, and she had found Tawhi (Tuhoe, Tainui, Ngāti Tūwharetoa, Ngāti Raukawa, Ngāti Hine) curled around a hot-water bottle under a blanket on the couch, doing her best not to inflame the aching pain emanating from the tumours on her spine, to which her original breast cancer had spread. The oxycodone wasn’t doing enough and Tawhi found herself suffering towards the end of every four-hour period, when she was finally allowed to take another dose. “I was a complete mess,” Tawhi says.
Stephen (Te Aupouri, Te Rarawa) explained how that previous visit had resulted in “a bit of a korero. I went back to our nurse-practitioner who agreed, yes, we’ll increase the… medication”. Stephen motioned around the room: the door was ajar, the curtains were open to reveal Nala, a pitbull puppy, pawing playfully at the glass, and Tawhi was up and chatting animatedly, offering cups of tea or water. “Life is living… From a medication change, a really significant impact,” Stephen said. “That’s so true,” Tawhi agreed, a small black vape clasped in one fist and a tissue in the other, which she absentmindedly passed back and forth throughout the visit.
When I saw her again a month later, Tawhi explained how she’d been able to taper her medication down, describing the increased energy the lower dose gave her as a reclamation of her “mana”.
One of Stephen’s earliest memories is being scolded as she ran through the wharenui, interrupting the preparations for her grandmother’s tangi. She says Māori, often exposed to dying and tangihanga on the marae “very, very early” have a different relationship to death, one that draws on ongoing relationships with departed ancestors. “They are always in our thoughts. They are always in our everyday conversations. Like when I die, my mum’s going to be there to come and get me. That is not a scary concept for me.”
Stephen says it gives her and patients like Tawhi a common cultural understanding on which to draw. “This is the longest frickin’ illness I’ve ever had in my whole life,” Tawhi says, “and a lot of people have come onto that journey with me.” She mentioned the team of healthcare professionals – surgeons, nurses, oncologists – into whose orbit cancer has brought her. It is with Stephen, however, Tawhi feels like she can “be an open book. Kim pretty much knows who I am and what I’m going through.”
Stephen sees the barriers dissolve when a Māori patient encounters a Māori nurse on their doorstep. Where there might be awkwardness or even embarrassment, she says, if a Pākehā nurse was to ask whether someone had enough money to catch a taxi to their next early-morning appointment, with her nothing is off the table. There is never any need to explain whanau situations that might be unfamiliar to someone from a different cultural background, and it is a given that Stephen will arrive with a packet of chocolate biscuits as a koha. “It’s just that knowing,” Stephen says.
Her European-sounding name, she thinks, gives her an insight into how patients’ attitudes might change depending on the background of who they are dealing with. Initial communication might be over the phone or via text, and can feel stilted. “But once they see my face, they’re like, ‘Oh, come in girl’ and there’s no explanation needed.” The comfort of Stephen and Tawhi’s relationship, both believe, allowed for the frictionless resolution of Tawhi’s medication issue, and for their general closeness. “She’s like the big sister,” Tawhi says.
Tawhi regards herself as lucky to have found Stephen – and hospice in general. Despite having herself nursed relatives through death by cancer in the past, she was only dimly aware of the service that hospice offered before being referred by her oncologist in April 2025. Stephen posits that lack of awareness as an extension of the well-documented inequity in access to primary healthcare faced by Māori in New Zealand. Her own mother, she explained, had had such poor engagement with the healthcare service that her death from cancer occurred only six weeks after she had finally taken her complaints to a GP.
It is worth considering, for a moment, what “not reaching” people might mean: unmanaged pain and lonely terror, an unrelieved struggle with the existential limits of being human when all the biggest questions about what that means are magnified by the fact of coming to the end of being one.
A 2024 report by Te Ārai Palliative Care and End of Life Research Group, detailed the experiences of the New Zealand demographics that have been underserved by hospice care: rural communities, children, the homeless, and Māori, as well as many others. As Dr McAllum earlier told me: “We’re not reaching people who have the need; we’re largely reaching people who have the ability to access us.”
A 2025 article in the New Zealand Medical Journal estimated that in 2023 between 21,490 and 27,914 people required specialist palliative care, but that only 10,800 people had any involvement with the country’s hospices. Naylor lamented the yawning gap between demand and capacity: “We definitely think hospices could be reaching more people directly than hospices do.”
It is worth considering, for a moment, what “not reaching” people might mean: unmanaged pain and lonely terror, an unrelieved struggle with the existential limits of being human when all the biggest questions about what that means are magnified by the fact of coming to the end of being one. Poet Philip Larkin called the fear of death “a special way of being afraid / No trick dispels”. He’s right, of course – no trick dispels. But the care and the support, the kindness and expertise, of professionals like Stephen and McAllum, the community that Evans has found: that is no trick. One senses that the simple human kindness at the core of those services might be the only secular antidote to that fear. If only more New Zealanders – and a wider spectrum of New Zealanders – could access it.
“People,” says Naylor, “could be suffering unnecessarily simply because there’s not enough resources to allow them to go on to the hospice service. And that shouldn’t be acceptable to a government or to a health agency, and certainly it is very challenging for hospice staff who are in this work, because that’s what they’ve come to do, to look after these people and make sure they don’t suffer.”
The funding shortfalls projected by the Martin Jenkins report are based, it states, on the assumption that a third of New Zealanders, about the number Hospice NZ currently reaches, will require “palliative care in a hospice setting” as they die. But the real need, Naylor estimates, of people who need specialist palliative care is probably closer to 45 percent – it’s just that Hospice NZ currently lacks the resources to expand its reach.
Essentially, then, the funding crisis that is forecast is actually already upon us – it’s just that we as a society have been conditioned to the limitations of our palliative care system as it currently functions. And unless something is done, that crisis will only compound from here.
Health New Zealand (HNZ) declined to be interviewed on the topic, instead issuing a statement to The Spinoff from Martin Hefford, HNZ’s director living well, that acknowledged “there are areas where the system can do better. We are committed to improving access to palliative care so that every person, regardless of where they live, can receive the care they need.” As part of that work, HNZ has been developing a National Palliative Care Work Programme since 2023, which will “support a nationally consistent approach to palliative and end-of-life care planning, funding, service delivery, and outcomes”.
Naylor sits on the steering group that is guiding the development of that programme, which he hopes will provide, when its work is complete later this year, “some real clarity about what services should be available to everybody in New Zealand, how they will be funded, and who will be delivering them”.
Minister of Health Simeon Brown told The Spinoff that he wants “to make sure that all New Zealanders have access to palliative care, and to make sure that they can get that care in a way that delivers according to their needs”. But he repeatedly deferred to the progress of the National Palliative Care Work Programme when pressed on any details as to what his government would provide in terms of extra funding for the sector, and wouldn’t be drawn on further details – other than to acknowledge that “over time [it] will require further investment to make sure that we can deliver the right type of care”. “It’s really important that we enable services which allow New Zealanders to die in a way which gives them dignity,” Brown says. Naylor welcomes Brown’s interest in, and support of, hospice, but notes that – so far, at least – it “hasn’t translated into more funding, which is what we’d really like”.
As with so much of New Zealand’s creaking public healthcare system, it is a matter of money – or the lack thereof. Naylor believes that Hospice NZ’s origins as a charitably funded service have allowed successive governments and their administrative structures to more easily justify the fact that, even as it has increased its importance to the overall healthcare system, it still needs to rely on donations, volunteer labour and a nationwide retail operation to sustain itself. If it is truly seen as the vital cog in New Zealand’s healthcare system that Brown insists it is, would that model be acceptable? Naylor thinks not: “We have been pushed to the margins a bit, and that’s why we don’t have sufficient funding to meet the needs of people who are dying around the country,” he says. “Death has been pushed to the margins of healthcare.”
For Evans, her experiences with hospice have, in some ways, liberated death from that location on the margins, allowing her to face the subject head on. Whereas much of society might recoil from discussion of the topic, within the walls of hospice one need not sugarcoat the reality. Hospice friendships, she says, offer real comfort as spaces in which to confess and confront one’s fears, as do regular sessions with the hospice-supplied psychologist who, for the best part of two years, has been visiting Evans in her home to talk with her about her concerns, assuage her fears.
“They will listen to you, and they encourage you to talk about the things that are worrying you. They help you understand what you’re going through, and it helps you to face thoughts,” she says. “You do worry about how you are going to die, and how it’s going to happen.”
The recent death of a dear friend reignited some of those thoughts and fears. Maurice had volunteered as a driver for Mercy Hospice, and soon decided that he would primarily be Evans’ chauffeur, shuttling her to and from her appointments at Mercy Hospice. The two became firm friends, his portrait displayed so prominently in Evans’ home I initially took it to be that of her late second husband.
When he died suddenly last year, aged just 74, it left Evans “bewildered”, she says, and once again re-examining the existential questions about death’s finality that every examined life must sometimes – in dark fretful sleepless hours, or in calm private contemplation – fall into. “You’re there, you’re alive,” Evans says. “And then you get cremated and there’s nothing left, only the ashes.”
But those are questions for each of us to settle to our own satisfaction; society should have other priorities, and it would do us well to carefully consider what those are. Evans: “Some people die in their own homes without anyone around them. With hospice, you know, you’ve always got someone to comfort you.”