UK has the highest quality of death
The UK leads the way in terms of palliative care, despite its far-from-perfect healthcare system, according to a new report. In many nations, standards of end-of-life care suffer from inadequate policy, high costs, cultural barriers and poor access to painkillers.
While ‘quality of life’ is a common phrase, ‘quality of death’ is considered far less often. Too many people, even in countries that have excellent healthcare systems, suffer a poor quality of death – even when death comes naturally. According to the Worldwide Palliative Care Alliance, while more than 100 million patients and family care-givers worldwide need palliative care annually, less than eight percent of this number actually receives it.
With this in mind, the Economist Intelligence Unit has devised a ‘Quality of Death’ Index to rank countries according to their provision of end-of-life care. The Index, commissioned by the Lien Foundation and published today, measures the current environment for end-of-life care services across 40 countries.
At the top of the table is the UK, which has led the way globally in terms of its hospice care network and statutory involvement in end-of-life care. The UK's top rank comes despite the country having a far-from-perfect healthcare system. It is placed joint 28th in the Basic End-of Life Healthcare Environment sub-category (which accounts for 20 percent of the overall score). But the UK ranks first in the Quality of End-of-Life Care sub-category, which includes indicators such as public awareness, training availability, access to pain killers and doctor–patient transparency (and accounts for 40 percent of the overall score).
Many rich nations lag a long way behind in the overall score: these include Denmark (22nd), Italy (24th) and South Korea (32nd). In these cases the quality and availability of care is often poor and policy co-ordination lacking. The bottom-ranked countries in the Quality of Death Index include, unsurprisingly, developing and BRIC countries, such as China, Brazil, India and Uganda, where despite notable exceptions of excellence – such as the Indian state of Kerala and services delivered through Hospice Africa Uganda – progress on providing end-of-life care is slow. In the case of China and India, further problems are vast populations for whom end-of-life coverage extends to only a fraction of those in need.
The Economist Intelligence Unit has analysed the Index results in a white paper, for which it interviewed experts around the world. The key findings are as follows:
- Combating perceptions of death, and cultural taboos, is crucial to improving palliative care. Death and dying are stigmatised in some cultures to the point where they are taboo, as in Chinese culture. In Western societies death has become medicalised and curative procedures are often prioritised ahead of palliative care. In the US, discussion of end-of-life care often inflames religious sentiment that holds the sanctity of life paramount. The issue is complicated by the perception that ‘hospice care’ is often associated with ‘giving up’.
- Public debates about euthanasia and physician-assisted suicide may raise awareness, but relate to only a small minority of deaths. While debates about these issues gain the most media attention, they affect only a tiny proportion of the terminally ill. (Consequently, policies on these issues are not included in the Index, although the legal status of ‘do not resuscitate’ orders is included.) Nonetheless, pressure brought on policymakers over these issues can be a catalyst for the improvement of palliative care services, as in Australia, where the federal overturning of a Northern Territory euthanasia law in 1996 led to increased national funding for end-of-life care.
- Drug availability is the most important practical issue. Pain control is the point from which all palliative care stems, and the availability of opioids (morphine and its equivalents) is fundamental to quality of end-of-life care. But across the world an estimated 5 billion people lack access to opioids, principally due to concerns about illicit drug use and trafficking. A lack of training is also a problem, with many doctors and nurses ignorant of how to administer them.
- State funding of end-of-life care is limited and often prioritises conventional treatment. In many countries – even where palliative care treatment is available through national healthcare systems or insurance – end-of-life care bodies rely on charitable donations and philanthropic activity to support them. In the US, while palliative care is available through public medical insurance, patients must relinquish curative treatments to be eligible for reimbursements (unlike in the UK, for example).
- More palliative care may mean less health spending. By increasing the proportion of community and homecare, palliative care can reduce costs associated with hospital stays and emergency admissions. In the US in particular, with the recent passing of a major healthcare reform bill, this is likely to become a focus of debate. In Spain, one study found that in 2006 a shift away from the use of conventional hospital treatment towards palliative care, an increase in homecare and lower use of emergency rooms, generated savings of 61 percent compared with expenditure recorded in a 1992 study. However, the costs associated with non-cancer palliative care are higher than for cancer-related care. And as the population ages, more end-of-life care will be needed overall.
The full white paper is available for download free of charge at www.eiu.com/sponsor/lienfoundation/qualityofdeath.
Economist Intelligence Unit / Expatica