Quality of Death: Ranking End-of-Life Care Across the World

2010 July 19
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EIU/Lien White Paper

The Economist Intelligence Unit of the Economist and Lien Foundation in Singapore joined hands to produce a white paper on Quality of Death (pdf) that was published on 14 July 2010.

A poor quality of death means intense suffering for the dying person and his family and the situation can improve only with improved access to palliative care services.

The white paper lists 40 countries and ranks them according to Quality of Death. UK ranks first, and sadly, India comes at the very bottom as the 40th, next to Uganda. As a redeeming feature, the exceptional performance of Kerala in this field is highlighted in the paper.

Grim reapings: An attempt to rank end-of-life care in different countries

Quality of Death Ranking

CUSTOMER-SATISFACTION surveys are commonly used to improve the service in hotels and shops. Alas, they are unsuitable for rating the quality of death. So the Lien Foundation, a charity, commissioned the Economist Intelligence Unit, our sister company, to devise a ranking of end-of-life care. The report, published on July 14th, rates 40 mostly rich countries by how well they care for the dying.

Britain tops the table. For all the health-care system’s faults, British doctors tend to be honest about prognoses. The mortally ill get plentiful pain killers. A well-established hospice movement cares for people near death, although only 4% of deaths occur in them. For similar reasons, Australia and New Zealand rank highly too.

Some countries, such as Denmark and Finland, that normally score higher than Britain on human-development indices rank lower on the quality-of-death index. They concentrate more on preventing death (which they see as a medical failure) rather than on helping people die without suffering pain, discomfort and distress. America scores poorly because of the health insurers’ rule that they pay for palliative care only if a patient relinquishes curative treatments.

The report combines hard statistics such as life expectancy and health-care spending as a share of GDP with weighted assessments of other indicators. One is the public awareness of the availability of hospices. Another is whether a country has a formal policy or legislation on treating the terminally ill (only seven of the 40 do).

Brazil, China, India and Russia, the four largest emerging economies, cluster at the bottom of the table. Their health-care systems still take little account of dignity in death (a sprinkling of hospices in places such as St Petersburg in Russia, or Kerala in India, are honourable exceptions). The report’s authors blame cultural factors as well as bureaucratic resistance. In China, for example, a strong taboo hangs over discussing death. The ranking may spur improvement. But for those who mind most, complaining about poor deathbed treatment is unusually difficult.

Index Methodology

The Index scores 40 countries (30 OECD nations and 10 select others) using data and interviews with a variety of doctors, specialists and other experts across four categories: Basic End-of-Life Healthcare Environment; Availability of End-of-Life Care; Cost of End-of-Life Care; and Quality of End-of-Life Care. 27 main indicators fall into three broad categories:

  • Quantitative indicators: Eleven of the Index’s 27 indicators are based on quantitative data, such as life expectancy and healthcare spending as a percentage of GDP.
  • Qualitative indicators: Ten of the indicators are qualitative assessments of end-of-life care in individual countries, for example “Public awareness of end-of-life care”, which is assessed on a scale of 1-5 where 1=little or no awareness and 5=high awareness.
  • Status indicators: Three of the indicators describe whether something is or is not the case, for example, “Existence of a government-led national palliative care strategy or agenda”, for which the available answers are Yes, No or In Progress.

Palliative care features strongly in the key findings:

  • The UK leads the world in quality of death.
  • Combating perceptions of death, and cultural taboos, is crucial to improving palliative care.
  • Public debates about euthanasia and physician-assisted suicide may raise awareness, but relate to only a small minority of deaths.
  • Drug availability is the most important practical issue.
  • State funding of end-of-life care is limited and often prioritises conventional treatment.
  • More palliative care may mean less health spending.
  • High-level policy recognition and support is crucial.
  • Palliative care need not mean institutional care, but more training is needed.

The full report can be downloaded here in PDF format…

& visit the Lien Foundation’s interactive website: Life Before Death

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