The UK has the highest quality of death

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 100m patients and family care-givers worldwide need palliative care annually, less than 8% 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 places equal 28th in the Basic End-of Life Healthcare Environment sub-category (which accounts for 20% 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% 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 5bn 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% 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.

Index methodology

The Quality of Death Index measures the current environment for end-of life care services across 40 countries: 30 OECD nations and 10 select others for which data was available. The Economist Intelligence Unit’s research team devised the Index, collated data and built the model from a wide range of indicators. They interviewed a variety of doctors, specialists and other experts to compile and verify the data.

The Index scores countries 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. Twenty-four individual indicators fall into three broad categories:

• Quantitative indicators: Eleven of the Index’s 24 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", for which the available answers are Yes, No or In Progress.

The Index is an aggregate score of all of the underlying indicators, normalised to make the data comparable. Data is first aggregated by category and then overall, based on the composite of the underlying category scores. To create the category scores, each underlying indicator was aggregated according to an assigned weighting, determined by the Economist Intelligence Unit’s research team following consultation with experts interviewed for the research. Each category is also accorded a weighting within the overall score. Quality is given the largest weighting, accounting for 40% of the overall score; Availability accounts for 25%, Basic End-of-Life Healthcare Environment 20% and Cost 15%.

Although the index scores were calculated to two decimal places, they have been rounded to one decimal place in the chart above and in the white paper. For this reason, countries which appear to have the same score may nonetheless have different rankings.

A full methodology description is available in the Appendix of the white paper, available for download free of charge at www.eiu.com/sponsor/lienfoundation/qualityofdeath.

Press enquiries:

Joanne McKenna, press liaison, +44 (0)20 7576 8188 / joannemckenna@eiu.com
David Line, editor, +852 2585 3873 / davidline@eiu.com

About the Economist Intelligence Unit

The Economist Intelligence Unit is the business information arm of The Economist Group, publisher of The Economist. Through our global network of more than 650 analysts and contributors, we continuously assess and forecast political, economic and business conditions in more than 200 countries. As the world's leading provider of country intelligence, we help executives make better business decisions by providing timely, reliable and impartial analysis on worldwide market trends and business strategies. For more information, please visit www.eiu.com or follow us on www.twitter.com/theeiu.

A word from the Lien Foundation

The Lien Foundation is a Singapore philanthropic house noted for its model of radical philanthropy. It invests in innovative solutions, convenes strategic partnerships and catalyses action on social and environmental challenges. The Foundation drives institutional capacity building to address crucial community needs, and empowers individuals to reach their full potential. It seeks to enhance educational opportunities for the disadvantaged, excellence in eldercare and environmental sustainability in water and sanitation. The Foundation’s Life Before Death initiative seeks to get people thinking and talking about a universally taboo subject - death & dying - and to highlight the urgent need for improved care for the dying.

For more information on the sponsor and this research visit www.qualityofdeath.org.