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Global Quality of Death Index - USA in 9th Place

  • Date: 2010/07/14 (Rev. 2011/03/31)
  • The Lien Foundation
  • Synopsis : Quality of Death Index ranks countries according to their provision of end-of-life care.

Main Document

United States Tied for 9th Place in Economist Intelligence Unit's First Ever Global 'Quality of Death' Index - In many nations, standards of end-of-life care suffer from inadequate policy, high costs, cultural barriers and poor access to painkillers.

The Economist Intelligence Unit today released a "Quality of Death" Index that ranks countries according to their provision of end-of-life care. The first-ever global study, commissioned by the Lien Foundation, a Singapore philanthropic house, measures the current environment for end-of-life care services across 40 countries. The United States is tied for the ninth spot with Canada.

While "quality of life" is a common phrase, "quality of death" is considered far less often. According to the Worldwide Palliative Care Alliance (WPCA), while more than 100 million patients (and family care-givers worldwide) need hospice care annually, fewer than eight (8) percent actually receive it.

"To highlight this gap and advocate for better care for the dying, the Lien Foundation commissioned the Index which provides a global benchmark on the provision of end-of-life care," said Mr. Poh Wah Lee, Chief Executive Officer, Lien Foundation.

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 US does not have an overall more favorable ranking principally because of the financial burden of end-of-life care, which reflects the high overall cost of US healthcare. The US ranks better in terms of infrastructure - at positions seven and eight for Quality and Availability of End-of-Life Care respectively. 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.

"The US's ranking in the 'Quality of Death' Index indicates the need for our nation to build a system of care around bringing the care to the patient - preferably in their own homes - by providing support for family caregivers, care teams that can go to homes with emergency coverage, and strong integration of hospice care expertise to maximize quality of life for both patient and family," commented Dr. Diane Meier, Director of the Center to Advance Palliative Care (www.capc.org) and Professor of the Department of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine. "This means fewer resources for hospitals and nursing homes, and more resources for home and community-based care services. The US is fortunate among nations to have broad access to hospice care under a Medicare benefit that serves nearly 40% of all people who die, as well as their bereaved families and loved ones."

For the first time in the history of humanity, people over the age of 65 will soon outnumber children under the age of five. By 2050, about one-in-five Americans will be over the age of 65, with about 5% percent reaching 85 and older (up from 2% today). Much hospice care can be - and is - given at home; more than 75% of those receiving such care in the US die in their own homes. By increasing the proportion of community and home-care options, hospice care can reduce costs associated with hospital stays and emergency admissions.

"Quality-of-death is key to quality-of-life, especially with aging populations," said Poh Wah Lee, Chief Executive Officer, Lien Foundation. "We hope that the results of the index will spark 'die-logues' and drive public awareness as well as help decision makers determine priorities and formulate policies."

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 care coverage extends to only a fraction of those in need.

The Economist Intelligence Unit has analyzed 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 hospice care. Death and dying are stigmatized in some cultures to the point where they are taboo - as in Chinese culture. In Western societies death has become medicalized and curative procedures are often prioritized ahead of hospice 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 tiny 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 hospice 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 hospice 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. Lack of training is also a major problem in the US, with many doctors and nurses ignorant of how to safely and effectively administer opioid analgesics.
  • State funding of end-of-life care is limited and often prioritizes conventional treatment. In many countries - even where hospice care treatment is available through national healthcare systems or insurance - end-of-life care providers rely heavily on charitable donations and philanthropic activity for support. In the US, while hospice care is available through public medical insurance, patients must relinquish curative treatments in order to be eligible for their hospice benefits (unlike in the UK, for example).
  • More hospice care may mean less health spending. By increasing the proportion of community and home-care, hospice care can reduce costs associated with hospital stays and emergency admissions. In Spain, one study found that in 2006 a shift away from the use of conventional hospital treatment towards hospice care, an increase in home-care 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 hospice 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.qualityofdeath.org

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

About the Lien Foundation www.lienfoundation.org

The Lien Foundation is a Singapore philanthropic house noted for its model of radical philanthropy. It invests in innovative solutions, convenes strategic partnerships and catalysis 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 Life Before Death initiative visit www.lifebeforedeath.com.

Editor: How Long Will I Live - Life Span Expectancy Chart

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