UK is ranked top out of 40 countries on quality of death thanks to hospice network
A new quality of death index has shown substantial variations in end of life care in different countries across the world, with the UK ranking top because of its hospice care network and statutory involvement in the care of people who are dying.
The Economist Intelligence Unit, the business information arm of magazine the Economist, devised the quality of death index to rank countries according to the provision of end of life care services. It includes 24 indicators that evaluate quantitative measures such as life expectancy and healthcare spending as a percentage of gross domestic product (GDP), qualitative factors such as public awareness of end of life care and status indicators, including the existence of a government led national palliative care strategy.
Analysis of the quality of death index for 40 different countries found that the UK had the top score. Despite achieving a low ranking (28th) on the quality of its healthcare system as a whole, it scored very highly on the quality of end of life care, which included good availability of training, access to pain control, and doctor-patient transparency.
Many rich nations lag a long way behind, including Denmark (22nd), Italy (24th), Finland (28th), and South Korea (32nd), largely because of poor quality and availability of care and a lack of policy coordination. The US and Canada ranked equal ninth.
“Quality of life is a common phrase. The majority of human endeavours are ostensibly aimed at improving quality of life, whether for the individual or the community,” the report authors suggest. “But quality of death is another matter.” It found that fewer than 8% of the estimated 100 million people around the world who would benefit from hospice and palliative care annually have access to it.
A key factor influencing a country’s quality of death score was state funding of end of life care. The researchers found that this was limited in many countries, where curative treatment is prioritised. Even where palliative care treatment is available through national healthcare systems or insurance, the research found that organisations providing end of life care often have to rely on charitable donations and philanthropic bodies to support them.
“Few nations, including rich ones with cutting-edge healthcare systems, incorporate palliative care strategies into their overall health policy—despite the fact that in many of these countries, increasing longevity and ageing populations mean demand for end of life care is likely to rise sharply,” the report authors warned.
The study, which was funded by the Lien Foundation, a Singapore philanthropic organisation, showed barriers to optimising the transition to end of life care. For example, in the US, even though palliative care is available through public medical insurance, patients have to relinquish curative treatments to be eligible for reimbursement.
Access to effective pain relief emerged as another key factor in determining quality of death scores. The availability of opioids is fundamental to providing good quality of end of life care, the research group argued. “But an estimated five billion people across the world lack access to opioids, principally due to concerns about illicit drug use,” they said. A lack of training in their use by healthcare professionals was also a problem. The report called for legislation to improve access to opioids, and increased training in their administration.
The researchers concluded that high level political commitment and a coordinated policy are essential to improving end of life care. And attitudes to death need to change. They found that death and dying are stigmatised to the point where they are taboo in some cultures—as in China. This prevents any developments in the provision of end of life care. “Combating negative perceptions of death, and cultural taboos about dying, is crucial to improving palliative care in many countries,” they suggest.
David Line, senior editor of Industry and Management Research, the Economist Intelligence Unit, Hong Kong, said that the group plans to repeat the quality of death index rankings on a regular basis.
“We hope this will inform the ongoing debate that needs to be had about end of life care,” he said. “The findings show that countries ranking top—the UK, Australia, and New Zealand —have statutory support for an integrated policy on end of life care. Top level support is important, but this also has to be followed through with a holistic programme, which also addresses cultural attitudes to death.”
Cite this as: BMJ 2010;341:c3836
The report, The quality of death. Ranking end of life care across the world, is available at