No one likes to think about the end, even if everyone knows it’s coming. We prefer to prepare for more joyful milestones: birthdays and marriages, graduations and employment. These all factor into our measures of well-being — our quality of life.
We’re repeatedly told to plan for retirement, yet we rarely talk about what will happen at the end of that slow sunset. As a result, according to the Economist Intelligence Unit, we neglect to think about “dying better.”
In its second Quality of Death Index, published Tuesday, the Economist ranks the quality of palliative care in 80 countries. As it did in 2010, the United Kingdom comes out on top. The U.S. ranks ninth.
The report distinguishes between end-of-life care and palliative care, which is defined by the World Health Organization as limited not only to care in the final stages of a terminal illness, but also includes early assessments, psychological attention and support systems.
Commissioned by the Lien Foundation, a Singaporean philanthropic organization, the index looks at indicators across five categories: palliative and health-care environment, human resources, affordability of care, quality of care and community engagement.
By and large, the greatest predictor of how a country fares on these measures is wealth. The list’s top 20 is dominated by wealthy Western and Asian-Pacific countries. Australia and New Zealand are just behind the U.K. in second and third, while Taiwan and Singapore are sixth and 12th.
Though America’s score of 80.8 (out of 100) is respectable, it’s far below the 93.9 garnered by its mates across the pond. The report cites comprehensive national policies, the extensive integration of palliative care into its National Health Service and a strong hospice movement for the U.K.’s superior showing.
In America, the Medicare program for individuals aged 65 and over plays a large role in its high rank. But affordability remains a key issue.
“The financing systems in the U.S. have created significant problems,” says James Tulsky, an expert on psychosocial oncology and palliative care in Boston. “So one of the recommendations of the report is to break down barriers between medical and social funding.”
Across the markers of Quality of Death, the U.S. scores poorest on affordability of care, ranking 18th.
The Economist Intelligence Unit credits the Affordable Care Act with helping deliver sweeping changes throughout the U.S. health-care system, though the private sector has also developed ways of delivering on the increased demand for palliative services.
The action from the private sector has a drawback, however. “The obvious disadvantage is that private sector is beholden to shareholders to provide quarterly returns,” says Diane Meier, director of the Center to Advance Palliative Care at Mount Sinai Hospital’s medical school, in the report. “So the worry is that important needed care that is expensive might not be offered.”
The index’s surprise successes are Mongolia and Panama — 28th and 30th overall — two poorer countries that ranked above ostensibly more advanced places like South Africa and Brazil.
Mongolia owes its impressive record to a single doctor, Odontuya Davaasuren, who is leading the push for a national palliative care program.
Before she helped establish the Mongolian Palliative Care Society in 2000, the report notes, the country had no hospices or palliative care teaching programs, and used just two pounds of morphine a year.
“No one talked about it,” Davaasuren tells The Economist. Now, there are ten palliative care facilities in Mongolia’s capital alone.
In a statement for the International Palliative Care Leadership Development Initiative two years ago, the doctor recalled the cruel passing of a ten-year-old Mongolian girl from leukemia. With limited painkillers, her disease made it so she could not move, sleep or smile; “she suffered from severe pain until her death.”
Davaasuren has assured that such cases are now increasingly rare. “Learning palliative care, doing palliative care, I feed my heart and brain,” she said. “I believe that my life has been used well.”
The full list of rankings is on page 15 of the report.
The top 10, in order, were:
- New Zealand
The bottom ten were:
- Dominican Republic