Five years ago, The Economist commissioned a report on the quality
of death throughout the world. Now, the magazine has issued an all new report
on the same topic, expanding and improving its methodology and increasing the
number of countries studied from 40 to 80. Whenever this kind of global study
is released, my interest is in how the US performed and in what we can learn
from other parts of the world, much as I wrote about in my recent posts on the
WHO Report on Ageing. And as usual, the interesting part is not so much the
bottom line—the US came in 9th among the 80 countries surveyed—as
the specific strengths and weaknesses that determined the bottom line.
The report broke down its assessment into 5 domains:
palliative and health care environment; human resources; affordability; quality
of care; and level of community involvement. The first 3 areas each contribute
20% of the overall score, quality contributes 30%, and community involvement
10%. If we look at each of these areas, what we find is that the US
sub-rankings were 6, 14, 18, 8, and 9, which is to say we were dragged down by
a relatively weak supply of palliative care professionals and by high costs. In
the areas of national policy towards palliative care, quality of care, and
public awareness, we were strong but not superlative. In other words, while we
have made enormous strides in training a palliative care workforce, developing
fellowship programs for physicians, nurse practitioners, and social workers, we
have a long way to go, given the size and aging of our population.
What is particularly noteworthy is the case of Taiwan, which
the report regards as a model to watch and to emulate. Taiwan ranks number one
in Asia, and #6 overall. It has successfully increased the number of hospices
by 50% between 2004 and 2012; and it has markedly changed its culture to
encourage discussion of prognosis. In Taiwan, everyone has a health insurance
card that includes key medical information, and older individuals now often
include their code status on this card. In addition, the country is piloting a
program to monitor end of life care in rural areas using smartphones and
tablets. It has published resources for caregivers in six languages. And it
allows patients and their caregivers to Skype with their doctors.
Taiwan is not the only country that out-performed the US (the
other 8 are the UK, Australia, New Zealand, Ireland, Belgium, Taiwan, Germany,
and the Netherlands. At least in healthcare, particularly for older people and
those near the end of life, American exceptionalism is a myth. We can do
better, and we should.
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