October 12, 2015

The Quality of Death

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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