Apparently the United Kingdom is the best place to die, followed by Australia, New Zealand, Ireland, Belgium and Taiwan. The Economist Intelligence Unit has ranked countries in terms of 20 quantitative and qualitative indicators which measure the effectiveness of end-of-life care. The measures include the quality and affordability of palliative care, as well as society’s attitude towards it. In the United Kingdom the hospice movement, which delivers much of the country’s palliative care, is funded largely through charitable donations. It falls to position 17 looking at healthcare spending alone, perhaps showing that is up to all of society to care for the dying and that individuals can make a real difference.
This issue is an important one. Many people call for the option to end the lives of the terminally ill because they are afraid people will have to suffer too much pain. However, with good hospice care and pain management, in reality the terminally ill rarely need experience a physically painful death. Dr Pollock, who is principal research fellow at the University of Nottingham’s Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care commented of the study that the involvement of hospital staff in addition to family members is often helpful, as most people do not want their death to be a “burden” on their families and will worry about this. It is up to all of us, together with government services, to help to support friends and loved ones. Surely the most basic thing we can do is recognise the worth and value of their lives, reassuring them that it is not a ‘burden’ for others to care.
Further evidencing that determination and a society that values palliative care are just as important as funding, one of the most remarkable findings in the report is that Mongolia now leads the low-income countries, ranking 28th overall ahead of many more advanced economies with many more resources. Mongolia is a poor country that only 15 years ago had no hospices or palliative care teaching programmes at all. Its turnaround is largely attributed to the work of a single doctor, Odontuya Davaasuren, a pediatrician who learned about the latest advancements in end-of-life care at a conference in Sweden and wanted to apply what she learnt to her home country. Her work has helped to establish 10 palliative-care facilities in Ulaanbaatar, affordable morphine is now available and prescribed more widely, and provincial hospitals are now able to accommodate terminally ill patients. There are also nursing, home care, and spiritual and social services. Palliative care is now included in health and welfare legislation and taught at medical schools. Ranking just behind Mongolia, Uganda has also dramatically increased the availability of morphine through a public-private partnership between the health ministry and Hospice Africa, a British charity.
However, some countries that might be expected to perform more strongly given rapid recent economic growth, such as China and India, are not doing so well. In China a rapidly ageing population makes the result particularly worrying. The adoption of palliative care in China has been slow and the government is only just beginning to recognise its importance by providing more funding and facilitating better awareness. Traditionally the family unit looked after elderly relatives making government resources unnecessary, but the one child policy has now made this untenable.
Outside of China’s 400 specialised cancer hospitals, there are still only a handful of charity hospitals and community health centres that offer palliative care services to patients. China’s overall ranking of 71st out of 80 countries reflects the limited availability, cost and poor quality of palliative care. Shi Baoxin, director of the Hospice Care Research Center at Tianjin Medical University, comments that “It’s hard for hospice care to develop mainly because of the lack of education about death,” and this factor also makes effective psychological treatment of dying patients more challenging.
In spite of recent progress around the world, the Economist Intelligence Unit shockingly notes that experts estimate that globally less than 10 percent of people who require end-of-life care actually receive it. As populations live longer, society must now also grapple with the pain management of people who might acquire multiple diseases and require complex and costly management. Developing countries with less money available obviously find the pain management of the dying the most challenging. However, Mongolia’s inspiring story shows that, even when money is an issue, good pain management is possible when society values hospice care and the comfort of the dying, and we all work to achieve it.