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Canada slips from Top 10 best places to die

A woman holds the hand of her mother who is dying from cancer during her final hours at a palliative care hospital in Winnipeg July 24, 2010. REUTERS/Shaun Best

Canada slipped out of the global top 10 in the latest Quality of Death rankings released by the Economist Intelligence Unit (EIU), a reflection of increasing costs and a lack of a national strategy on palliative care.

The Quality of Death report ranks 80 countries on palliative and end-of-life care. Countries are scored on 20 indicators in five different categories, for a total possible score of 100. This year the United Kingdom came in first with a score of 93.9, thanks to factors like the integration of palliative care into its National Health Service.

Canada’s ranking at 11th place, with a score of 77.8, puts the country below not just the U.K. but also Taiwan, the United States and France. (In the first Quality of Death report, published in 2010, Canada tied at 9th with the U.S. though the methodologies were different.)

The country lacks a strong national strategy on palliative care, in part because health care is under provincial jurisdiction. But affordability dragged down the country’s score considerably, considering that Canada placed 22nd in that category — despite having a publicly-funded system. This is because much of the end-of-life care in Canada happens outside a hospital setting and many of the at-home costs of palliative care are not covered, Sharon Baxter, executive director with the Canadian Hospice Palliative Care Association, told the Toronto Star.

And another new report shows that dying at home may not actually be preferable, beyond the cost issues in this country.

“When patients wish to die at home, every effort should be made to achieve this outcome. However, until resources are in place to adequately and equitably support home deaths, the current promotion of patient choice risks raising expectations that are not realized,” reads a statement from Kristen Fellow, principal research fellow at the University of Nottingham, on her research into dying at home.

But there is some positive news for Canadians in the Economist’s report. Its writers did find that Canada overall has an adequate number of specialized palliative care professionals, though there may be some shortages in particular regions or support functions. And the country ranked sixth for overall quality of palliative care, which considered factors like availability of opioids to manage pain and support for shared decision-making.

The report also addressed the issue of the right to die and doctor-assisted suicide — something Canada is currently grappling with as the Feb. 6 deadline for new legislation approaches. So far the issue is largely absent from the campaign trail, and no province other than Quebec has publicly released a plan.

But the EIU report cautioned that legalized assisted suicide cannot be seen as an alternative to quality palliative care.

“The reason that assisted suicide laws are polling so well these days is that the public has a well of fear, anger and distrust about the care they will receive and how they and their families will die. And the hard truth is that this is well-founded,” says Dr. Ira Byock, executive director and CMO of the Institute for Human Caring at Providence Health and Services, in the report.

The Economist ranked the 80 countries in the categories of palliative and healthcare environment, human resources, affordability of care, quality of care and community engagement. And for the first time in the report, it compared the quality of a country’s palliative care with its demand for such care. That supplementary assessment looked at factors, including the burden of diseases requiring palliative care, the old-age dependency ratio and the speed of the population’s aging from 2015-2030.

That analysis showed that China (score: 23.3) is particularly vulnerable as its large population ages and the incidence of conditions like cardiovascular disease rises, the report says.

Generally, a country’s income level strongly indicated the quality of its palliative and end-of-life support. But there were some surprises. Panama, for example, ranked 31 and is including palliative care with the country’s primary-care services. And 28th-place Mongolia has an increasing number of hospices and teaching programs thanks to the work of Odontuya Davaasuren, a doctor the report credits with pushing for the country’s national program for palliative care.

The report was commissioned by the Lien Foundation, a charitable organization in Singapore, and more than 120 palliative care experts were consulted in its creation.

The Economist Intelligence Unit and the Canadian Hospice Palliative Care Association could not be reached for comment by press time.