The World's Worst Places to Die

  • Many Ways to Die

    The Hippocratic Oath dictates “first, do no harm.” When it comes to dying however, there are many interpretations of what is harmful and helpful to a patient. Many doctors trained to aggressively treat any condition in order to prolong life view any mitigation of their efforts as harmful. Others, who emphasize both mental and physical health, see prolonging life in a vegetative state as harmful. The culture of dying varies from one country to the next, as people talk, treat and grieve death in different ways due to religion and culture. And just as some countries enjoy a better quality of life, some enjoy a better quality of death. With this in mind, the LIEN Foundation, a group dedicated to “radical philanthropy," commissioned a study to look at the quality of death around the world. Photo Credit: Adrian Boliston
    What Makes a "Good" Death?
  • What Makes a "Good" Death?

    The report, produced by the Economist Intelligence Unit, ranks 40 countries on 24 different indicators to assess the basic end-of-life health care environment. Such factors include whether doctors discussed death with patients, and the availability, cost and quality of end-of-life care. By weighing these indicators separately — quality of end-of-life care is given the most weight — the report reflects how well different countries address the needs of those who are dying. This report evaluates 40 countries based on availability of data and the existence of some sort of health care. It does not consider countries where death tends to occur outside of any health care system at all. Surely it's worse to die in a country without health care, but such examples have more to do with a nation’s health care system in general than how it deals specifically with death. We have included per-capita health care spending by each country’s government, from the UN’s most recent Human Development Index, in 2009. Generally speaking, hospice and palliative care at the end of life reduces aggressive (i.e. expensive) interventions, making health care more affordable to all. So, a comparison between a country’s quality of death and its ranking for health spending speaks to the efficiency of those countries’ systems. Photo Credit: Jose Goulao
    5th Worst Country to Die in: Mexico
  • 5th Worst Country to Die in: Mexico

    In U.S. headlines, death in Mexico mostly pertains to the country’s drug trade, not its hospitals. Mexico gets good marks for the existence of an official national palliative care strategy and life expectancy, but it's health infrastructure is lacking. Medicines are in short supply, the number of doctors, nurses and hospital beds available to dying patients are scarce, and the number of hospices is inadequate for the aging population. While total spending on health care is in the top half compared to other countries, the money spent on end-of-life services is one of the worst. Public spending on health care (per capita): $327 Photo Credit: Linda N.
    4th Worst Country to Die in: China
  • 4th Worst Country to Die in: China

    Caring for such a massive population, and one mostly spread out in rural areas, will likely be a long struggle for the communist Chinese government. Despite several years of high GDP growth, bringing health care to the masses has lagged, and China ranks dead last in the indicators used to assess the availability of end-of-life care in the rankings. Population control, long a priority, has led to a well-established Do Not Resuscitate (DNR) policy, which China gets good marks for in the report. And despite very low per-capita spending on health care, the availability of painkillers in China suggest that with some policy and infrastructure changes, the country can do better at getting medications to those in need. For now, however, the country with more than 1.3 billion people has a difficult time taking care of its dying. Public spending on health care (per capita): $144 Photo Credit: Randy Pertiet
    3rd Worst Country to Die in: Brazil
  • 3rd Worst Country to Die in: Brazil

    Recently Brazil has made strides in improving the health care of its citizens. After almost 20 years of positive GDP growth, life expectancy in Brazil rose to 72.9 years in 2008 from 69.7 just 10 years earlier. The free public health care system improved the country’s health overall, but quality of care at the end of life remains inadequate. Cultural reasons appear to play a role in the very Catholic Brazil, where there is very little public funding for end-of-life care, training for such services in medical schools is uncommon, and there is no official policy or strategy for health care during the final stages of life. Public spending on health care (per capita): $367 Photo Credit: Agecom Bahia
    2nd Worst Country to Die in: Uganda
  • 2nd Worst Country to Die in: Uganda

    Despite being one of the poorest countries in the world, Uganda has at least shown an awareness of the importance of quality care at the end of life. Perhaps also motivated by the idea that proper palliative and hospice care reduce overall medical costs, the Ugandan government has concocted a national strategy for end-of-life care and the public is well-informed about their options. Unfortunately, the AIDS epidemic hit Uganda especially hard, and while the country deserves great credit for reducing the rate of infection (down to 4.1% of the population in 2003), the number of terminally ill AIDS patients face a great lack of resources in the Ugandan health care system. Public spending on health care (per capita): $39 Photo Credit: Gavin Langille
    The Worst Country to Die in: India
  • The Worst Country to Die in: India

    With a population more than a billion, India has one of the lowest per capita spending levels on health care in the world. The economy is growing, but rural and urban poverty is a problem with which the government-funded universal health care system struggles to keep up. Patients pay next to nothing to be seen in state-run hospitals, while the poorest pay nothing at all, making the system entirely dependent on the public budget. What money there is for health care goes primarily toward immunization campaigns and preventing malnutrition, which among other health issues, are prioritized over care at the end of life. There is a ray of hope in the Indian state of Kerala, where the local government achieved notable successes after targeting end-of-life care specifically. But so far those best practices have not been adopted in other parts of the country. Public spending on health care (per capita): $21 Photo Credit: Harsha K R
    5th Best Country to Die in: Belgium
  • 5th Best Country to Die in: Belgium

    In Belgium, the doctors are plentiful and trained in administering end-of-life care. The government has also established a good pension and social security scheme to cover much of the population’s health care costs. Because the system relies on reimbursement for private health insurance costs, out-of-pocket expenses can be high in Belgium, but the overall level of wealth in the country allows for good access to quality care by most of the population. With a clearly articulated national palliative care strategy the system can be improved, but the overall quality of care in Belgium makes it the fifth best place to die. Public spending on health care (per capita): $2,264 Photo Credit: Redvers
    4th Best Country to Die in: Ireland
  • 4th Best Country to Die in: Ireland

    The Irish health care system, nationalized in 2005, had a spotty record in its first few years. This can be attributed to growing pains, but waiting lists drive people to the country’s robust private market for health care. This may change, and for end-of-life care, change is already on the way. The government health service is in the process of developing a national strategy for palliative care. Such a strategy will help keep costs down and leverage the existing health infrastructure to better serve the well-informed public’s demand for better care options. Public spending on health care (per capita): $2,413 Photo Credit: William Murphy
    3rd Best Country to Die in: New Zealand
  • 3rd Best Country to Die in: New Zealand

    New Zealand's public-private hybrid health care system has been successful in keeping down the costs of end-of-life care. A nationally-articulated palliative care strategy ensures that patients are given the right to refuse treatment even if it will shorten their lives. Two attempts have been made to allow for euthanasia or assisted suicide in New Zealand, with the most recent attempt in 2003 only narrowly defeated. With this progressive approach to the quality of care at the end of life, New Zealand is the third best place to die on the list. Public spending on health care (per capita): $1,905 Photo Credit: 111 Emergency
    2nd Best Country to Die in: Australia
  • 2nd Best Country to Die in: Australia

    Australia, like its neighbor New Zealand, has done well at providing for end-of-life services for its population. A strong network of public and private hospitals work together addressing the needs of the whole population. Australia does get marked down in the study for the availability of hospital beds as well as the need for more hospices and palliative care programs. But while there may be room for improvement, the country is doing better than almost all others at caring for people who have reached the end of their lives. Public spending on health care (per capita): $2,097 Photo Credit: Jez
    The Best Country to Die in: United Kingdom
  • The Best Country to Die in: United Kingdom

    During the health care reform debate in the U.S. last year, frequent warnings were made about developing a system based on the British one, which opponents identified as deeply flawed. While the U.K. ranks 18th in cost and a surprising 28th in the ranking for the “basic end-of-life healthcare environment” (likely due to the inefficiencies in the National Health Service), its number one spot in quality and availability of health care put it at number one on the list. With an excellent hospice care network older than any other country’s along with the freedom for patients to pursue palliative care without giving up on curative care (as in the U.S.), the quality of death in the U.K. is the best in the world. That said, the country could improve its public health care system while minimizing costs, making it an even stronger leader in end-of-life care. Public spending on health care (per capita): $2,434 Photo Credit: Sara Richards
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