Cross Country Comparison of Expert Assessments of the Quality of Death and Dying 2021.

Journal Article (Journal Article)


Few efforts have attempted to quantify how well countries deliver end-of-life (EOL) care.


To score, grade, and rank countries (and Hong Kong and Taiwan) on the quality of EOL care based on assessments from country experts using a novel preference-based scoring algorithm.


We fielded a survey to country experts around the world, asking them to assess the performance of their country on 13 key indicators of EOL care. Results were combined with preference weights from caregiver-proxies of recently deceased patients to generate a preference-weighted summary score. The scores were then converted to grades (from A-F) and a ranking was created for all included countries.


The final sample included responses from 181 experts representing 81 countries with 2 or more experts reporting. The 6 countries who received the highest assessment scores and a grade of A were United Kingdom, Ireland, Taiwan, Australia, Republic of Korea, and Costa Rica. Only Costa Rica (upper middle) is not a high income country. Not until Uganda (ranked 31st) does a low-income country appear on the ranking. Based on the assessment scores, twenty-one countries received a failing grade, with only two - Czech Republic (66th), and Portugal (75th) - being high income countries.


This study provides an example of how a preference-based scoring algorithm and input from key stakeholders can be used to assess EOL health system performance. Results highlight the large disparities in assessments of the quality of EOL care across countries, and especially between the highest income countries and others.

Full Text

Duke Authors

Cited Authors

  • Finkelstein, EA; Bhadelia, A; Goh, C; Baid, D; Singh, R; Bhatnagar, S; Connor, SR

Published Date

  • April 2022

Published In

Volume / Issue

  • 63 / 4

Start / End Page

  • e419 - e429

PubMed ID

  • 34952169

Electronic International Standard Serial Number (EISSN)

  • 1873-6513

International Standard Serial Number (ISSN)

  • 0885-3924

Digital Object Identifier (DOI)

  • 10.1016/j.jpainsymman.2021.12.015


  • eng