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A life or “good death” situation? A worldwide ecological study of the national contexts of countries that have and have not implemented palliative care

Clark, Joseph; Barnes, Amy; Campbell, Mike; Gardiner, Clare


Joseph Clark

Amy Barnes

Mike Campbell

Clare Gardiner


Context: Palliative care advocates argue that service implementation is feasible in all settings. Yet, services have developed patchily in low- and middle-income settings. Beyond Human Development Index indicators, there has been limited engagement with the broader development challenges facing nations tasked with implementing palliative care. Objective: The objective of this study was to describe how indicators of national development relate to levels of palliative care services in 207 countries around the world. Methods: We conducted a ecological study to identify relationships between potential predictor variables and the level of national palliative care development. A total of 28 predictor variables from the following six domains were selected using hypothesized relationships with levels of palliative care development: disease demographics, socioeconomics, health systems, politics, demographics, and economics. The outcome variable was level of national palliative care development on a six-point scale. Spearman's correlation was used to measure the strength of the association. Results: Twenty-six of 28 variables were statistically significantly associated with levels of palliative care development in 207 countries. Palliative care is more developed in countries with high—percentage of deaths from noncommunicable disease, population proportion aged 65+ years, gross national income, and tourism. Development is lower in countries with high levels of political corruption, infant mortality, deaths by infectious diseases, and weak democracy. Prevalence of undernourishment and levels of private health expenditure were not significantly associated with palliative care development. Conclusion: Palliative care development is highly consistent with broader national development indicators. It is less in countries where sudden deaths are more likely and benefits from palliative care provision are likely to be very limited. In such countries, resources may be prioritized toward life-prolonging therapies and key aspects of palliative care need only be implemented before fully integrated palliative services. Findings suggest that there may be a “tipping point” in societies, where the relative need for life-prolonging therapies becomes less than the need for integrated palliative care services.


Clark, J., Barnes, A., Campbell, M., & Gardiner, C. (2019). A life or “good death” situation? A worldwide ecological study of the national contexts of countries that have and have not implemented palliative care. Journal of pain and symptom management, 57(4), 793-801.

Journal Article Type Article
Acceptance Date Dec 5, 2018
Online Publication Date Dec 27, 2018
Publication Date 2019-04
Deposit Date May 15, 2019
Publicly Available Date Dec 28, 2019
Journal Journal of Pain and Symptom Management
Print ISSN 0885-3924
Electronic ISSN 1873-6513
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 57
Issue 4
Pages 793-801
Keywords Anesthesiology and Pain Medicine; General Nursing; Clinical Neurology
Public URL
Publisher URL
Related Public URLs
Additional Information ©2019, Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license


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