The discussion on the WHO palliative care indicator – good or not good enough?

Lukas Radbruch is a board member of the International Association for Hospice and Palliative Care (IAHPC) and was president of the EAPC from 2007 to 2011

Carlo Leget, vice-president of the EAPC, has started a discussion on the indicator: “Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer”, which is part of the suggested set of indicators and targets for 2025 for the global monitoring framework for non-communicable diseases (NCDs) that have been suggested by WHO in a discussion paper launched in March 2012.1

He rightly raised a number of critical points with this indicator, inviting us to start a discussion on the suitability of that indicator. Not that any easy answer is likely; some research groups, including our own here in Bonn, Germany, (Pastrana et al. 2008, Stiel et al. 2012, Stiel et al 2011 2,3,4) have been working for some time now on the definition of suitable indicator sets for palliative care. We all have failed until now to find such an indicator set, let alone a single indicator that would cover all of palliative care.

However, WHO is looking at the development worldwide and is probably more concerned about developing countries, and I think they are right to do so. The number of people who do not have access to opioids for cancer pain management is so great in Africa, Asia and Latin America, and these patients need pain relief first of all and other interventions only later. This is not about finding the optimal indicator set for developing countries; this is a public health approach. Look at it in a different way and see that the glass is half full, not half empty: WHO has selected only 12 indicators, and has included palliative care! So palliative care is among the top 12 issues on the global health agenda, on the same level as access to basic technologies and medicines (which is another of the indicators). Isn’t that an achievement?

The board of directors of IAHPC has recently discussed the indicator proposal, and though there was criticism from all around, the board also agreed that having an indicator on palliative care included in the WHO set is a great step forward indeed.

I agree that the indicator may be not good enough in our specialist perception. But it is not only good, but great, to have this indicator included in the set of 12 WHO indicators. If you see the film ‘LIFE Before Death’ ( and hear Henry Ddungo say that he would like to give the crying patient next to him morphine, ‘but unfortunately they are out of stock today’, that is where the indicator is needed.

1.World Health Organization (WHO), 2012: Second WHO Discussion Paper (version dated 22 March 2012). A Comprehensive Global Monitoring Framework including Indicators and a Set of Voluntary Global Targets for the Prevention and Control of Non-communicable Diseases. (accessed 12 April 2012).
2. Pastrana T, Jünger S, Ostgathe C, Elsner F, Radbruch L. A matter of definition –key elements identified in a discourse analysis of definitions of palliative care. Palliat Med 2008; 22(3): 222-32.
3. Stiel S, Pastrana T, Balzer C, Elsner F, Ostgathe C, Radbruch L. Outcome assessment instruments in palliative and hospice care – a review of the literature. Support Care Cancer 2012.
4. Stiel S, Psych D, Kues K, Krumm N, Radbruch L, Elsner F. Assessment of quality of life in patients receiving palliative care: comparison of measurement tools and single item on subjective well-being. J Palliat Med 2011; 14(5): 599-606.

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