Palliative care gets a 'D' in Canada

Canadians like to praise our health care system. You won't believe how poor we do at palliative care.
Quebec city's healht agency has confirmed the first known case in Canada of someone legally receiving medical aid in dying. (Canadian Press)
Canadians like to praise our health care system. You won't believe how poor we do at palliative care.

This year alone, a quarter of a million Canadians will die -- many with pain and other symptoms that are left untreated. The reason is a lack of access to palliative care. An article just published in the Canadian Medical Association Journal (apologies for the paywall) offers some fixes. 

Palliative care is defined basically as care that doesn't cure but instead improves quality of life - usually by controlling symptoms such as pain. Many studies and reports have documented a lack of palliative care services in Canada.  According to the 2015 Quality of Death Index report prepared by the Economist magazine's Intelligence Unit, Canada ranks 18 out of 80 nations in availability of palliative care services.  The results aren't terrible; they're kind of mediocre.  Canada ranks behind Panama and Mongolia in efforts to develop and promote palliative care.  The bottom line is that the majority of people who might benefit from palliative care in this country won't have access to it.

You may wonder why Canada doesn't have a better record. The authors of the article in CMAJ say Canada relies too much on doctor specialists in palliative care. Currently, the country is facing a serious workload shortage. The Canadian Society of Palliative Care Physicians the organization that promotes access to palliative care for all Canadians has just 500 members.  A 2015 report by the Canadian Medical Association found that in 2012, just 0.28% of all Canadian doctors worked in palliative, compared to 0.52% in the U.S. and 0.38% in Australia.  Other problems include a chronic shortage of palliative care beds and even fewer hospices. 

Devoting more doctors and more beds to palliative care won't be enough to fix the problem, say the authors of the article in CMAJ.  They argue that palliative care runs under a model that is out-date:  a model geared to provide supportive care for people with cancer who have just three to six months to live.  The authors argue that deaths not due to cancer make up two-thirds of all deaths in Canada - a huge cohort that is largely under-served by palliative care. 

We're talking about frail seniors who don't have cancer but do have diseases like chronic heart and kidney failure, chronic obstructive pulmonary disease (COPD) and chronic pain due to severe arthritis of the back.  Those patients are far less likely than cancer patients to get palliative care.  Though palliative and hospice programs claim to provide comprehensive support, the authors say that support is often limited to treating pain.  They say that palliative care units rarely provide non-invasive ventilation to people with advanced COPD who are having trouble breathing, or dialysis for symptom relief in people with advanced kidney disease.

As the family member or the friend of people with cancer, I've seen examples in which they receive excellent care and examples in which they receive lousy care or no care at all.  For people who don't have cancer, palliative care is not even on the radar screen.  As an ER physician, not a shift goes by that I don't see people who could benefit from palliative care who don't get any at all. I'm talking about people with chronic heart and lung disease.  They don't get referred to palliative care doctors. If they do receive palliative care, it's at the very end of life at a time when they get very little benefit out of it. 

More specialists aren't the answer because you can't crank them out fast enough.  The authors of the CMAJ article say we need to spread the work among family doctors, registered nurses and nurse practitioners, social workers and home health workers.  They say specialists and family doctors should receive mandatory training in palliative care including non-cancer patients.  Instead of demanding more beds, palliative care services at home must be beefed up.

Most important, care must be geared to non-cancer patients.  A program in Halifax for people with COPD called INSPIRED COPD Outreach Program teaches patients how to manage many of their own symptoms.  Every 26 patients enrolled in the program saves the system $100,000 in hospital costs.  Thirty-eight per cent of patients enrolled were able to die at home instead of hospital; that's a big improvement on prior experience. 

The potential payoff for improved palliative care is huge.  Unless the demand is addressed, the problem of inadequate and inappropriate palliative care will only get worse.


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