In Canada, 61 per cent of deaths occur in hospital. By comparison, that number sits at 30 per cent in the Netherlands, and 20 per cent in the United States.
This is a gross systemic failure, and a tremendous waste of money. It’s also the polar opposite of what people say they want – which, ideally, is to die in a homelike setting, surrounded by family and friends. Only about 15 per cent of Canadians die at home, despite polls that consistently show that is the preference of about 85 per cent of the population.
And when Canadians do get access to palliative care, it’s rarely in an appreciable way. Too often, we are dying in pain, scared and alone – overtreated and under-cared for.
“Canadians spend more on end-of-life care than other high-income countries, including the U.S., yet we achieve poor results compared to most,” according to Kieran Quinn, Sarina Isenberg and James Downar, the perhaps overly polite authors of a new report published by the C.D. Howe Institute that focuses on the economics of Canada’s end-of-life problem. “There are structural factors and inefficiencies within our health care system that facilitate unhelpful and unwanted medical interventions at the end of life.”
When you are speaking to politicians, they say, you need to speak their language: in terms of money. But this is about much more than money. It’s about respect and dignity, especially of our elders.
Each year, about one in every 100 Canadians dies. The vast majority of those deaths, 80 per cent, are people over the age of 65. And most die of chronic illnesses like cancer, cardiovascular disease, diabetes and COPD (chronic obstructive pulmonary disease). In other words, the way people decline and die is actually fairly predictable. So why do so many people – three in five – end up dying in hospital, where they often get all manner of unnecessary treatment in intensive care units?
It’s not because health care workers are unfeeling or uncaring, argue the report’s authors, who either research or work in palliative care. It’s because of they way the system is structured.
To begin with, Canada has far too few palliative care beds, where the focus is on easing pain, in hospitals. In Ontario, it’s about two per 100,000 population, according to 2014 data; that is less than half the number in the U.K., at 4.2 per 100,000 population as of 2017.
Hospice beds, in specialized facilities that deliver end-of-life care, are even rarer. There are about 270 in all of Ontario. The provincial auditor-general calculated that an adequate number would be somewhere between 945 and 1,350 hospice beds.
Further, hospices depend largely on private funding and charitable donations to operate. They are not an integral part of Canada’s much-loved medicare system.
Then there is home-care, which is largely assumed to be responsible for palliative care, but simply doesn’t have the resources to deliver. Out-of-pocket costs for families can be astronomical.
Perhaps the greatest perversity of Canada’s end-of-life care, however, is in our long-term care homes. Despite the fact that LTC homes are places people go to live out their final days, only six per cent of LTC residents benefit from palliative care.
During the COVID-19 pandemic, long-term care homes have been ravaged; more than 18,000 of Canada’s 28,800 pandemic deaths have occurred in these congregate settings. Palliative care services were non-existent in these facilities.
Money and beds aren’t the only problems. There is a lack of trained personnel in institutional settings, a lack of support for families trying to care for dying loved ones at home – and a lack of co-ordination of care system-wide.
We also have a death-denying culture that makes it difficult to discuss these issues openly, which discourages people from doing advanced care planning.
Most of the health care costs in our lifetimes are incurred in the final months, and so it only makes sense that we should pay attention to those. And the cost of treating, say, a cancer patient during their last six months of life is twice as high in Canada as in the Netherlands. That’s not because Dutch patients are denied care; it’s because they’re spared unnecessary care. The C.D. Howe report suggests that $400-million a year worth of medicare savings could be found simply by getting dying patients in appropriate settings – by focusing on quality of life, rather than on invasive, often inappropriate acute care.
That’s what palliative care is all about: Controlling symptoms, minimizing pain and giving people a sense of comfort and control in their final days.
Providing good medical care to save lives is important. But so too is ensuring everyone has a good death.
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