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Changes needed to boost end-of-life care in Canada: doctors

August 24, 2016

TORONTO — Canada needs to broaden its approach to palliative care to provide support to patients with serious chronic illnesses, not just those with cancer, suggests a group of doctors who deal with end-of-life care.

Writing in Monday’s edition of the Canadian Medical Association Journal, the specialists suggest major changes are needed to improve access to palliative care, especially for patients with such conditions as end-stage heart failure and chronic obstructive pulmonary disease, or COPD.

Canada is ranked 18th out of 80 countries worldwide by the Economist Intelligence Unit for provision of palliative care, even lagging behind Mongolia and Panama in strategies to develop and promote such services to patients, the authors write.

“We ought to be doing better and can be doing better,” co-author Dr. Graeme Rocker, a respirologist at Dalhousie University, said in an interview from Halifax. “And it wouldn’t take a seismic change for us to achieve a higher level.

“Our aim isn’t to be increasing our ranking, as it were, but it’s (about) providing adequate care to the patients who need it.”

Rocker said studies show that two-thirds of the estimated 250,000 Canadians who die each year have illnesses other than cancer, yet most don’t have access to the same types of palliative support as do cancer patients. For instance, only 20 to 30 per cent of those referred to a hospital palliative-care unit have a non-cancer illness, research has found.

He and co-authors Drs. James Downar and Sean Morrison, palliative-care specialists at the University of Toronto and the Mount Sinai School of Medicine in New York, respectively, say all doctors should be trained in the provision of end-of-life care, in part because there’s a dearth of palliative-care physicians.

The Canadian Society of Palliative Care Physicians has fewer than 500 members across the country, far below the number of practitioners in such specialities as cardiology or oncology, although some primary-care doctors also provide end-of-life care for their patients.

“There’s a tendency for all of us to manage patients with the standard treatment approaches and then when things start turning really bad, we might be asking our palliative-care colleagues to become involved and take over the management of the patient in the late stages,” explained Rocker.

“But we can’t rely on that for the future because there simply are not enough palliative-care specialists or palliative-care nurses who can provide that level of support for what will become an increasingly large number of elderly patients in Canada with chronic illness and multiple interacting symptoms.”

Dr. Cindy Forbes, outgoing president of the Canadian Medical Association (CMA), said Canada does not have a national palliative-care strategy, but the doctors group is pressing the government to include end-of-life services in the new Health Accord being negotiated between Ottawa and the provinces and territories.

“The Liberal Party in its platform and during the election campaign promised $3 billion for home care. It’s certainly our understanding that it’s their intention to include home care and palliative care (within that funding),” Forbes said Monday from Vancouver, where the 83,000-member organization is holding its annual meeting.

“So we are going to push to make sure they honour that promise,” she said. “So one of our objectives is to make sure that every Canadian has access to palliative care.”

That’s also the mandate of the Canadian Hospice Palliative Care Association (CHPCA), which advocates for an approach that integrates end-of-life services into regular care by general and family practitioners looking after patients with frailty, dementia or chronic diseases like COPD or advanced heart disease.

Expanding the scope of palliative care beyond specialists in that field is critical with the aging population, agreed CHPCA executive-director Sharon Baxter, who pointed out there are fewer than 85 residential hospices “in the whole country,” with an average capacity of only nine beds.

“We’re talking hundreds of beds, not in the thousands of beds,” Baxter said from Ottawa. “So if a person has been taken into hospital and they could benefit by going into a residential hospice, they’re not always in every community. They don’t always have empty beds.”

Rocker said not only must access to end-of-life care be expanded overall, but it also needs to be refocused so more services are offered to patients in their homes or in community-based hospices, rather than delivered primarily in acute-care hospitals.

Surveys have repeatedly shown that most Canadians want to die at home or in a hospice when the time comes, but too often a lack of community-based services means patients end their lives in a hospital bed.

“There are many places throughout Canada where there simply isn’t access to that kind of care at the end of life,” Rocker said. “So what choice do patients and their families have if they can’t die at home?

“What other alternative is there, other than an acute-care facility, which is the last place really that patients want to go?”