Two recently released reports emphasize the need for a continued spotlight on palliative care
By Derek Miedema, Researcher,
Two recently released reports pay attention to the need for palliative care in Canada. The Institute of Marriage and Family Canada released Achieving Quality Palliative Care in Canada this week. The paper tells the story of palliative care in Canada, through the voices of palliative care heavyweights, Senator Sharon Carstairs (retired) and Dr. Balfour Mount, a Montreal-area oncologist. In a ten-page, easy-to-read format, the report highlights the five Ws of palliative care, stressing that this specialty is in dire need of attention because we have an ageing population. If current levels of palliative care remain the same, we are going to experience decreased access, simply because more people need it.
Similarly, on November 17, 2011, the Parliamentary Committee on Palliative and Compassionate care released a 200-page report. Not to be Forgotten: Care of Vulnerable Canadians examines three aspects of care: Palliative care, suicide prevention, and the prevention of elder abuse. With respect to palliative care, the report thoroughly examines the current situation in our country and makes recommendations for future developments in expertise and delivery. Most importantly, the report states that “palliative care is not only the best model for caring for vulnerable and dying Canadians; it also embodies truths that could be transformative for our whole health care culture.”  In other words, current palliative care practice should be adapted to animate disciplines across the entire medical system for the benefit of vulnerable Canadians across the country.
This was an all-party committee and they traveled the country conducting hearings and listening to the stories of Canadians with regards to palliative care, suicide prevention and elder abuse. While the committee report is not binding, it offers a thorough understanding of these issues.
How can palliative care transform our health care system?
The report lays out several ways that improved palliative care can change the medical system for the better. In place of medical disciplines currently separated from one another as though in silos, integrated care through all stages of a disease trajectory could benefit all patients with a long-term illness in the following ways:
Palliative care can be delivered by the same people from home to hospice to hospital. In this way a person’s caregivers can remain constant to ensure continuous care through all its stages.
How could this reality be translated to the entire healthcare system? Palliative care offers a model through the fact that it is “person-centred, family-focused and community based”.  The report states that:
Palliative care delivery could be coordinated to the needs of the client in a much more seamless fashion, with for example the home care team introducing palliative principles from the very beginning of the care relationship… Should a person not be able to live at home until they die, palliative care in a LTC facility, or residential hospice is needed. This could be seamlessly arranged by the client’s integrated continuing care coordinator. Palliative care becomes a gradual and normal transition within the continual care process.” 
Such integrated care would mean that a person could have the same palliative caregivers from the moment of diagnosis to the moment of death, greatly reducing their stress of being unknown to successively new caregivers.
Home care services are a vital part of health care services in Canada, especially in the context of an aging society. Supports for caregivers, such as a hospice volunteer who visits for a few hours a week, can be vital to maintaining their health. If caregivers break down under the stress of caring for their loved one, then they and the government will need to shoulder the cost of a long-term care home. Providing home care services for a few hours each day is much cheaper than paying for a bed in a long-term care facility.
The report notes that “a palliative care bed in a hospital is estimated to cost $600-800 dollars per day compared to $200 a day to have such a bed at home or $300 a day to maintain a bed at a community based hospice.”  If the expansion of palliative care services takes dying patients out of acute care wards, this could result in savings.
What needs to improve?
The report makes clear that there is still much work to be done to improve palliative care delivery in Canada. The recommendations below must be considered in the context of scarce government resources.
Expansion of services
The Canadian Cancer Society estimates that only between 16 and 30 per cent of Canadians have access to quality palliative care.  Government investment is paramount if the excellent palliative care currently provided in local pockets is to be made available to everyone across the country, no matter where they live. In particular, the report states, “Canada needs to develop its capacity for residential hospices. Provinces need to adequately fund the operating costs of these facilities. Hospices across the country spent enormous amounts of time and energy struggling to raise the funds to stay open. This time and energy could be better utilized in care giving, if governments would supply adequate funding.” 
Too many people in Canada are dying painful deaths. This is partly because palliative care is not equally accessible throughout the country, neither through direct care nor through referral. More importantly, pain control is a struggle because we don’t teach it well in our medical schools. From the report: “the mean number of hours designated for pain teaching over the entire academic training program (of pre-licensure health science and veterinarian training) was 15 for dentistry, 16 for medicine, 31 for nursing, 28 for occupational therapy, 13 for pharmacy, 41 for physical therapy and 87 for veterinarians.” 
A veterinarian receives five times the number of hours of pain teaching as a medical doctor. Clearly, such education must be expanded so that even general practitioners across the country would know enough to keep their patients comfortable until they can refer to a pain control specialist.
To this end, the Committee urges health care practitioners “to treat pain as the ‘fifth vital sign’, and to regard pain management as central to their vocation.” 
The Canadian Cancer Society estimates that the work of caregivers in Canada could be valued at $25 billion in 2009, were it paid labour. 
Caregivers face the stress of everyday life combined with the stress of caring for a loved one as they deteriorate. The report argues that “as the population ages and as more people require care, we must look at ways to support and sustain the precious resource of family caregivers; giving them the tools they need to carry out their vital role, while maintaining their health and equilibrium. If we don’t we risk the situation where we will have to treat two severely ill patients rather than one.” 
One way that government helps caregivers is through Compassionate Care Leave through Employment Insurance. With respect to Compassionate Care Leave, the committee recommends that “the federal government expand the provisions of the E.I. based compassionate care benefit to a minimum of 26 weeks coverage” and makes the benefit flexible, “allowing caregivers leave for episodic caregiving needs.” 
Government itself can never take sole responsibility for this aspect of caregiver support. Yet as the report recommends, government needs to partner with local communities to fund local hospice services. This would allow local hospice organizations to lessen, but not do away with their reliance on fundraising and therefore dedicate more time to providing care to their community. In this way, more people living with illness can have palliative care delivered in their home. And, if the need arose to leave home for full time care, the person could still remain in their local community.
We must work to recognize palliative care as a necessary part of our healthcare system and this report helps identify this. Then we can work to ensure people receive the dignified, quality care they need, throughout life and especially before death.
Download the full report here.
 Albrecht, H., Comartin, J., Valeriote, F., Block, K., Scarpeleggia, F., et al. (2011, November 17). Not to be forgotten: Care of vulnerable Canadians. p. 23. Retrieved November 24, 2011 from http://pcpcc-cpspsc.com/wp-content/uploads/2011/11/ReportEN.pdf
 Ibid., p. 23.
 Ibid., p. 26.
 Ibid., p. 28.
 Canadian Institute for Health Information. (2007). Health care use at the end of life in Western Canada. Retrieved December 5, 2011 from http://secure.cihi.ca/cihiweb/products/end_of_life_report_aug07_e.pdf (The committee notes that 16 per cent likely represents access on average across the country, with 30 per cent availability only in metropolitan areas.
 Ibid., p. 27.
 Watt-Watson, J., McGillion, M. et al. (2009). A survey of pre-licensure pain curricula in health science faculties in Canadian universities. Pain Research and Management. Vol. 14, No. 6), pp. 439-444. Retrieved November 30, 2011 from http://www.pulsus.com/journals/abstract.jsp?jnlKy=7&atlKy=9192&isuKy=888&isArt=t&HCtype=Consumer
 Albrecht, H. et al., p.47.
 Canadian Cancer Society. Success stories. Retrieved December 1, 2011 from http://convio.cancer.ca/site/PageServer?pagename=GEN_CAN_fight_success_stories
. Albrecht, H., et al., p. 61.
 Ibid., p. 64.