Palliative care in Canada ‘is inadequate and must adapt,” charges an article published today in the Canadian Medical Association Journal.
Canadian palliative care is still mostly geared to end-of-life treatment of cancer, though most Canadians actually die of something else, the study’s authors write.
“Somebody who’s in a large urban centre who’s dying of cancer is very likely to get good palliative care, but people dying of anything else, anywhere else, are not that likely to get good palliative care,” says James Downar, a Toronto doctor who co-wrote the article.
The last stages of life are fairly predictable for terminal cancer patients, but less so for people dying slowly of heart disease.
WATCH: The Canadian Cancer Society says end of life care is not available to all Canadians and many are falling through the cracks at a time when they need compassionate care. Jacques Bourbeau looks at the effect and how things need to change.
“Admission to a palliative care setting favours those who have a more predictable trajectory, who have an expectation of death within a certain time frame. That’s very difficult to predict with people with chronic illness,” explains Graeme Rocker, a Halifax doctor who was another co-author.
“Patients who live with, for example, COPD, (chronic obstructive pulmonary disease) may have a relatively poor functional status for a year or more.”
The result is that cancer patients are five times more likely to get palliative care than people suffering from organ failure, and 10 times more likely than people whose lives are ending through general frailty.
More broadly, Downar points to a cultural problem in health care: although we all die, medicine seeks to conquer disease and prolong life. Managing and easing death can feel like a betrayal.
“Acknowledging the transition to comfort care can sound an awful lot like defeat. You become a defeatist, a traitor, almost. That’s a problematic concept in medicine.”
READ MORE: Palliative care crisis in Canada
One result, Rocker says, is that palliative care becomes literally the poor cousin of other branches of medicine — it gets little grant money compared to other fields in health care.
An Ontario report showed that palliative care services typically expect patients to die less than three months after admission. While this often meets the needs of cancer patients, those with other diseases, like congestive heart failure, can have a much longer “dying trajectory” and need care for longer.
Lacking other options, people end up dying in hospitals, which often lack the calm and comfort that the dying need.
In a recent medical journal article, 52 per cent of the Canadian deaths studied took place in hospital, as compared to 42 per cent of comparable deaths in England. A survey of end-of-life cancer cases in seven developed countries showed that Canada had the highest rate of people dying in hospital.
“They’re not dying where they want to die, they’re dying in a place that is really not comfort-focused, dying in a crowded medical ward that is noisy, that is not peaceful, that is not comfort-oriented, being cared for by staff who may not be comfort-focused staff,” Downar says.
“The irony of this situation is that it’s also the most expensive bed in the system. We’re relying on it because we don’t have sufficient resources in the other settings.”
One solution is to help the dying stay at home.
“If most people had the choice, they would prefer to die at home, receiving supportive care in their home environment,” Downar says.
The authors point to several home-based palliative care systems that work in Canada: Nova Scotia and P.E.I., for example, let paramedics manage home-based palliative care.
“As the population ages, and more people will be living longer, and have chronic illnesses with multiple symptoms, they impose a huge burden on their families and the health care system,” Rocker says.
“Our current model of care is not coping already, and will certainly not cope in the future.”
About 250,000 Canadians die every year.
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