Opinion

Virtual care evens the odds in ‘palliative care lottery’

Avengers: Age of Ultron was a 2015 blockbuster movie from Disney/Marvel Studios. The follow-up sequel to the 2012 Avengers sees Earth’s mightiest heroes facing a villain of their own making, Ultron, a sentient artificial intelligence peacekeeping program created by Tony Stark to help “put an iron ring of protection around the world.” Unfortunately, Ultron comes to view the Avengers, and humanity in general, as a threat to peace on Earth and seeks to eradicate them.

What does this have to do with palliative care in Ontario? Well, Ultron ultimately became “too much of a good thing.” In Ontario, health care shifted to virtual care almost overnight in March 2020 after the World Health Organization declared a global pandemic in response to the spread of COVID-19. More than one year later, virtual care – the use of telemedicine and videoconferencing to deliver health services remotely – has become a mainstay of health in Ontario.

I must admit that I was not an early adopter or even very enthusiastic about virtual care prior to the pandemic. The potential was certainly there in all its glorious promise, but I believed that patients and families would not like it and that the downsides would outweigh the benefits.

Yet, just as I thought that drive-thru coffee (who could be THAT lazy?!) and internet shopping (who would EVER trust their credit card number on the internet?!) would never take off, boy, was I mistaken.

Demand for home palliative care services increased as patients nearing the end of life avoided going to hospital due to restrictive visitor policies and fear of exposure to COVID-19. Most patients at end of life prefer to receive care and die at home. Unfortunately, there is an enormous imbalance in supply of providers to meet demands since there are relatively few home-based providers to deliver such care. With a limited number of palliative care clinicians able to deliver care in the home, virtual care has offered an ideal way to increase the capacity of our system to care for them.

A colleague of mine wrote previously about “the fog of virtual care” and her desire to get back to more face-to-face encounters with patients and families. She is not wrong. There is great value in assessing patients in their home environment. However, I have no desire to see us backslide from this “new normal.”

Previously, I wrote about a patient, Henry Fedak, who would have benefited from earlier engagement with a palliative approach. Henry did, however, benefit enormously from the shift to virtual care.

His wish, similar to the 60 to 80 per cent of patients with serious illness, was to die at home. Henry was discharged from hospital on a Friday afternoon. Our program received a phone call from his son, Brian, around noon on a Sunday. By 11 p.m., Henry was dead. The difference between Henry dying at home and dying in hospital: virtual care.

Through the use of virtual care, we were able to conduct a quick yet focused assessment of Henry’s situation. Based on that, we were able to rapidly initiate home-care services, implement a Do Not Resuscitate order, a home pronouncement plan and a specialized kit of medications aimed at reducing and treating distressing symptoms. In less than 12 hours, we had been able to assess and clarify his goals of care, manage his symptoms, and provide end of life care in his final hours. None of this would have been possible if we were trying to do it all in person.

Virtual palliative care can be a more convenient and efficient delivery model for patients with financial constraints, mobility issues or advanced illness who can’t attend a health-care appointment. It allows providers to see more patients without additional travel time and provide benefits to the health system through reductions in the cost of clinic and hospital resources. Perhaps most importantly, virtual care has been shown to reduce mortality and hospitalization in patients with heart failure, is effective in improving symptoms for patients with anxiety and depression, improves quality of life and reduces acute health-care use in patients with dementia.

A recent survey conducted by the Ontario Palliative Care Network examined the use of virtual palliative care across the province. It found that multiple providers were using virtual palliative care, including physicians, nurses, care managers and social workers. The survey provided valuable insight into how health-care systems may refine virtual palliative care to optimize its future use. For example, virtual palliative care may be inadequate to conduct comprehensive assessments or manage complex symptoms remotely. But it certainly seems well suited to psychosocial support, medication adjustment, routine check-ins and enhancing communication between inter-professional teams of care providers.

Despite its many benefits, there are serious and warranted concerns that virtual care may further exacerbate existing disparities in access to palliative care resulting from 1) personal or sociocultural barriers, including limited comfort with technology, low health literacy, disability, low income and limited English proficiency; and 2) structural barriers, including geographic isolation, limited broadband capacity and unavailability of technical hardware. It may also deepen the divide by depriving rural patients of access to in-person care. Therefore, the adverse consequences of this “digital divide” most prominently affect low-income, rural, disabled, racial and ethnic minorities and older adults.

An article in the BMJ asks, Virtual visits in palliative care: about time or against the grain?

“While the additional value from adding the option of virtual visits is not in question, numerous issues are raised around how to decide between face-to-face and virtual visits in individual cases and how best to set up such provision within an organisation. Unsurprisingly, it appears clear that a ‘one-size-fits-all’ mentality is a poor fit for the individualised needs of the heterogeneous palliative care population. Virtual visits have great potential even if they are not a panacea.”

What I can tell you from personal experience is that virtual care has meant even shorter wait times for our patients to see a palliative care specialist, more same day/next day appointments for urgent referrals and more frequent contact with patients and their family/caregivers overall. Initial data on rural delivery of virtual palliative care also suggests it improves patient, caregiver and provider experience, is effective for patient and medication monitoring, improves quality of life and symptom management, and improves provider efficiency. Our program is carrying a roster of patients far greater than we ever thought possible given our finite resources. Virtual care has truly expanded access to high-quality palliative care in Windsor-Essex. There is no reason why it can’t do the same in the rest of Ontario and across Canada.

Throughout the pandemic, we have conducted a great deal of virtual visits, both initial consults and follow up visits. We have managed patients exclusively through virtual care and home visits but also provided “blended care” by providing care in the most appropriate format.

There’s a saying that goes “there is no greater zealot than a covert.” I am now certainly a convert to virtual palliative care.

Some things in life are obvious improvements on the original, like pineapple on a pizza or mayonnaise on French fries. Like a basic Pokémon, virtual care is the evolution of health care in Ontario. The job of our health-care leaders and decision makers now is to create health policy to ensure all Ontarians have fair and equal access to virtual care.

Back to the Avengers. Thankfully, the risk of a renegade, murderbot AI is low in our case. But there is always that concern about “too much of a good thing.” Like all things, we need to find a balance between face-to-face encounters and virtual care in all areas of medicine, not just palliative care.

Like all technology, it comes with risks and benefits. Virtual care is here now and there is no going back. But overall, virtual care will be a huge step forward in improving access to palliative care and closing the gap that is the “postal code lottery” in Ontario and Canada.

Ed. note: This article is a collaboration between Darren Cargill and Kieran Quinn, but it is written in Darren’s voice.

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4 Comments
  • Terry Tribe says:

    Thank you for your article — valuable reflections on what has changed. As a ‘seasoned’ (i.e. older) Spiritual Care Practitioner, it was challenging to switch to virtual visits when Covid-19 stopped in-person appointments. It felt daunting to imagine sojourning with patients and loved ones without using the power of presence and the physical cues that are a valuable part of those visits. However, after a 79-y/o spouse proudly contacted me on Skype (I had already used the phone, Zoom and FaceTime), I knew that establishing warm, supportive relationships could transcend the familiar face-to-face meetings. I’ve been humbled and in awe of the deep, trusting conversations that have allowed patients & loved ones to reconcile existential angst, sort through conflicts and find spiritual peace.
    Earlier this month, during a final conversation, a patient told me how helpful our conversations had been in helping her to tell her story and by doing so, come to terms with her life ending illness. Though we never met in person, the Power of the Universe (she would say, “God’s Love”) connected us in a most helpful way.
    (Fighting against Pandemic isolation… one virtual visit at a time!)

  • Albert J Kirshen says:

    Darren and Kieran: I would submit that your ability to help this individual was not as much due to virtual care, as it was attitudinal on your part. Not all services can jump in, as you did, on a weekend. Not all Home Care services in Ontario are as flexible as yours, to start all that up in his last 12 hours. For that you should both be commended. At the same time, I worry about the impacts on you and your team if you are not properly resourced to do just what you did. As I age, I’m finding it more difficult to work my normal 12-13 hour, 6 day per weeks as I used to. I find I need additional time to “recharge my batteries”. So thanks for being a role model in this, but please talk about self-care amid all this, and placing limits.

    In addition, while I agree and try to act to behave as you did, what harm are we doing to the Family physician’s relationship with THEIR patient? What has our role, and that of other specialists, been in distancing patients and Family physicians by taking specific responsibility, and diluting their connection? In gaining more medical knowledge and specialized expertise, have we “sliced and diced” the patient into their component parts instead of their whole person?

    —Albert

    • Darren Colin Cargill says:

      Hi Albert,

      First, great to hear from you! Long time no chat, I hope you are doing well my friend.

      I can’t disagree with anything you are saying in the first paragraph. Services should be properly resourced and burnout is a serious concern.

      As for the second paragraph, the patient in question had a fantastic family physician that I know quite well. He is a pillar of our community. This physician regularly refers to our program, which is the highest of compliments. I even helped to take care of his own father at EOL, also a physician.

      Our program never removes the family physician from the patient’s team. We simply join the team. We invite every family physician to continue to participate in their patient’s care and encourage them to visit patients when admitted to our hospice residences.

      Great points. Thanks Albert.

  • Darren Colin Cargill says:

    TY Healthy Debate for posting my joint collaboration with Dr. Quinn. The smart parts are his.

    Look forward to everyone’s questions, comments and gratuitous insults.

Authors

Darren Cargill

Contributor

Dr. Darren Cargill is a fellow of the College of Family Physicians of Canada, the Royal College of Physicians of Canada, and American Association of Hospice Palliative Medicine. He is the medical director for the Hospice of Windsor and Essex County and lead physician for its community-based Palliative Medicine Program. He is one of only two certified hospice medical directors in Canada and has his designation as a certified Canadian physician executive. He serves on the board executive of the Canadian Society of Palliative Care Physicians (CSPCP).

Kieran Quinn

Contributor

Kieran Quinn is a general internist and palliative care physician at Sinai Health System and an early career health services researcher affiliated with the University of Toronto and the Institute for Clinical Evaluative Sciences (ICES).

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