Thousands of Ontarians are waiting in hospital beds, too frail to go home. Long wait times, however, hold up their admission to care facilities. There is a better way.
Andrew, who lives with advanced dementia, suffered a heart attack while at home. He received high-quality ICU care and subsequently was transferred to the hospital ward. In keeping with Andrew’s wishes, the family decided to forego any further invasive tests or procedures in favour of comfort-based care. Andrew and his family preferred him to be at home, but like many Canadians who cannot afford to take leaves from work or hire private caregivers, government-funded home care services were not nearly enough.
Unfortunately, Andrew joined the ranks of 6,000 other patients in Ontario who are deemed to need an “Alternate Level of Care” (ALC). They do not need to be in hospital, but there is nowhere safe for them to go.
The ALC population represents approximately 17 per cent of hospital bed occupancy in Ontario. When these numbers surge, emergency departments swell, hallway medicine becomes the norm, and elective procedures and surgeries are cancelled to ease the burden on hospitals. We have seen this even more frequently during the pandemic. What was less understood until recently is that 40 per cent of these patients are in their last three months of life. Also, 30 per cent of patients designated ALC end up dying in an Ontario hospital while waiting for an available bed in a care facility. Is this really the best we can do for patients in their last months of life?
Is this really the best we can do for patients in their last months of life?
Government investment in palliative care represents a crucial part of the solution. Given Ontario’s population needs, we require more than 1,000 additional residential hospice and palliative care unit beds than are currently available. The funding for these beds needs to be targeted to the areas of the province that need them the most: where the highest proportion of patients designated ALC are situated. The government already has access to this data; it now needs to act on it. In addition, the government only funds approximately 50 per cent of hospices’ operational funds, leaving hospices to fundraise the remainder and detracting from their focus on providing care. When targets are not met, hospice beds close.
Sadly, this also leads to significant inequity in access, as communities with fewer resources are unable to support their hospices. It is well known that specialized facilities such as residential hospices are able to provide better end-of-life experiences for patients and their families and are, in fact, a fraction of the cost to operate compared to hospital beds.
In addition, the pandemic has highlighted the chronic under-resourcing of long-term care facilities. Despite residents wanting to remain in their care home for receipt of comfort-focused end-of-life care, hospital admissions have become commonplace as facilities struggle with staff and medication shortages.
As such, we support the proposal to have additional “high-intensity” (and well-resourced) beds in long-term care to help prevent these unnecessary transfers to hospital, allowing residents to remain in their home-like environments.
To make this happen, we would need increased ratios of nursing and personal support worker staff in long-term care, and funding for physicians to provide after-hours coverage in care facilities.
None of these are new ideas and in fact have been discussed by federal and provincial governments on several occasions. They were discussed nationally in 2018 when the Framework on Palliative Care in Canada was introduced. They were discussed again in 2020 when the Compassionate Care Act was passed in Ontario. But where are the results?
The Auditor General for Ontario has stated that we would save $161 million per year if we were to adopt these measures. These savings could then be re-invested to address the primary-care crisis or build new long-term care homes.
Let us stop discussing this and start acting. To solve Ontario’s ALC crisis, we need meaningful action on these recommendations. Our loved ones deserve better.
Wearing my hat as a Palliative Care specialist, I can but agree with the position presented. HOWEVER, when I change to wear my hat as a Geriatric Medicine specialist, I can only be outraged that it is preferable to “make them comfortable and accept dying”, instead of adequately assessing and managing symptoms. When the focus is on the dying, rather than the living, this group of persons is undertreated. Labelling the person, in other physicians’ and hospitals’ minds, as “Bed blockers” is, in my personal view, a strong contributor to the 30% death rate you quote. Surely there is some appropriate in between, where appropriate management, within the person’s wishes, however expressed, focussed on their needs, exists. Attaching a different label has the very significant risk of becoming a self-fulfilling prophecy. Knowing both sides of this coin at an expert level, I must, regrettably, disagree with your suggestion, rather advocating for patient focussed care, in a non-hospital environment, provided by appropriately skilled individuals.