Focus on palliative care will help hospitals recover from COVID-19

Binge watching has now become the norm for those of us who subscribe to streaming services such as Netflix, Crave or Amazon Prime. As a Stephen King fan growing up, I was pleased to see King’s classic The Stand show up on Prime. I watched the 1994 mini-series and looked forward to the remake.

The premise of The Stand is eerily relevant. A worldwide super flu pandemic engulfs the world in a matter of weeks, killing 99.9 per cent of the population. The remaining 0.1 per cent struggle to survive in that post-apocalyptic world.

While COVID-19 does not have the same mortality as Captain Trips, the effects on our economies and health-care system have been staggering. Worldwide, we are approaching 138 million infections and 3 million deaths. In Canada, we have seen 1.178 million cases and 23,000+ deaths, with Ontario accounting for more than 445,000 cases and almost 8,000 deaths. The Macdonald-Laurier Institute ranks Canada at 11th in its COVID Misery Index, well behind countries that have contained the pandemic such as Norway, New Zealand and Australia.

Our current wave is stretching ICU capacity beyond its limits and patients are being transferred out of GTA hospitals on a daily basis to accommodate increasing numbers requiring hospitalization. As such, recovery of our health-care system might seem a far-off thought. Eventually, however, our attention will turn back fully toward the patients who have seen their care cancelled or postponed.

A recent study published in JAMA showed a dramatic 60 per cent decrease in cancer surgeries when the pandemic began a year ago as hospitals reallocated resources like beds, ventilators, and medical staff to ensure they were prepared for a sudden influx of COVID-19 cases. In Ontario, more than 36,000 Ontario cancer patients had their surgeries delayed last spring. This number will only grow as a second “ramp down” has recently been ordered across the province. Steini Brown, co-chair of the Ontario COVID-19 Science Advisory Table, told a news conference April 29 that almost 275, 000 surgeries and procedures had been delayed in Ontario as a result of the COVID-19 pandemic and the hospital ramp downs.

Lack of screening and preventative care means that many cancer patients will be presenting later, sicker and in many unfortunate situations, at an incurable stage of their disease.

And it is not only cancer patients who suffer. Patients suffering from chronic disease have seen their care affected as well.

A Fraser Institute study highlighted that the pandemic contributed to Canada’s longest medical wait times in the modern era last year, at 22.6 weeks, costing 1.2 million patients almost $2.8 billion in lost wages and productivity. That doesn’t include the 10.5-week median wait time before seeing a specialist after being referred by a family doctor.

The additional cancellation of medical procedures has increased wait times by a record 143 per cent compared to 1993, the first year of comparable data, when the median wait time was 9.3 weeks.

Even before the COVID-19 pandemic, our hospitals were bursting at the seams. Many hospitals routinely operated at more than 100 per cent capacity. Once hospitals are able to turn their attention back to addressing this backlog created by the COVID-19 response, where will they find this capacity? Returning to normal means returning to a health-care system that was already in crisis.

So how can palliative care play a role in addressing surgical backlogs?

The Ontario Medical Association Section of Palliative Medicine’s 2018 submission to the Premier’s Council on Improving Healthcare Outcomes and Ending Hallway Medicine outlined the many benefits of palliative care to the greater health-care system as well as the benefits to patients, families and caregivers.

We already know that palliative care:

• reduces the use of hospitals, ERs and ICUs for patients with non-cancer diagnoses;
• decreases hospitalizations overall;
• improves quality of life for patients;
• reduces stress for caregivers.

Through community-based palliative care teams and family physicians who provide palliative care, more patients can receive their care in the community. This will free up important hospital resources like hospital beds, including ICU beds, as well as human resources such as nursing staff, to address the surgical backlog. 

If more long-term care residents can receive their care in their LTC home, in the community, rather than being transferred to hospital, this prevents potentially unnecessary emergency rooms and hospital admissions. This care-in-place can be assisted and supported by consultative palliative care teams who can assist with advance-care planning, timely goals of care discussions, and symptom management for complex patients.

Hospitals understand the need for community care in reducing hallway medicine. A 2019 Ontario Hospitals Association pre-budget submission highlighted the need for more investments and expanded access to community-based care.

“Home and community care relieves pressure on hospitals by preventing unnecessary emergency room visits and helping patients remain at home or return home quickly and safely. Most patients prefer to receive care in their own homes and communities, where it is significantly less expensive to deliver,” the submission read.

Furthermore, palliative care can help address pre-existing capacity issues such as alternate level of care (ALC). In Canada, an ALC designation is given to patients who do not require the intensity of services provided in an acute-care setting but are waiting to be discharged to a more suitable setting. Estimates provided by the Ontario Palliative Care Network suggest that half of the 189,254 ALC days accrued in the last 90 days of life can be attributed to wait times for long-term placement or for services that can be provided in assisted living facilities. Crudely estimated, if expenditures associated with ALC service days would be diverted to residential care, residential palliative care and home care, the potential saving in Ontario alone is estimated at $161 million per year based on cost estimates from the Auditor General of Ontario.

However, to take advantage of the benefits of palliative care, we need to increase patients’ access to palliative care. This includes:

• ensuring basic competencies for all health-care providers;
• graduating more doctors and nurses who can provide palliative care;
• building and funding more hospices to provide end of life care;
• funding home care services to meet the inevitable demand;
• Removing structural barriers to access for palliative care.

Clearly, palliative medicine has a role to play with health-system recovery in Ontario. Unfortunately, access to high-quality palliative care remains a “postal code lottery” and patchwork of care across Ontario. High-quality palliative care should be the norm for patients facing a life-threatening illness, not the exception.

Back to The Stand. I was able to binge watch the series over a weekend during the lockdown (which one, I can’t remember anymore). Thankfully, the end of our pandemic story will be vastly different than the one in King’s tale. I won’t ruin the ending for you (because “what happens in Vegas, stays in Vegas”), but if we are to hit the ground running with health-system recovery post-pandemic, we need to start laying the groundwork now.

That planning should include palliative care for all who need it.

This article reflects the views and conclusions of the author and does not necessarily reflect those of Ontario Health. No endorsement by Ontario Health is intended or should be inferred.