Australia offers lesson in palliative care
In May, Palliative Care Australia and KPMG released a report highlighting the need to overhaul the palliative care system in Australia while also making significant investments in the system to realize cost savings.
According to the Economics of Palliative Care: Investing to Save report: “All Australians who need palliative care are simply not having access to services when they need to, particularly at home and in community settings. As we prepare for an ageing population and other unexpected stresses to our healthcare system, like COVID-19, we must look seriously at reforming our system to ensure it can meet people’s needs into the future.
“Palliative care is about quality of life, living well with a palliative diagnosis and about dying well. Through an additional annual investment of $365 million on national reform, we can save up to $464 million in other health system costs while making the system work best for those experiencing it. We have to spend money to save money and that’s backed by leading economists.”
Why should this matter to Canadians? Because a similar approach is needed here.
The Institute for Clinical Evaluative Sciences (ICES) has reported that community-based palliative care reduces emergency room use and hospitalizations, decreases aggressive medical interventions and provides better quality care when compared to usual care. In some cases, patients live longer when they receive high-quality palliative care. A Canadian Society for Palliative Care Physicians report shows that inpatient palliative care services can save $7,000-$8,000 per hospitalization and reduce hospital costs by 24 per cent.
A recent BMJ study highlights the potential benefits of palliative care in non-cancer illnesses. Palliative care was associated with 12 per cent reductions in emergency department visits and hospital admissions and a 41 per cent reduction in intensive care unit admissions from patients dying from chronic organ failure (such as heart failure, cirrhosis, and stroke).
In August 2019, the federal government released its own “Action Plan” for palliative care in Canada. I was critical of the plan then and remain so now.
Make no mistake, action is necessary. In its own 2018 predecessor document Framework on Palliative Care in Canada, the government admits that while 75 per cent of Canadians would rather die at home, only 15 per cent have access to the necessary community-based services. This can be generalized to Ontario where ICES confirms that only one in five patients receives a home visit from a physician in the last year of life and that only 50 per cent of Ontarians receive palliative care services, with the majority of that taking place in a hospital. According to Health Quality Ontario, access to community-based palliative care has stalled.
Yet in Ontario (and I suspect this holds across Canada), residential hospices must fundraise more than 50 per cent of their operating expenses just to keep their doors open and the lights on. Imagine if this was the case for any other medical specialty. Would anyone stand for this in obstetrics, oncology, surgery or primary care?
Canadians may enjoy looking down their nose at the U.S. healthcare system but the U.S. recognized palliative medicine as a speciality almost a decade before Canada and now has more than 1,800 hospitals with palliative care programs, which means that more than 80 per cent of American patients who are hospitalized for serious illness have access to palliative services. We don’t even measure this in Canada or Ontario.
Of those five items listed in the federal government’s “action plan,” few have the funding or the potential to move the needle substantially enough to insure that your patients, your parents, your siblings, your friends, your family will have access to palliative care services when needed.
More reports and more nibbling around the edges will not make a difference in our patients’ care.
And they will need them – we all will.
A 2016 report from the Canadian Cancer Society titled Right to Care: Palliative Care for all Canadians states: “Palliative care funding must be increased in order to meet the expected increase in incidence of cancer and other chronic diseases as well as the aging population. The recommendations in this report and others must be accompanied by adequate funding for the human resources and healthcare infrastructure needed to improve access to and quality of palliative care for all Canadians. There also needs to be increased investment in palliative care research to continue developing and evaluating effective practices.
“Palliative care will result in the better use of our healthcare dollars by reducing demands on costly care and tailoring care to better meet patients’ needs and circumstances. However, upfront investments will be required.”
The BMJ study states that “Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.”
Real action takes resources and investment. This would include:
- More doctors and nurses trained in the basic and core competencies of palliative care.
- Greater access to personal support and social workers, who are the cornerstones of interdisciplinary collaboration.
- Creating a department of palliative medicine in each and every medical school that can be the academic home for education and research spanning all medical specialties.
- Closing the funding gap by dedicating funds from Federal Health Transfers that must be spent on palliative care services such as home and end-of-life care.
- Embedding a patient’s right to palliative care in legislation.
While well intentioned, I fear that the federal government continues to miss the mark and that this represents yet another wasted opportunity to improve the care of seriously ill and dying patients in Canada.