CCBI News – Palliative Care: Access and Costs

March 31, 2023

Dear Friends of CCBI,

Palliative Care: Access and Costs

One of today’s most important ethical questions is the provision of quality palliative care, but another vital question relates to its equitable distribution. Ever since Senator Sharon Carstairs produced the statistic that only 15% of Canadians receive the palliative care that they need, (Still Not There, 2005) and a few years later upping that figure to about 30% (Raising the Bar, 2010) CCBI and others have advocated for an increase in that number and have written about changes as and when they occur. Legalization of euthanasia and assisted dying in 2016 put a spotlight on the issue once more, when the government began to compare palliative care to other ‘choices’ like euthanasia, as part of a ‘spectrum of care,’ simply one of the choices a person can make at end-of-life as though no moral distinctions need concern us.

We know, however, that not all choices are moral, and they are not always equitable. Euthanasia is, of course, always morally wrong in Catholic teaching, while palliative care is not only morally acceptable but helps to demonstrate our understanding of the need to protect the dignity of life from conception until natural death. Palliative care is one of the ways in which we can try to make the dying stage of life as physically comfortable and as emotionally and spiritually enriching as possible. Palliative care is the most humane choice at end-of-life, and is an area where more research, best practices, spiritual and societal support should be encouraged and provided.

Although Senator Carstairs was writing over a decade ago, a report in 2018 by the Canadian Institute for Health Information (CIHI) similarly showed that only about 15% of Canadians receive palliative home care in their last month of life. This figure applies only to home care and does not give a full picture of the overall provision of care, but the point is, as we have reported many times, the vast majority say they would prefer to die at home, yet this statistic does not reflect much movement in that direction. People’s expressions of their wishes are not being taken seriously enough, not in 2005 and before, and not now. As Senator Carstairs wrote: Still Not There. At least the Report said, “People who received palliative home care in their last year of life were 2.5 times more likely to die at home than other home care clients,” which shows some progress. It went on to say, “Early access to palliative care is effective in reducing emergency department visits and intensive care unit stays at the end of life.” Fewer hospital visits result in a reduction in patient stress and also in costs for health services.

Early access, however, does not always occur, since another study in 2017 in Ontario found that 38.8% of patients accessed care only in the last month before death, while only 12.0% had access in the second month beforehand. The conclusion? Many people still don’t have access to the care they need, often receiving it very close to the end stages, and then only because they had been admitted to hospital on an emergency basis. For palliative-stage patients and for palliative care physicians such as Dr José Pereira, who directs the community-based group ‘Pallium’ which provides care and advocates for earlier access, these are not encouraging statistics.

A Fact Sheet from the Canadian Hospice Palliative Care Association reveals that, “Almost half of Canadians (47%) say hospice palliative care is available to all those at the end of their life regardless of their illness. Only 19% say it is available to those dying of life-threatening illnesses. However, one-third of Canadians (34%) are not sure to whom hospice palliative care services are available.” It is puzzling that knowledge of palliative care and its benefits is still not better disseminated. Perhaps it would be more advantageous if, instead of being the responsibility of the various palliative care groups, all of whom do wonderful work, it could be more centralized, with information from, say, Health Canada, being dispersed nationally on a broad basis to educate and benefit all Canadians.

Given the ongoing tussle between provinces and federal government about budgets and transfers to provinces for health care, it is generally recognized that costs are one of the most important factors in providing palliative care in all types of setting. Next week we will look into this more closely, since I recently read a report saying,”… the estimated total societal cost of end-of-life care was $34,197.73 per patient over the entire palliative trajectory (4 months on average). Results showed no significant difference (P > 0.05) in total societal costs between home and hospital death patients.” I have never heard this before. I thought home care was significantly less costly than hospital care, but this report emphasizes that, “Higher hospitalization costs for hospital death patients were replaced by higher unpaid caregiver time and outpatient service costs for home death patients.” This is surely something that must be clarified in the question about providing palliative care at home, which we know most people want!

Access to Palliative Care in Canada | CIHI

Canada needs equitable, earlier access to palliative care | CMAJ

new_fact_sheet_hpc_in_canada-summer2017-final-en.pdf (chpca.ca)

Societal costs of home and hospital end-of-life care for palliative care patients in Ontario, Canada – PubMed (nih.gov)

Pope Francis’ Intentions for march

For Victims of Abuse
We pray for those who have suffered harm from members of the Church; may they find within the Church herself a concrete response to their pain and suffering. We pray that parishes, placing communion at the centre, may increasingly become communities of faith, fraternity and welcome towards those most in need.

Moira and Bambi