This is part of the Globe's in-depth series on the agonizing decisions surrounding end-of-life care in the 21st century. For the complete series, click here
Of all the financially grim statistics confronting Canadian health care, this ranks among the grimmest: About 25 per cent of all health-care costs are devoted to caring for patients in their last year of life.
Provincial governments are scrambling to contain health-care spending, even as an aging population begins to place increasing demands on the system. Yet there is also a growing recognition among policy makers that they cannot make efficient spending decisions without a better understanding of the economics of death.
Almost 70 per cent of people die in the hospital, including some in high-tech intensive-care beds, which cost about $1-million a year to operate. Many patients fail to complete advance directives or communicate preferences to their families, meaning they could be subject to costly, invasive treatments they did not actually want.
"The bottom line is if you don't know how much something costs, then it's really difficult to say how much we should spend," said Konrad Fassbender, an assistant professor at the University of Alberta's oncology department, and one of the few researchers who has attempted to quantify the cost of various end-of-life procedures. "In health, we somehow have bought into the fact that we need to provide this level of care at any cost, without any real data of its effectiveness, without any knowledge of how much it costs."
Prof. Fassbender's research shows it costs the health-care system about $39,947 to treat a patient with organ failure near the end of life; $36,652 for a terminal illness; and $31,881 for frailty. Sudden death is the least costly at $10,223.
In 2008, 238,617 Canadians died and the number is continuing to climb each year. By 2026, that figure is expected to increase to 330,000 and a decade after that, to 425,000, according to Statistics Canada. Health care continues to consume a large portion of program spending in every province; in Ontario it's 42 per cent and in the near future that could rise to 50 per cent if health-care costs grow faster than other areas of government spending.
Some suggest that by filling out advance directives, it can help ensure that patients receive treatments they want at end of life. The Royal Society of Canada's report on end-of-life decisions earlier this month pointed out the need for people to express their wishes.
Hugh Walker, adjunct professor of health economics at Queen's University medical school, who did studies on costs of care for dying cancer patients, knows this issue well, which is why he has an advance directive.
"Lots of people, my wife and I included, have signed 'do not resuscitate' or 'do no heroic intervention' orders," said Dr. Walker, who at 73, still works. "… We don't want to live our lives in a long-term setting and we didn't want the other one to have a long life of disability."
And yet, end-of-life wishes and the costs of care associated with it remain taboo topics in Canadian health care.
In the 1990s, Peter Ellis, a former chief executive officer and president of Sunnybrook Health Sciences Centre, took a novel approach: Each patient received a letter in the mail some weeks after they were sent home, showing how much their hospital stay cost the public health system. The practice ended soon after he left in the late 1990s, but at least he got patients thinking about health care as something that carried a price to the public purse.
"I see some projections about the ongoing growth in the cost of health care in Ontario and Canada and it's frightening," Mr. Ellis, a health-care consultant, said Monday in a telephone interview from Leeds, England. "The question is how can you get control of it."