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The hottest political issue in health care in the years to come will, without a doubt, be end-of-life care.
While physician-assisted death grabs all the headlines, it is a fairly marginal issue. Even with all the provisions in place – such as the proposed legislation in Quebec that clearly sets out the rules about who can receive medical aid in dying – only a tiny percentage of patients in specific circumstances can and will opt to accelerate death.
On the other hand, virtually everyone wants a humane death, one where pain and suffering is minimized as much as possible. In other words, most people want and need palliative care – physical, mental, emotional and spiritual support for themselves and family members.
Yet, only about 16 to 30 per cent of Canadians currently receive any palliative care at the end of life, depending on where they live. (Fewer still get follow-up grief counseling and bereavement services.)
Obviously we can do a lot better.
But if people are going to get appropriate end-of-life care, the system has to be structured in a manner to deliver that kind of care. It has to be made a priority, and embraced as a philosophy.
There are two principal reasons that palliative care has lagged in this country: 1) we have a hospital-centric system, meaning that most people spend their final days in hospital, where they invariably get treatment and often over-treatment and; 2) the fear that creating palliative care facilities will be an additional cost for an already overburdened health system.
A new report, prepared by the Institute of Marriage and Family Canada, offers some interesting insight on both of these issues.
Using data from Ontario, the report shows that, between 2003 and 2011, 7,525 individuals in the province died in a palliative care bed, compared to 32,217 in intensive care unit beds and 85,754 in acute care beds.
Those are stunning figures.
They tell us just under six per cent who died in an Ontario hospital during the past decade did so on a palliative care unit.
What the ideal numbers should be is not entirely clear but research from other countries provides some clues. One study out of Belgium suggest 9.4 per cent of hospital patients could benefit from palliative care; a U.K. study based on the clinical judgment of physicians, placed the figure at 17 per cent; but that same U.K. study, using guidelines, found that 36 per cent of patients actually fit the profile for palliative care. (It's not 100 per cent because not all illnesses have a predictable course and people die in many circumstances outside of hospital.)
In short, conservatively, somewhere between one in 10 and one in three hospital patients should be in palliative care at end-of-life.
The question for policy-makers then becomes: Would providing this level of palliative care be cost-effective?
The new report from the Institute of Marriage and Family Canada suggests that it would be. Consider that research out of the U.S. found that a patient in palliative care costs anywhere from $400 to $2,000 a day less than in intensive care.
In Canada, we're not very good at calculating per patient costs but there are increasing efforts to do so. One of these is the Ontario Case Costing Initiative, which looked at costs of treatment for patients who died in hospital.
Data from that project show that, in 2011, the average cost of a palliative care case was $10,286 and lasted seven days on average; by comparison, the average stay in acute care was 15 days, costing $18,692, while intensive care comes in at $22,355, for 17 days on average.
You have to be careful with raw data but they do suggest that, while palliative care may be costly on a daily basis, the alternative is often prolonging treatment at an even greater cost overall. Wouldn't that money be better spent offering comfort rather than an escalating number of interventions at end-of-life?
The IMFC also used the data to calculate how much money Ontario would have saved if more than six per cent of patients had ended up in palliative care, based on three scenarios:
- If 9.4 per cent patients had died in palliative care, Ontario could have transferred 596 acute care and 235 intensive care patients in 2011 at a savings of $8-million;
- If 17 per cent of hospital patients were treated on palliative wards, that would have meant 1,927 fewer in acute and 761 fewer in intensive care and costs would have come down $25-million;
- Finally, with 36 per cent of terminally ill patients cared for in palliative care, there would have been 5,257 fewer acute and 2,077 fewer intensive care patients for the year, resulting in savings of $70-million.
Those are not whopping amounts of savings, especially when you consider that Ontario spends $47-billion a year on health services from the public treasury.
But as the population ages, deaths will increase markedly, particularly predictable deaths that are best suited to palliation.
Consider that there were about 243,500 deaths in Canada in 2010 and that, by 2035, the number will rise to 375,400.
If each of those cases costs a couple of thousand dollars more because we don't invest in palliative care at end-of-life, it will be a tremendous waste of money.
Besides, it's not just about the money. The goal of our health system should be not only prevention and care to facilitate a good life, but to appropriate care to ensure a good death.
André Picard is the health columnist at The Globe and Mail.
André Picard