Bill C-277 (Historical)

Framework on Palliative Care in Canada Act

An Act providing for the development of a framework on palliative care in Canada

This enactment provides for the development of a framework designed to support improved access for Canadians to palliative care.

Framework on Palliative Care in Canada Act

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

moved that Bill C-277, an act providing for the development of a framework on palliative care in Canada, be read the second time and referred to a committee.

Mr. Speaker, today, I am pleased to stand before the House to bring a private member's bill that would benefit not only my riding of Sarnia—Lambton, but all Canadians.

All of us will eventually come to the end of our lives. We all want to ensure that we live as well as we can for as long as we can. That is why Canadians need proper palliative and end-of-life care. Bill C-277 would provide a framework for palliative care in Canada.

Last parliamentary session, the Parliamentary Committee on Palliative and Compassionate Care studied the matter and came forward with recommendations. This bill is the result of those recommendations.

The committee published an excellent report outlining the current Canadian situation with respect to palliative care. The preamble for my bill is directly pulled from its report. This committee did a complete assessment of current palliative care options in Canada and identified specific areas and needs to be addressed. The report outlined the importance of strong and consistent palliative care options in Canada as well as the necessity of a framework under which to conduct these efforts.

This bill is also timely since, as a result of the Carter decision on assisted dying, the external committee report also recommended that palliative care be available to all Canadians.

The final report of the external committee on options for a legislative response to Carter v. Canada emphasized the importance of palliative care in the context of medically-assisted dying. It stated that a request for medically-assisted death could not be truly voluntary if the option of proper palliative care was not available to alleviate a person's suffering.

As we all can attest, each of the parties in the House has shown itself to be in favour of implementing a palliative care program in Canada, but very little has been formally announced. We can all agree on the importance of palliative care as well as the importance of making these measures accessible, in a consistent fashion, to all Canadians who need them.

Bill C-277 would define the services to be covered. It would establish standard training requirements for the various levels of service providers. It would come with a plan to achieve consistent access to palliative care for all Canadians. It would define the mechanism by which this is best achieved, with the measurements and data needed to track success.

Canada has an ever-growing number of individuals of all ages experiencing chronic and terminal conditions. Good palliative care covers a wide range of services, such as acute care, hospice care, home care, crisis care, and spiritual and psychological counselling.

A palliative philosophy of care is needed to address a whole variety of needs through an adapted and patient-centred process. The creation and implementation of a palliative care framework would give Canadians access to consistent, high-quality palliative care through hospitals, home care, long-term care facilities, as well as through residential hospices.

When we look at the current palliative care system, we can recognize the work that needs to be done. Current programs are evolving provincially and many are fragmented with little consistency and communication between the parts. A palliative care framework will bring these fragmented parts together in an effort to create a more cohesive, patient-based program, with a common definition of services covered, training standards, and a plan to ensure equal access for all.

There is a need for governance of the consistent implementation and monitoring of palliative and home care. This would require clear and open communication between federal and provincial governments as well as medical practitioners, institutions, and patients.

I would like to acknowledge the Canadian Medical Association, the Canadian Cancer Society, the Canadian Nurses Association, the Canadian Society of Palliative Care Physicians, Pallium Canada, ARPA, the Canadian Hospice Palliative Care Association, and many of their member hospices, like Bruyère Continuing Care, St. Joseph's Hospice, and West Island Palliative Care Residence, the Heart and Stroke Foundation of Canada, the Kidney Foundation, the ALS Society, the Canadian Association of Occupational Therapists, and the more than 50 organization members of the Quality End-of-Life Care Coalition of Canada for their ongoing promotion and support of this bill.

It is through organizations and groups like these that we can integrate palliative care into the current health care system and make a true difference in the lives of Canadians.

Support from across Canada is also evident in the 83 petitions on palliative care that have been presented to the House in this session alone. Thousands of letters have been received by members of Parliament on all sides of the House.

The current palliative care options in Canada are simply inadequate and do not meet the needs of Canadians.

In 2011, it is estimated that only 16% to 30% of those in need were receiving proper palliative and end-of-life care. Our current health care system favours short-term acute care, which it does extremely well. However, it lacks the capacity and the funding to properly, and consistently, provide quality long-term palliative and end-of-life care. The cost of acute care is four times that of hospice palliative care, so there is an opportunity to provide more of this kind of care for less money.

Regional accessibility is also an important issue. Currently, palliative care options are available in most heavily populated regions. However, the availability of palliative care in remote or less populated areas is often very limited or non-existent. There is a pressing need for a plan to address how to provide services to these areas. The region where you live should have no impact on whether palliative care is or is not available to you.

Palliative care would also offer an enhanced quality of life for those who, for various reasons, do not choose medically assisted dying. Data in countries that offer assisted dying shows that where good palliative care is available, 95% of people choose to live as well as they can for as long as they can. Palliative care will provide an option that would be preferable to many medical practitioners, nurse practitioners, and health care institutions that for religious and conscience reasons would prefer to help their patients live well.

With those 65 and older making up approximately 15% of the Canadian population, the geriatric and palliative care needs of Canadians will only increase. Palliative care can be cost efficiently delivered within the home or in community-based systems, such as hospices, nursing homes, and long-term care homes.

Funding palliative care in homes and in stand-alone facilities will alleviate pressure on hospitals and free up many much-needed hospital beds.

The proper training of medical practitioners and nurse practitioners is an important step in creating a comprehensive and well-equipped palliative care structure. On average, medical and nursing students spend as little as 20 hours of their four years of study learning about palliative and end-of-life care. In 2011, there were fewer than 200 geriatricians in Canada. Today, the estimated need is upwards of 600.

This bill will also have a positive impact on the lives of caregivers. In 2011, there were an estimated 4 million to 5 million family caregivers in Canada, who contribute $25 billion to the Canadian economy. These same caregivers often have a heavier financial burden and have to miss one or more months of work because of their duties. Family caregivers provide 80% of all home care in Canada, and 77% of these caregivers are women.

This might seem like a lot of statistics, but these numbers are not to be taken lightly. Caregivers experience financial, social, and physical burdens that can have lasting effects on their lives. I quote the Canadian Cancer Society when I say that “Canadian caregivers are the invisible backbone of the health care system, providing $25 billion in unpaid care”.

This added support will encourage palliative care in the home, which has been demonstrated to be beneficial for everyone involved. Allowing patients to stay in their homes for as long as possible is a wise and compassionate choice that should be offered to every Canadian.

As we can imagine, long-term data on the subject is hard to come by. What data we do have shows that Canada has a lot of work to do in the field of palliative care. Dr. Fred McGinn, of the Hospice Society of Halifax, calculated that in 2011 there were over 200 residential hospices in the United Kingdom and over 1,300 residential hospices in the United States. However, there were only 30 free-standing residential hospices in Canada.

Canada needs to develop its capacity for residential and hospice palliative care. In terms of actual spending, it costs between $600 and $800 a day to have a palliative care bed in a hospital. Comparatively, it costs only $55 a day to have palliative care beds at home. In-between these, it costs $200 to $300 a day to have a palliative care bed in hospice. In extreme cases, it could cost upward of $1,200 a day for beds in acute care in hospital while a patient is awaiting other accommodations, so it would be much more cost-effective to fund quality at-home and in-hospice palliative care beds over beds in hospitals.

Our lack of data and research on palliative care is why I believe it is essential we include further research and data collection in the bill. Many other UN countries have or have had laws in place with regard to palliative care.

A report from the United Nations and World Wide Palliative Care Alliance suggests that the cost of care at end of life, measures between 25% and 30% of all medical expenditures. Shockingly in Canada, 50% of palliative care funding currently has to come from charitable donations. This report determined that overall, the utilization of hospital based and in-home based hospice and palliative care services significantly reduced the cost of care, while providing equal if not better quality care for patients.

In this House, the government has stated it would allocate $3 billion to home care and to palliative care over the next four years.

This bill to create an overarching framework guaranteeing quality palliative care would provide an ideal complimentary legislation to Bill C-14 in the sense that it will take into account the concerns expressed by health professionals all while creating a quality palliative care strategy. Having end-of-life options gives patients a real choice in an already difficult situation.

Establishing a clear and comprehensive palliative care framework will allow patients to make well-informed decisions about how they spend their remaining time with family and friends.

I believe that my riding of Sarnia—Lambton is an excellent example of palliative care done right. One in five residents of Sarnia is 65 or over, and this number is on the rise. Sarnia is considered to be ahead of many communities with its 10-bed hospice and eight to 10-bed hospital palliative care unit. We have more than five palliative care specialists in our area, and as a community, Sarnia—Lambton has many institutions and groups that support and deliver palliative care, such as St. Joseph's Hospice, the Bluewater Health Palliative Care Unit, and the Erie St. Clair Community Care Access Centre and the VON.

Unfortunately, resources such as these are not abundant everywhere. This has been attributed to a lack of medical training and personnel in this field and a lack of funding. A very small number of Canadians in need of palliative care are able to receive it. With less than 30% of Canadians having access to quality palliative care, concrete changes need to be made.

As a large portion of our population approaches retirement, the issue will just continue to grow. I am looking to create a framework to implement consistent and quality palliative care across Canada. No Canadian should be denied these essential end of life programs and services because of their region or their finances. Every Canadian deserves the right to be able to end their life in peace and comfort knowing that they had the final choice. The bill will result in Canadians having that real choice.

I would once again like to thank the numerous groups, organizations and hospices for their support. After all, 95% of people who have good palliative choose to live as well as they can for as long as they can. I believe every Canadian should be given that option, so let us join together with one voice to call for quality palliative care as a right of all Canadians by supporting Bill C-277.

[Kate Young, Liberal, Parliamentary Secretary to the Minister of Transport]

Mr. Speaker, it gives me great pleasure to stand in the House to say that I will be supporting this bill. I am very happy to because of my own personal experience watching my mother struggle at the end of her life 15 years ago. Even in a city the size of London, we did not have enough beds 15 years ago, and I would not want anyone to go through that.

I have a question about whether the member has considered aligning the bill with some of the best practices of the provinces that are well ahead of the federal government on this.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Mr. Speaker, now is the time to start to leverage the best practices the provinces are starting to implement. Some are further ahead than others. Organizations like Pallium Canada, the Canadian Society of Palliative Care Physicians, and the Canadian Nurses Association have best practices and are able to help leverage them. Now is the time to get the framework and define the services we would have and the standard training requirements and make sure that we roll this out in the most efficient way possible.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

Mr. Speaker, the member for Sarnia—Lambton makes a great contribution to this House of Commons. Certainly the New Democrats will be supportive of this bill as well.

That being said, I recall that just a few years ago in this House, the Conservative government cut the national Secretariat on Palliative and End-of-Life Care. I am hoping that this signifies a change in direction for the Conservative Party.

Can the member acknowledge that this is a change in direction for the Conservative Party and that all Conservative members will be supporting her bill?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Mr. Speaker, as the member knows, I am bringing a fresh perspective to this place. All of the members of the Conservative Party will be supporting this bill, because we recognize that all Canadians need this.

When we studied Bill C-14 this year, we heard all of the witnesses and the people who were providing input say that we need to have good palliative care if we are going to have a true choice. To find out that 70% of Canadians have no access to any kind of palliative care was astounding to me. Therefore, I am happy to say that we will support this, and that is a change.

[Harold Albrecht, Conservative, Kitchener—Conestoga, ON]

Mr. Speaker, I also want to add my congratulations to my colleague from Sarnia—Lambton for the incredible amount of work she has done in bringing us to this point today. She mentioned in her speech a number of national organizations that are supporting her bill.

In my own area, I have the privilege of having a number of hospices that provide excellent palliative care. We have Innisfree House and Lisaard House and the HopeSpring Cancer Support Centre. I am wondering if my colleague would expand a bit on her knowledge of the palliative care agency in her area, Bluewater Health, which provides excellent palliative care. I have had the privilege of visiting it, but I would like to hear a bit more about the kind of service it provides.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Mr. Speaker, I would like to thank the member, because he was one of the members of the parliamentary committee that first brought this forward. I appreciate all the work that committee did.

Definitely in my riding we have a very integrated approach. There is St. Joseph's Hospice, and there are palliative care beds in the hospital. There is also community care and the VON home care types of services. They are all working in partnership under five palliative care specialists, who are incredibly rare in Canada. For a community as small as Sarnia to have this kind of expertise and for them to be working that way together is a real model we want to leverage.

As I was putting the bill together, I talked to different hospices, excellent hospices, in other places in the country. Those best practice models are what we need to learn from and implement as we go ahead. There is an opportunity for the government, with a lot of flexibility, to determine how we will apply the solutions that are needed, how we will bring the infrastructure, and what the timing of all of those things will be.

I look forward to working with all my colleagues on all sides of the House to get a better solution for Canadians.

[Kamal Khera, Liberal, Parliamentary Secretary to the Minister of Health]

Mr. Speaker, I am pleased to stand today to discuss Bill C-277, an act providing for the development of a framework on palliative care in Canada. With the introduction of this bill, the member for Sarnia—Lambton has taken a significant step forward in our national dialogue on palliative and end of life care, and I want to thank the member for bringing this forward. I appreciate the opportunity to provide some reflections on this extremely important initiative.

Palliative care is an issue that is gaining increasing attention across our country. This was further magnified by discussions on end-of-life care options that occurred earlier this year when medical assistance in dying became a legal option. Views on this matter differ, but we can all agree that patients should have access to a full range of care options to treat pain and other symptoms at the end of their life.

Palliative care is an approach to health care that focuses on the needs of patients who live with life-threatening conditions as well as on their families. Research shows that it can have a significant impact on improving quality of life for patients, while reducing the stress and burden on their families. As demographics in Canada shift, the need for end-of-life care is increasing. Canadians have been loud and clear in calling for access to high-quality care for those who are approaching the end of their life.

Before being elected as a member of Parliament, I had the privilege of being an oncology nurse at St. Joseph's Health Centre. I have actively provided palliative care to many patients and I have seen first hand the impact that good quality palliative care has on patients at the end of their lives and their families.

While palliative care has been improving in Canada, we know there is still much work to be done. Some studies have reported that as few as 16% to 30% of dying Canadians have access to palliative care, depending on where they live in the country.

More recently, a study by Health Quality Ontario found that 40% of Ontarians who died in 2014-15 had not received a palliative care service. Access often depends on physician referrals, the availability of services, and the awareness of care options among patients and their families. The Ontario study found that most patients did not start receiving palliative care until the last months of their lives. This is a concern because early access can be critical, if not the most important, for maintaining the best possible quality of life for a patient. The study also found that fewer than half of the patients who received palliative care received it at home. Most of us want to stay in our homes and communities for as long as possible. When asked, the majority of Canadians said that they would prefer to spend their last days at home. In spite of this, close to two-thirds of deaths in our country are still happening in hospitals.

The Canadian Cancer Society issued a report this year called “Right to Care: Palliative care for all Canadians”. It highlighted a number of gaps, and barriers to palliative care in Canada, such as a lack of standards, limited data, insufficient training for providers, and inadequate support for caregivers.

This study and others like it show that now is the time to work together on addressing these gaps. As was said many times during the debate on Bill C-14, improving palliative care is a priority for our government. In fact, the preamble of this bill clearly signals our intent to support improvements to a range of end of life care services in Canada.

Canadians need real options that respect their plans and preferences for care in what is often a very difficult stage of life. It is obvious that Canadians are looking to their governments to make this happen. Stakeholders, including the Canadian Medical Association, the Canadian Hospice Palliative Care Association, the Quality End of Life Care Coalition of Canada, the Canadian Nurses Association, and the Canadian Cancer Society, have all called for national leadership in the area of palliative care, and we have been listening.

Our government believes that Bill C-277 would provide us with a timely opportunity to take a leadership role on this issue. We support the creation of a framework for palliative care.

I would like to recognize the efforts of the member for Sarnia—Lambton in putting forward such a thoughtful proposal for what this framework could look like. However, in considering this bill, I would urge each member to also consider the need to respect jurisdictional roles and responsibilities in this area. As we know, health is a shared responsibility in our country, with most of the responsibility for delivering care falling under the purview of the provinces and territories. Most provincial and territorial governments already have some form of a palliative care strategy, plan, or framework, or have policies or programs in place to support palliative care. Several provinces recently dedicated funding to improve palliative care services in their respective jurisdictions.

The bill needs to be better aligned with the scope of federal roles and responsibilities in relation to palliative care, and we will be introducing amendments to that effect. The government is well positioned to complement, bolster, and spread the important work under way across the country by provincial and territorial governments, as well as stakeholders across the health care sector.

I believe that amendments could be made that would achieve this objective while respecting the spirit of the bill. As we all know, the government provides provincial and territorial governments with long-term funding for health care. Our government made a platform commitment to provide $3 billion to provinces and territories to deliver more and better home care services for Canadians, including those who need palliative care. This commitment is being pursued in the context of the health accord. Negotiations with provinces and territories are ongoing, and I am optimistic that, in the future, there may be synergies with a proposed framework.

The division of responsibilities for health between the government and provinces and territories presents us with both challenges and opportunities. If we move forward with implementing this bill, it will be important to talk to provincial and territorial governments and key stakeholders on the appropriate scope of a palliative care framework.

It will also be important for us to learn from the significant body of work on palliative care that has been published in recent years. This includes reports from Parliament, provincial and territorial advisory bodies, and stakeholders, such as the Canadian Medical Association.

One key example is the Canadian Hospice Palliative Care Association's 2015 report, “The Way Forward,” which seeks to integrate a palliative approach to care throughout the health care system.

I would like to close by thanking the House for the opportunity to reflect on the importance of this bill, and to offer some considerations as we move forward, reviewing it in greater detail. I believe that a framework for palliative care is the right approach for Canada. I look forward to further discussion on what that framework should look like, so that we can all have better access to palliative care for all Canadians. Once again, I thank the member for bringing this extremely important piece of legislation to this House.

[Tracey Ramsey, NDP, Essex, ON]

Mr. Speaker, I am pleased to be speaking about Bill C-277, an act for the development of a framework on palliative care in Canada. I will be supporting this bill at second reading.

The New Democrats have a dedicated history of supporting and advocating for a pan-Canadian palliative care strategy to deliver end-of-life services for Canadians. Now, more than ever, our advocacy is needed. As Canada's aging population puts unique stresses on our medical system, it is increasingly important that we have a coherent strategy for palliative and end-of-life care across Canada. This is an issue that touches every Canadian and leaves an impact on every single family.

When we have good options for palliative care, we can ease the many burdens of families so they are able to make these difficult transitions. When services are fragmented, too many people fall through the cracks right when they need the support the most.

Only 16% to 30% of Canadians today who require formalized end-of-life care have access to it. This is an extremely concerning figure. It means that the majority of Canadians who have spent their lives working hard, contributing to our economy, raising families, building communities, and working towards creating a Canada that we can all be proud of will not have the end-of-life care they deserve. Even fewer Canadians receive grief and bereavement services.

The time to act on this issue is long overdue. It is said that the mortality rate will increase by 33% by 2020, making the need for palliative care an urgent one, even more so within the context of the legalization of physician-assisted dying. The provision of high-quality palliative care services is all the more important, as it provides meaningful options for end-of-life decisions.

Currently, nearly 25% of the total cost of palliative care is borne by families, and significant disparities remain across Canada with respect to access to end-of-life care, quality of care, and those out-of-pocket expenses. At least 50% of hospice palliative care services are funded by charitable donations, which continues to restrict the size, scope, and access Canadians have to palliative programs.

Very few Canadian provinces have designated hospice palliative care as a core service under their provincial health plans, and in the remaining provinces, hospice palliative care may be included in provincial home care budgets or other health service budgets, leaving the funding vulnerable to redistribution and cuts. We must have a national strategy that can protect the palliative care of Canadians who have access to it, expand access to care for Canadians who do not have it, and improve the quality and affordability of care for all.

On average, it is estimated that Canadians spend 54 hours per week caring for a dying loved one at home. For most people, this is simply not feasible. Most people in my community need to work to support themselves and their families. Currently, family caregivers provide more than 80% of care to their loved ones, which takes an economic toll on them personally.

If the government provided support to an end-of-life strategy and replaced these family caregivers with specific palliative care professionals trained to provide the proper type of care for those who are at the end of their lives, it would take a huge financial strain off of our more expensive acute and emergency care facilities.

A national strategy for palliative care would also have positive effects on families across Canada beyond the financial costs. End-of-life care is a difficult and emotional time for families. Studies overwhelmingly suggest that women are more often affected as they tend to be the primary caregivers within families. The mental and physical strain of acting as a caregiver is linked to societal expectation of women to provide a greater degree of care at the end of life for family members.

I, like many others in the House, have a personal experience with this exact scenario. My 94-year-old grandmother, the matriarch of our family, Mary Murphy, passed away on October 22 this year. She was fortunate to have been in long-term care, but could not be placed in hospice care due to a lack of space.

My grandmother was blessed to have five angels, daughters who were selfless caregivers to help her through her end-of-life journey; and my mother, Linda, and her four sisters, Nancy, Janet, Kathy, and Debbie. Our family is eternally grateful to them for putting their lives on hold to ensure that my grandmother's dignity and comfort in her last days was a top priority. However, I cannot help but think of what hospice care options could have been provided to my family during this difficult time.

By supporting this legislation at second reading, we can promote a fuller discussion about the familial and gendered ramifications for a palliative care strategy.

The NDP has repeatedly called for the betterment of end-of-life care. On October 31, 2013, the member of Parliament for Timmins—James Bay, introduced Motion No. 456, which called for the establishment of a palliative and end-of-life care strategy. His motion called for the federal government to work in conjunction with the provinces and territories on a flexible and integrated model of palliative care. The motion passed with nearly unanimous support the following year, on May 28, 2014.

It is frustrating to once again have to advocate for something we all know Canadians would greatly benefit from. The government has made no substantial progress on this file, and this bill seems to essentially replicate the initiatives taken by the NDP nearly three years ago. It was the New Democrats who called for the dignity of Canadians at the end of their lives. The initiative for a pan-Canadian palliative strategy is an NDP one, not only due to the replication of Motion No. 456, but also due to the continued advocacy the New Democrats have given this issue.

Sadly, as we may recall, the Conservatives cut the national secretariat on palliative end-of-life care in 2006. For nearly 10 years, no action to implement a new strategy was taken. Although we continue to talk about moving forward for families and those needing a comprehensive national strategy for end-of-life care, Canadian families need action on this issue. I was pleased to hear the member indicate that the Conservatives will support this initiative.

I was proud of the work of my NDP colleague, the member for Victoria, during the meetings held by the special joint committee regarding the Carter decision by the Supreme Court of Canada. The member for Victoria fought hard to bring forward palliative care provisions to create a properly funded pan-Canadian strategy of palliative and end-of-life care, and to re-establish Health Canada's secretariat on palliative care.

The Standing Committee on Justice unanimously passed NDP amendments on palliative care, which were added to the preamble of the bill. While I was happy to know that our amendments were included, ultimately I was disappointed, as the preamble did not hold as much legal weight as the actual text of the legislation.

I would also like to remind this place that although we fought to incorporate palliative care into the Liberal majority joint committee report on physician-assisted dying, I was surprised to find this year's federal budget contained zero federal funds earmarked for palliative care. The budget this spring and the update this fall simply failed to deliver on these concrete recommendations.

Although my NDP colleagues have done so much work to bring forward a national strategy for palliative and end-of-life care, both in previous and within this current Parliament, neither the former Conservative government nor the current Liberal has government has helped those Canadians needing this essential care provision.

I believe it is common for us all to think we have more time. Especially when I was younger, I could not imagine planning into next month, let alone planning for my senior years, or thinking about my own end-of-life care. However, as I get a little older and I see family members and loved ones around me age, I hope I also get a little wiser. Part of that growing wisdom is acknowledging that as a community and as a nation, we need a vision and a plan.

People in Essex have told me that they believe in comprehensive health care systems, which include home care, long-term care and palliative care. In this vision and plan, it is vital that the government take into account Canada's vast diversity. Across the country, from urban to rural, Canadians have different needs, influences, and preferences to take into consideration when designing and implementing an end-of-life care plan. It must also respect the cultural, spiritual, and familial needs of all Canadians, including Canada's first nations, Inuit, and Métis peoples.

This is bigger than any of us individually. It is bigger than any of our individual parties. It is a moment when we have to try to work together to have that vision. I would like to think that we can stand together in the House, and do just that. Our worth as a society is measured by the support we give to those members who are most vulnerable. Let us provide them with more than just words and hyperbole. Let us work together to put forward a comprehensive pan-Canadian palliative and end-of-life care strategy that works for everyone.

[Harold Albrecht, Conservative, Kitchener—Conestoga, ON]

Mr. Speaker, it is with great pleasure that I rise in the House today and speak in favour of Bill C-277, An Act providing for the development of a framework on palliative care in Canada.

Over the past 10 years I have served in this place, palliative care has been one of the issues that I have spent a lot of time on, and so I would like to thank my colleague, the hon. member for Sarnia—Lambton, for introducing this bill and taking up this great cause at this crucial time in Canadian history.

This legislation is essential for two fundamental reasons. First, it addresses a major gap in our Canadian health care system. The vast majority of Canadians do not have access to an essential health care service, palliative care. Second, in a post-Carter decision Canada, we need to understand the realities and questions Canadians now face when nearing the end of their lives.

My roles and experiences as co-founder of the parliamentary committee on palliative and compassionate care, as a member of the joint committee on assisted suicide and euthanasia, and as an advocate for suicide prevention throughout the last decade, inside the chamber and outside, have all ultimately shaped how I approach this subject, my deep conviction that we need to do better, and that we need to see this legislation passed and implemented as soon as possible.

I would also like to add that as a Christian, the value of life from conception until natural death, and the recognition that life is a sacred gift from God also shape how I approach the topic of sustaining comfortable living for those suffering in their last days.

I would like to begin with a quote from Jean Vanier, founder of L'Arche Canada, as recorded in the final report of the parliamentary committee on palliative and compassionate care entitled, “Not to be Forgotten”:

Each of us is fragile, with deep needs for both love and a sense of belonging. We begin and end our lives vulnerable and dependent, requiring others to care for us.... In our states of dependence, our need cries out for attention and care. If this need is well received, it calls forth the powers of love in others, and creates unity around us, the gifts of the vulnerable to our world. If our cry and our need are unmet, we remain alone and in anguish.... The danger in our culture of productivity and achievement is that we easily dismiss and ignore as unproductive the gifts and the beauty of our most vulnerable members, and we do so at our own peril, dehumanizing ourselves.

The question that we all need to ask ourselves is this: Will we now withhold from our society the love, the care, the attention for our most vulnerable, and in the process dehumanize not only those who need our care, but also ourselves, we, who should be providing that care?

As our committee report, “Not to be Forgotten”, states:

Adequate palliative and end-of-life care becomes more essential as the numbers of Canadians requiring these services grows. Canada is not providing adequate palliative and end-of-life care for all who need it.

In Canada, only 16% to 30% of those who need it, receive palliative care. If that is a failing grade in any ordinary exam, how much more so is it in the context of our dying fellow citizens, friends, and relatives? This is not merely a failing grade, this is a disastrous failing grade. Our report went on to say:

Despite efforts made by palliative care providers, Canadians have a long way to go to meet our goal of quality end-of-life care. Canadians in all parts of our country should be able to get effective palliation of their pain and symptoms, and have their psycho-social and spiritual needs addressed.

So the question is this. What quality of life do we want to provide for Canadians? The provision of proper palliative care is absolutely essential if we are truly serious about maximizing the quality of life of all Canadians, who find themselves in need of these additional supports at a time when they are most vulnerable.

As our report states:

We recommend that the federal government in collaboration with the provinces and territories implement a right to home care, long term care and palliative care, for all residents of Canada, equal to the current rights in the Canada Health Act, to those services defined as “insured health services”, including hospital services, physician services and surgical dental services.

Bill C-277 follows up that same expectation in stating:

The Minister of Health must, in consultation with the representatives of the provincial and territorial governments responsible for health, as well as with palliative care providers, develop and implement a framework designed to give Canadians access to palliative care—provided through hospitals, home care, long-term care facilities and residential hospices—that, among other things,

(f) evaluates the advisability of amending the Canada Health Act to include palliative care services provided through home care, long term care facilities and residential hospices.

In a post-Carter Canada, we need to realize that the environment in which people approach the end of life has changed drastically. According to researchers Tang and Crane, “The risk of suicide doubles for people with chronic pain”.

Now that people have access to medically-assisted suicide, I would argue that there is a high probability that this number may drastically increase as the Canadian population ages and experiences higher rates of chronic pain as outlined above. However, we know that good palliative care can eliminate 99% of all pain.

The heart of the issue, outlined well by the expert panel appointed by our previous Conservative government, is that a request for physician-assisted suicide cannot truly be voluntary if the option of proper palliative care is not readily available to alleviate a person's suffering. While palliative care is not exclusively for the terminally ill, terminally ill Canadians must be given the choice to live as well as they can for as long as they can.

The government has failed to address this gap in our medical system, either through Bill C-14 or budget 2016. Current provincial and territorial approaches to the delivery of palliative care are fragmented. Federal leadership is needed to ensure that all Canadians have access to the same services and quality of care.

There are almost always problems in gaining access to palliative, and a good part of the reason is the lack of medical practitioners who feel qualified to provide state-of-the-art palliative care. There are not enough opportunities to access proper training. Recently, a large medical school in Ontario had 169 applicants for elective time, specifically devoted to study palliative care, yet there was only room for 35 of those applicants to be placed in the program. This problem needs to be corrected.

Again, from the report Not to be Forgotten:

Dr. Valerie Schulz of the Schulich School of Medicine in London Ontario has developed a simple and effective way to get medical students interested in palliative care. Each year 12 students from the undergraduate program become hospice volunteers. Undergoing 30 hours of training, each being mentored by an experienced hospice volunteer; they visit clients in their homes. The experience is priceless for the future doctors, as it gives them a chance to meet and converse with people outside the clinical environment, and without the need to bring a clinical perspective to the relationship. They relate to the hospice clients as persons, learning how they feel and react to the prospect of dying. Friendships are formed, and lessons learned, which will be of lifelong value to the future doctors in terms of person centred care. The clients also are transformed, touched that a future doctor would care enough to spend time with them in a companion role. This program is worth emulation, and broader application.

If larger numbers of medical and other health care students across Canada were able to experience one-on-one relationships as hospice volunteers, the positive effects on our medical culture would be immense. However, we need our medical schools to increase available training options for those students who want access to the specialized training.

Bill C-277 is a step in the right direction in protecting vulnerable Canadians. It builds on the non-partisan unanimously supported work of previous parliamentarians, and I hope all parties will be supporting this historic legislation.

Finally, let me quote from an anonymous author as it relates to palliative care, “To cure sometimes, to relieve often, and to comfort always. This is our work”.

[Kevin Lamoureux, Liberal, Parliamentary Secretary to the Leader of the Government in the House of Commons]

Mr. Speaker, it is a pleasure to rise to speak to this bill and to compliment the member across the way, who I know is a recipient of one of those parliamentarian awards.

This is indeed a very encouraging private member's bill. Just listening to the debate for the last 45 minutes, we get the sense of some momentum that could see the bill go to committee. I would like to see it go to committee. There seem to be some thoughts that maybe we could make some amendments to improve it. As members, we understand the need for furthering the cause of palliative care.

This has been an issue for me for many years. In fact, there was a time, when I was the health critic in the province of Manitoba, when I would go into a hospital facility and see patients waiting, because there was not enough palliative care. In some cases, they were sitting in hallways in hospitals, because there was not a facility or room, even for individuals who were in need of palliative care.

I do not know the severity today. I think there is a better appreciation of what palliative care is and how important palliative care is to all Canadians. It bridges all generations. One does not have to be seeing the end of life in a few weeks.

Where does one begin in trying to address this issue?

Many provinces would argue, and rightfully so, that we have to be careful about provincial jurisdiction.

What I respect about our current Minister of Health is her sense of passion that Canada needs to come to the table, in terms of strong national leadership, on a number of social health issues. Palliative care is one of those.

Just last spring we had a very, I would suggest, apolitical, passionate argument about assisted-dying legislation. During that debate, we saw members on all sides of the House moved to tears. Stories were told about why health care is so important.

Canada is at a critical time. We often hear about the financing of health care and that Ottawa needs to play that role. One of the things I respected so much about the Paul Martin government was that it established the health care accord in 2004 that put into place health care funding. It is the reason we had record amounts of financing going into health care in every region of our country. That health care accord expired in 2014.

We now have a Minister of Health who has reached out to the provinces, under the direction of the Prime Minister and the cabinet and I would like to think all members. I know that the Minister of Health is very much in tune with what is being said here today.

I would like to think that the message we should be sending to the Minister of Health is that Ottawa has to and must play a strong national leadership role in the future of palliative care and in ensuring that there is palliative care in every region of our country and some conformity. I understand and appreciate one of the questions that was posed to the sponsor of the bill, namely, what about the idea of looking for best practices? We need to acknowledge that some provinces are ahead of others on this very important issue.

From a Canadian perspective as someone who loves our country, it should not matter where we live, whether in Newfoundland and Labrador; the province of Quebec or Ontario; or in the city of Winnipeg, my favourite city; or out on the Pacific coast; or in many of our rural communities in every region, including up north, or wherever it might be. Wherever we live, we should have this sense of equality and equity. It should not be the case that if people want good palliative care, they have to live in this or that region of the country. We do not want to see that.

What we want to see and what I choose to believe the Minister of Health is looking for in terms of best practices is what role Ottawa can play in working with the different provinces in trying to make sure that those best practices are being implemented, and how Ottawa can best ensure that is taking place.

We need to ensure there is accountability. We all know that tax dollars are limited, and our taxpayers want us to spend wisely. As a former health care critic, I can say there is a lot of room for improvement of expenditures in health care and in the way in which health care is managed. I say that, knowing full well that in different provinces they approach things in different ways. That is why I argue, when we talk about palliative care, pharmaceuticals or medications, and even when we talk about emergency services, that we at least recognize in part that Ottawa has something to contribute to the debate. It is not just our responsibility to write cheques for billions and billions of dollars. We do that. We pump record amounts of money into our public health care system, and that is something we should do. Health care is part of our Canadian identity. We as Canadians love our health care system, but as Canadians we know there is room for improvement.

When I think of room for improvement, I think of things such as medications, mental health, and what we are debating here today, palliative care. From a personal perspective, I will be very up front in talking about the passing of my father and the fantastic work that our health care professionals, the backbone of our system, put in day in and day out. We cannot give them enough credit, the credit that is owed because of the loving and caring attitudes that so many of our health care professionals have. We owe it to them, we owe it to the patients, and we owe it to the clients and individuals to do the very best job we can as legislators. In other words, we need to get it right.

That is why I am pleased that the member has so openly acknowledged that, yes, this is her bill but that she is open to amendments at committee. I do believe that with amendments we can make this an even better piece of legislation. By doing that, all Canadians will benefit, which is something that all of us want to be able to achieve, especially on apolitical issues like palliative care, because we all care about palliative care.

[The Deputy Speaker, Conservative, Bruce Stanton]

Before recognizing the hon. member for Abitibi—Témiscamingue, I must inform her that she will have about two minutes to begin her speech, which she will of course be able to finish when the House next resumes debate on the question.

The hon. member for Abitibi—Témiscamingue.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Mr. Speaker, given the short amount of time I have, I would like to emphasize how important it is that we respect provincial jurisdiction over health care. I will therefore address my recommendations directly to the health critic in order to hopefully improve certain aspects of the bill.

The second thing I think is especially important in the bill and that she did not mention is the importance of talking about palliative care for first nation and indigenous communities. In the previous Parliament, my colleague from Timmins—James Bay moved an opposition motion, which I seconded. That motion was specifically about ensuring that indigenous communities have access to palliative care. When we talk about the federal and provincial governments coming to the table, for example, it is crucial that first nation representatives also be included, especially since the federal government is directly responsible for those communities, and it has the power to act now.

There is basically nothing going on in the area of palliative care for first nations communities. I visited a hospice in my riding, and the people there told me they were open to the idea of creating a room for first nations individuals, a room that respects their culture and the elements they want to integrate into palliative care.

Unfortunately, the hospice does not have the funding to do so. It welcomes first nations people when the need arises, and the people in charge are willing to move forward with such a project. There are opportunities to approve specific projects for first nations people that would ensure they have access to palliative care that meets their cultural needs surrounding death and grieving.

I believe it is very important to amend the bill to reflect the specific needs of first nations people and better understand the way their culture relates to death. We have to ensure that first nations people get funding for these projects right away so they can get them going, as many first nations communities are in remote and hard-to-reach areas.

I think this is an extremely important point, and I am going to talk to the bill's sponsor about it in view of the committee's work.

[The Deputy Speaker, Conservative, Bruce Stanton]

The hon. member for Abitibi—Témiscamingue will have eight minutes left for her speech when the House resumes consideration of this motion.

The time provided for the consideration of private members' business has now expired, and the order is dropped to the bottom of the order of precedence on the Order Paper.

The House resumed from November 23, 2016 consideration of the motion that Bill C-277, An Act providing for the development of a framework on palliative care in Canada, be read the second time and referred to a committee.

[The Assistant Deputy Speaker, Liberal, Anthony Rota]

Resuming debate. The hon. member for Abitibi—Témiscamingue has eight minutes to complete her speech.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Mr. Speaker, I did not think I would have the chance to complete this speech, so I am pleased to use the eight minutes I have left to do that.

In the first part of my speech, I had noted some things that the bill’s sponsor could come back to in committee. I had also suggested that she include the first nations governments in the consultation, because that is crucial. Often, the cultural approach to death is not really incorporated. Given the federal government’s duty to the first nations communities, it is essential that they be at the discussion table to express their needs.

In addition, there are enormous needs for palliative care in indigenous communities, because there are virtually no projects. Often, the communities are too small, so the feeling is that resources cannot be allocated specifically to palliative care. A number of first nations communities have no long-term care facility. Elders are therefore cared for by their province’s health care system.

When we go out and meet with the people who provide palliative care, we see that they are interested in developing projects. I have been to the Maison du Boulot Blanc in Amos, right next to the community of Pikogan. It sometimes takes in people from the Pikogan indigenous community who need its services. The people who work there are very happy to do that, but they say themselves that it is not the same, that the community is much more involved and there are a lot of people who come to support the dying person.

They do what they can in terms of needs, but if there were some openness to allocating federal funds for specific projects for the first nations, they would very definitely be open to having a room set up and decorated based on the person’s needs. That would reflect the desired approach, which is to accommodate clients who need palliative care.

This is something that will have to be discussed in committee. I urge my colleague to give immediate thought to people from indigenous communities who might be interested in talking about their situations and how they could be involved in delivering palliative care.

Although the administration of palliative care itself falls under provincial jurisdiction, I believe that the federal government has a role to play in bringing all the stakeholders together to discuss best practices. It is not about taking a paternalistic approach and bringing everyone together to tell them to look at the best practices happening elsewhere. It is about creating room for dialogue, where everyone can share their successes and failures in order to move palliative care forward.

We often forget certain particularities associated with palliative care. Pediatric palliative care is extremely difficult. How do we support a child who is dying of cancer or some genetic disease? We have a lot to learn by sharing ideas on this.

For instance, it is important to ensure that children who need palliative care are not forced to choose between being close to home or in a pediatric care centre. They are often hospitalized for long periods and find themselves far from home. Parents sometimes decide to bring their child home when it is time for palliative care to begin. When we talk about a special client group, it is often those in remote areas who have a hard time getting the care they need.

It would be helpful, then, to be able to talk about our practices in order to overcome these challenges. If the various ministries, provinces, and agencies involved could share tools with the rest of the country, we would all be better off.

Other patients are often neglected. For example, how does one help a person with a fairly serious intellectual deficiency prepare for death?

I have had to do it over the course of my career and it is not easy. Caregivers do not always have all the tools they need. They are used to working in a context where the person understands death and what is happening to him or her. However, it is often more difficult to help someone outside that context. I therefore think it is important for caregivers to have that skill.

When it comes to palliative care, for example, some deaths will affect caregivers more than others. That is why it is also important to talk about the distress they experience. Regardless of where the caregiver works, some cases will cause a lot of pain and sorrow. It is also important to be able to talk about that aspect of palliative care so that caregivers do not carry that pain and sorrow with them throughout their careers and can resist breaking down at some point.

Take, for example, soldiers who are deployed overseas and who have to be there for someone who is dying because there is no other choice. Sometimes these experiences are traumatizing and become difficult to live with after many years in the field.

In my opinion, it would be worthwhile adding this other element to the bill on palliative care, that is, monitoring the distress of caregivers, because we are hearing more and more about this issue.

Working with death every day is difficult. I believe it would be beneficial to monitor the distress of caregivers, especially those working in palliative care centres and paediatric and neonatal departments, who do their best to save infants, but are sometimes confronted by the reality that there is no other option but to let them go. These life situations can be difficult, and it would be advisable to monitor this aspect of public health.

I would like to thank my colleague and the House once again for letting me finish my speech. I look forward to my colleagues' comments.

[Bernard Généreux, Conservative, Montmagny—L'Islet—Kamouraska—Rivière-du-Loup, QC]

Mr. Speaker, I am pleased to rise in the House today to support my colleague, the member for Sarnia—Lambton, and her Bill C-277, an act providing for the development of a framework on palliative care in Canada.

Before continuing, I must first congratulate my colleague for her hard work since she was elected in 2015, and for earning the title of most collegial MP. She was awarded that title by her colleagues in the House, from all parties, when the prize was given by Maclean's and L'Actualité last fall. It speaks to the unstinting work done by my colleague, particularly on her present bill.

We are therefore very happy to have an engineer in our Conservative caucus as opposition science critic. That is why I am happy to speak today in support of her Bill C-277, a bill that has attracted attention from key health care stakeholders in my riding, Montmagny—L'Islet—Kamouraska—Rivière-du-Loup.

Like a number of rural ridings in Canada, we find that we have an aging population, and we can already anticipate that the demand for palliative care will rise considerably over the coming years. It has already started. It is therefore important to talk about it and give ourselves time to be well prepared.

Following a Supreme Court decision in Carter, last year, this Parliament passed Bill C-14, which provided a legislative framework for physician-assisted dying. Although the bill was well received by some people who wanted to avail themselves of this right, others had some concerns, because they wanted to make sure that this was not the only option available. In my riding, just like elsewhere in Canada, this is a real question: will we provide only a bill like that, or will we provide other types of care? The other types of care are much needed.

As my colleague from Sarnia—Lambton noted, in the final report of the external committee on options for a legislative response to Carter v. Canada, the Supreme Court stated that a request for physician-assisted death cannot be truly voluntary if the proper palliative care is not available to alleviate the suffering of patients.

This is where we are today. The bill proposed by my colleague seeks to improve the options available to Canadians at the end of their lives. It truly seeks to encourage consultations and dialogue with the provinces to develop a national framework so that palliative care is a real option. In fact, the plan highlights the importance of having access to palliative care of higher quality than what is currently available.

It is important that our seniors and other people with terminal illnesses are protected with healthy, safe, and comfortable options in the last stages of their lives if they do not wish to avail themselves of medical assistance in dying. This is an extremely important point. People must have access to high-quality care to be able to live as long as possible in palliative care facilities. This will prevent many people from even thinking about requesting that their lives be terminated. The dignity of people depends on it.

I would like to highlight the incredible work done in my riding by the Maison Desjardins de soins palliatifs in Rivière-du-Loup, which has provided an enormous amount of care since it opened in 2009. I should also mention the mission of the Fondation Hélène-Caron, which will soon be serving the region of Montmagny and l'Islet through the Maison d'Hélène. Passing Bill C-277 will send a message to organizations like those, all across Canada, that their work is recognized and greatly appreciated.

Last month, Dr. Louise La Fontaine, vice-president of the Société québécoise des médecins en soins palliatifs and a resident of Notre-Dame-du-Portage in my riding, wrote to me to say that Canadians across the country have joined together to draw attention to the importance of palliative care.

She recommends that a national policy be developed in order to considerably improve the quality and consistency of palliative care and access to it. She recommends examining and assessing new models of integrated care, broadening accreditation standards throughout the entire health network, and focusing on areas such as symptom management and advance care planning. Practitioners must also be trained so that they can work in accordance with the various models for integrating palliative care into the management of severe chronic illness.

That is convenient because many of the things she mentioned would be part of the legislative framework if my colleague's Bill C-277 passes.

By asking the Minister of Health to consult with her provincial counterparts, we can ensure that every region of Canada is included in the discussion and that best practices and innovative ideas in the palliative care field are shared. I want to emphasize that because it is an extremely important aspect of the bill. My colleague who just spoke mentioned first nations. Canadian regions differ from one another, of course. One feature of this bill is that it takes all those differences into account and creates a framework for sharing the good practices that some regions are using and looking at which ones would work elsewhere.

I encourage all of my parliamentary colleagues to join me in supporting Bill C-277 so that we can help people across our great nation. If passed, this legislative framework will meet their medical needs and give us a plan that reflects the looming new demographic reality.

I will close by saying that the Lower St. Lawrence region, where my hometown of La Pocatière is located, is the oldest in Canada. What my colleague wants to put in place to facilitate the aging of the population affects us in particular. The bill proposes to provide quality care and enable people to make a fully informed and conscious decision, and to live out their days in an environment where their dignity will be respected.

My brother-in-law died last year after having cancer for seven years. He was treated at a hospice in the Eastern Townships. I had the opportunity to visit him twice. My sister stayed with him for three months.

The Eastern Townships, where Magog and Sherbrooke are located, is well developed. The care offered in the region is already excellent. The experience that these people have developed over the years can most certainly be shared with Canada's other regions.

From what I could see, the quality of care that my brother-in-law received was incredible. I think it is important to mention that.

My colleague came to my riding last week. Our plan was to have her come to my riding to visit palliative care homes, but unfortunately, the weather did not co-operate. I want to thank her for making the effort to meet with my constituents, who have spent a great deal of energy and time fundraising. Palliative care homes are often autonomous thanks to the donations they receive. Donations keep these homes open and operating, as is the case in Rivière-du-Loup.

In Montmagny, Hélène Caron, who is in charge of the project, has cancer. She gives a lot of her time to ensuring that this home exists. It is not a self-serving gesture. She devotes her time to the people and the good of her community.

The bill is unifying. I think that all parties should support it and see it through. Then we could have a national framework for all palliative care homes and the necessary funding to ensure that they are operational.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Mr. Speaker, a few years ago, members from all parties in the House, including myself, established a committee on palliative and compassionate care. The mandate of the committee was to study the nature and scope of palliative care in Canada. I would like to congratulate the member for Sarnia—Lambton for following up on the committee's work with this important initiative.

My inspiration for joining the all-party parliamentary committee on palliative care, which was an ad hoc committee, was Teresa Dellar, a friend and Montreal social worker who founded the West Island Palliative Care Residence in my riding of Lac-Saint-Louis in Montreal's West Island

The residence has 23 beds making it the largest palliative care facility in Canada. It is a model for palliative and end-of-life care across Canada and throughout the world.

I had the joy and honour of being present at Rideau Hall this past November 25 with Teresa's husband, Gavin Fernandes, and sons Jonathon and Nicholas, when Teresa was awarded the Meritorious Service Cross by the Governor General for her vision and pioneering work in palliative care—and I would underscore that the member for Sarnia—Lambton happened to be there as well that day.

Some amendments will be necessary to make the bill better fit the constitutional and practical realities of health care in Canada.

For example, clause 2(1) calls on the Minister of Health to:

develop and implement a framework designed to give Canadians access to palliative care—provided through hospitals, home care, long-term care facilities and residential hospices—that, among other things,

(a) defines what palliative care is;

Unfortunately, it is not within federal jurisdiction to give, or require provinces and territories to give, access to palliative care.

That said, the federal government is well placed to support the efforts of the provinces and territories and stakeholder organizations, by focusing on aligning and extending federal levers in relation to health care system improvements.

We have already seen the government move in this direction during negotiations over a new health care accord, when it offered $5 billion over 10 years to the provinces for home care, a commitment that Marie-France Juneau, executive director of NOVA West Island, formerly the Victorian Order of Nurses, no doubt welcomed.

NOVA West Island offers indispensable services in a home setting to Montreal West Islanders dealing with cancer and other debilitating diseases like ALS.

Federal funding would benefit NOVA and its patients and leverage the efforts of its volunteers. In 2015–16 alone, 16,532 volunteer hours were donated by 232 active volunteers lending a hand with respect to a number of NOVA's services.

Clause 4(1) of the bill also requires amendment. Currently, it requires that the Minister of Health undertake a review and table a report on the effectiveness of the stipulated palliative care framework every five years. However, this would require the minister to report on progress in an area where the government has few levers to directly make change.

Instead, therefore, it would be more advisable to have the government simply report on the state of palliative care in Canada after five years, in this way aligning the bill with the law on medical aid in dying, which requires a parliamentary review on the state of palliative care in Canada within five years of its coming into force.

The federal government is also not in a position to dictate to the provinces what specifically constitutes medically necessary services that must be provided to be eligible for federal funding under the Canada Health Act.

It is further worth noting that there is, in fact, no positive right to publicly funded health care in Canada. This was affirmed in the 2005 Chaoulli decision, where the Supreme Court said, “The Charter does not confer a freestanding constitutional right to health care”, even though medicare is rightly considered a de facto right by Canadians—an entrenched, morally rooted societal norm, I would argue.

The federal government has never waded into defining what actually constitutes a medically necessary service. Nonetheless, I believe Canadians will come to expect palliative care as something that should morally and ethically be broadly made available to them at end of life—in other words, a de facto right.

The question is how this right will come to be realized. Some believe it will materialize through the courts. There are those who argue that under section 7 of the charter, the section that affirms the right to life, liberty, and security of the person, individuals must be afforded autonomous choice at the end of life, the basic principle at the core of the medical aid in dying legislation. However, if the degree of pain control provided by palliative care is not available, an individual's choice has in fact been limited.

In terms of section 15, the charter's equality provision, others make the argument that current provincial palliative care programs, although not technically viewed as medically necessary since the aim is not to cure but to care, de facto discriminate according to disability because they are generally aimed at those dying from cancer. It is interesting to note in this regard that the West Island Palliative Care Residence, once again a leader, caters not only to cancer patients but also to those with other terminal illnesses. A 2014 Globe and Mail article highlighting the residence stated:

At the outset, 98 per cent of palliative-care patients had terminal cancer...Increasingly, however, the hospice is seeing more patients with end-stage cardiovascular and renal disease, and with conditions such as ALS and multiple sclerosis

Also, palliative care is generally needed by those who are older. Therefore, some argue that the absence of broad access to palliative care amounts to a form of age discrimination.

I would like to take a moment to discuss the West Island Palliative Care Residence's vision for expanding palliative care in Canada. I believe it dovetails with the general framework and intent of Bill C-277. In particular, I would like to propose that the government partner with the residence, given its reputation as a national leading edge centre of excellence in palliative care, in advancing the palliative care agenda in Canada.

The residence draws on a community, namely Montreal's West Island, which harbours a critical mass of resources, including the leadership talents of medical practitioners connected to the McGill University and Université de Montréal medical centres. The residence has an important role to play in education and training and in the transfer of practice-based research and knowledge to the broader Canadian community. It intends to play this role by creating a newly formed division called the Montreal institute for palliative care. It is my hope that the minister will seize the opportunity to partner with the institute in fulfilling the government's expressed commitment to palliative care.

It is often said that the measure of a society's degree of enlightenment and civilization is found in how it treats its minorities and the extent to which it internalizes the principle of the equality of all its citizens, in the manner in which it accepts and integrates those with disabilities, physical and intellectual, and in how compassionately it embraces those struggling with mental illness. However, I would add to this list how it supports and comforts its citizens at the most vulnerable moment of their life; that is, at the end of life itself.

I recently read some interesting words of our Governor General, His Excellency, the Right Hon. David Johnston, which I am paraphrasing now. He said that the idea of Canada was worthy of expression and refinement. If the Canadian idea is embodied in, among other things, our national publicly funded health care system, then to make palliative care a more prominent part of that system is to further refine the idea of medicare and of what it means to be Canadian.

Let Canada show the world once again, like we have so many other times before, what it means to be a profoundly civilized nation, a nation that gathers its collective resources to enhance the dignity of the individual at the very moment when dignity itself is everything.

[Cheryl Hardcastle, NDP, Windsor—Tecumseh, ON]

Mr. Speaker, anyone who has watched a loved one suffer through the ordeal of a terminal illness understands the profound importance of palliative and hospice care on behalf of the patient and for the families and loved ones.

I join my caucus in stressing, over the course of this debate, the fundamental right we also stressed in debate on Bill C-14. The New Democrats believe that every Canadian has a right to high quality end-of-life care.

According to the government's own mortality projections, the mortality rate will increase by 33% by 2020, making the need for palliative care as a thoughtfully laid out national strategy an increasingly urgent one, even more imperative within the context of medical-assisted dying.

Current, nearly 25% of the total cost of palliative care is borne by families, and significant disparities remain across Canada with respect to access to end-of-life care, quality of care and those out of pocket expenses. At least 50% of hospice palliative care services are funded by charitable donations, which continues to restrict the size, scope and access Canadians have to palliative programs.

Very few Canadian provinces have designated hospice palliative care as a core service under their provincial health plan. In the remaining provinces, hospice palliative care may be included in provincial home care budgets or other health service budgets, leaving the funding vulnerable to redistribution and cuts. That is why the New Democrats believe we must have a national strategy that can protect the palliative care of Canadians who have access to it, expand access to care for Canadians who do not have it, and improve the quality and affordability of care for all.

I am happy today to speak in support of the bill.

The New Democrats were surprised to find this year's federal budget contained zero federal funds earmarked for palliative care, especially after we fought to incorporate palliative care into the Liberal majority joint committee report on physician assisted dying.

Earlier this year, New Democrat Charlie Angus tabled Motion No. 46, which would accomplish much of what this bill would.

[The Assistant Deputy Speaker, Liberal, Anthony Rota]

I just want to remind the hon. member that it is the member for Timmins—James Bay and she should not mention his name.

[Cheryl Hardcastle, NDP, Windsor—Tecumseh, ON]

I am sorry, Mr. Speaker. It was a slip of the tongue.

Among other things, the motion called for the government to work with the provinces and territories on a flexible integrated model of palliative care by establishing a universal right to palliative care and by implementing a pan-Canadian palliative and end-of-life care strategy that would be tied to dedicated funding.

As I said, we expected this funding to be in the government's first budget but it was not. Here we are in the House debating a private member's bill from a member of the Conservative caucus, which indicates to me that we are at a momentous point in time. There is broad agreement across party lines on this issue and so it is time to face our responsibility to governance that makes progress on human rights and end-of-life care. That we are ready to be progressive on palliative care is momentous and I applaud my hon. colleague for utilizing her private member's bill for this noble initiative.

I was disconcerted when the previous Conservative government eliminated the federally funded national secretariat on palliative end-of-life care. Had it left the support funding intact, maybe we would not be discussing this matter today but would have a resolution and the member for Sarnia—Lambton would not have had to table this bill. I am sure she has other noble causes she could turn her attention to.

As for the current government, the Liberals have had ample opportunity to enshrine quality palliative care as a right for all Canadians, no matter where they live. They could have developed a national strategy that would have eased the burden on both the dying and their families on one end and health care providers on the other, but it was not a priority. I am still flabbergasted when I think of the callousness demonstrated as debate on Bill C-14 was introduced with absolutely no indication that anyone in the government understood the responsibility to secure end-of-life care standards for human beings.

The most significant reason I asked to speak to the bill today was I wanted to lament the unnecessary suffering in the reality of our systemic inadequacies. A national strategy would address these sufferings. I want to hear in person the government's rationale for choosing not to act on this issue.

The New Democrats were surprised to find that the 2016 federal budget contained zero federal funds earmarked for palliative care, especially after we fought for the joint committee on physician-assisted dying to incorporate palliative care.

Given the lack of health care spending in the federal budget, it is no surprise that palliative care was missing. Hopefully by now all of us understand this, that home care is very relevant to this issue. The fact that the Liberal promise of $3 billion for home care turned out to be fiction is also very disconcerting as we take stock of our health care system, its mandate and purpose and know that to move forward we have to include palliative care options that patients and their families deserve to expect.

The Canadian Cancer Society has stated that improvements to the palliative care system in Canada are desperately needed. Without clear national standards and accountabilities, individual jurisdictions are left to develop their own policies, programs, and guidelines, resulting in inconsistent or inadequate access across the country.

In Ontario, for instance, 40% of cancer patients do not receive a palliative assessment in their last year of life. In some regions of Atlantic and Western Canada, administrative data showed that less than half of people who died in a hospital received palliative care. Remarkably, there are many jurisdictions in the country where we do not even know how many Canadians receive quality palliative care. We lack consistent and ongoing data collection at a systematic level, which leaves us unable to more effectively hold our health care systems accountable to make positive changes.

Also, it is not just an issue of data collection. It is vital that any national palliative care strategy takes into account the geographic, regional, and cultural diversity of urban and rural Canada. It must respect our diverse cultural, spiritual, and familial needs, including Canada's first nations, Inuit, and Métis people.

According to Dr. Mary Lou Kelley, research chair in palliative care at Lakehead University in Thunder Bay, the federal health care dollars that would help indigenous people receive end-of-life care at home have not kept up with the increasing demand. Health care for first nations is the responsibility of the federal government, and it does provide some home care services, but the system was never designed to provide complex health care to people with chronic or advanced terminal diseases.

Members might imagine my disappointment that the words “indigenous”, “first nations”, “Inuit”, or “Métis” do not appear anywhere in the text of Bill C-227. However, that is not a deal breaker because it is something that can be addressed meaningfully as we move forward on a national strategy.

New Democrats believe strongly that any legislation that deals with the matter of palliative care must take into account the geographical, regional, and cultural diversity of our urban and rural Canada, and Canada's first nations, Inuit, and Métis people.

As our population ages, palliative care will become an ever-increasing function of the health care system. The federal government needs to support health care workers with the training and resources necessary to deliver it all across Canada. All Canadians deserve to live their final days in dignity and comfort. That is why there is an urgent need to address the significant disparities that remain across Canada with respect to end-of-life care, quality of care, and out-of-pocket costs.

For years now, New Democrats have worked to improve palliative care services for patients and their families. As the party that founded public health care in Canada—

[The Assistant Deputy Speaker, Liberal, Anthony Rota]

Resuming debate, the hon. member for Oshawa.

[Colin Carrie, Conservative, Oshawa, ON]

Mr. Speaker, I am grateful for the opportunity to rise today in the House to support my colleague's hard work on Bill C-277, an act providing for the development of a framework on palliative care in Canada. We are in a time where Canada is seeing an aging population, and it is our role as parliamentarians to help prepare our economy and our health care system for the coming decades.

First, it is important to understand what exactly palliative care is. For someone who has a life-threatening condition or a serious illness, palliative care is used to help improve the overall quality of life, reduce and/or relieve any physical and psychological symptoms, help individuals have a more peaceful and dignified death, and provide support to families and friends while an individual is dying and afterwards.

Palliative care can be provided in a variety of settings. It is really dependent on the options and availabilities within a community. Palliative care is provided at hospitals, individuals' homes, long-term facilities, and hospices.

The bill ensures that all Canadians have a real choice in regard to their end-of-life plans, something that is extremely important now that physician-assisted dying is legal. The Supreme Court itself stated that a request for physician-assisted death cannot be truly voluntary if the option of proper palliative care is not available to alleviate a person's suffering.

As I've said in previous speeches, assisted suicide should only be made available on the rarest of occasions. Canadians expect and deserve a choice between quality palliative care and assisted death. The government has already committed to one of those, and it is now time for it to commit to the importance of high-quality palliative care in Canada.

We know that all parties are in favour of palliative care for Canadians, but we must ensure that all parties agree that the bill is in fact needed in Canada.

I will not lie, I do have some concerns about the current government's agenda when it comes to palliative care. The Liberals started off with promising all Canadians an immediate $3-billion injection for home care, including palliative care, but now the Liberals have changed course. The Liberals are using the urgency of palliative care in communities as a bargaining tool, and that, in my opinion, is absolutely offensive. The provinces that have agreed to the Liberals' terms when renegotiating the health accord were given funding for both mental health and home care, while others that have not yet agreed to the Liberals' terms have received absolutely nothing.

Again we see a lot of talk on home care specifically. I am not saying that home care should not be incorporated in the promised new funding, but to completely eliminate palliative care from the promised funding would be irresponsible.

The government must assure Canadians that there will in fact be some designation of money to palliative care. As I already said, the need for palliative care services is increasing. Currently, only 30% of Canadians have access to good quality palliative care and this is problematic. We must ensure that the government properly allocates some of the promised investment into palliative care, and ensure that this bill be supported by everyone.

Bill C-277 will ensure that action is taken to define services that would be covered. It would introduce a standard training requirement for various levels of care providers, and it would help to collect the necessary data to ensure palliative care is successful in Canada.

There is no reason for any party to oppose such a well-thought-out bill that has the support of so many stakeholders across the country including the Canadian Medical Association, the Canadian Cancer Society, the Canadian Nurses Association, the Canadian Society of Palliative Care Physicians, Pallium Canada, ARPA, the Canadian Hospice Palliative Care Association, the Heart and Stroke Foundation, the Kidney Foundation, the ALS Society, the Canadian Association of Occupational Therapists, and the more than 50 organization members of the quality care coalition.

It is by working hard with organizations and bringing awareness to the need for palliative care that we can make a difference and ensure that individuals at the end of their lives are under the best possible care. This allows families to feel comforted and individuals to die with dignity.

In my riding of Oshawa, there is a wonderful individual by the name of Dr. Gillian Gilchrist. Dr. Gilchrist worked at the Oshawa General Hospital as the medical director of the palliative care team. She was the driving force behind the first palliative care unit at Oshawa General Hospital in 1981, and is considered a pioneer in providing palliative care within our community and raising awareness of the need for end-of-life care.

Dr. Gilchrist, along with her team, were on call 24-7, over all of Durham region.

Today, Lakeridge Health, which the Oshawa General Hospital has become a part of, and Queen's University, have partnered to create the first academic chair in palliative care. This chair will be named after Dr. Gillian Gilchrist. The idea is to ensure that we continue to focus on important areas within palliative care and be able to improve how future patients receive the best end-of-life care possible. According to Dr. Gilchrist, there is a lot that proper palliative care can do for an individual who is at the end of his or her life. lt provides patients and loved ones with the necessary support through a difficult time, not just physical support but emotional support as well.

Proper palliative care cannot be done without a team or proper training. This is why we must support this bill to ensure that the proper resources are there for Canadians when we need them. Experts themselves have said that if given the choice of good palliative care or to end one's own life, 95% of patients would choose to live.

As Dr. Richard Reznick, dean of the Faculty of Health Sciences at Queen's University, said, “We have no desire to treat tomorrow's patients the way we're treating today's. We [must] treat them better.”

In conclusion, we must treat those people better. Many of the people requiring palliative care are seniors or veterans. Seniors built our communities, developed our businesses, and supported our economy. Seniors built this great country, fought in our wars, raised their kids, and ultimately created this prosperous country that we are all so fortunate to live in. It is our responsibility to ensure that the most vulnerable are taken care of. When these individuals, who have done so much for us, need the most support, it is Canada's turn to support them. It is our job to make them comfortable. This is why I will support this important bill. I encourage all members of the House to do the same. I want to thank my colleague for all of the good work she has done bringing this issue forward.

[Lloyd Longfield, Liberal, Guelph, ON]

Mr. Speaker, I thank the hon. member for Sarnia—Lambton for bringing this bill forward, for her leadership on palliative care in Canada, and for making sure that the conversation does not die between parliamentary sittings. I would also like to thank Hospice Wellington for helping me with its insights and input on what I am talking about tonight, and I thank the hospice centres across the country for the amazing work they do for some of our most vulnerable citizens.

This private member's bill aims to establish a national framework for hospice palliative care. My predecessor, Frank Valeriote, co-chaired an all-party parliamentary committee on palliative and compassionate care, along with the members from Kitchener—Conestoga and the former MP from Windsor—Tecumseh. Together the committee took the lead in crafting a report called “Not to be Forgotten”, which forms the foundation of Bill C-277.

The hard work demonstrated by this committee cannot be overstated. After a year of travelling, town halls, and consultations, the committee drafted a report that addressed at length the issues facing vulnerable Canadians, such as elder abuse, pain management, and family caregiver support. In speaking to Frank Valeriote about this bill coming back to Parliament, he said that it was one of the best experiences he had while he worked in this place.

This report establishes a clear and comprehensive guideline for the government to establish a national framework that will reinforce the fact that every Canadian life matters. This bill rejects the notion that Canadians who choose hospice palliative care are a burden on their families and on society. In fact, this bill acknowledges that palliative care offers patients time to live with dignity and to share precious time with loved ones.

Canadians deserve the freedom to make this fundamental decision about life and death without fear that their personal choices will be obstructed by politics or government. With 70% of Canadians left without access to adequate palliative care, we have a responsibility to act in the interest of patients and their families. This is why our government supports both access to palliative care and to medical assistance in dying.

End-of-life issues are as diverse as Canadians themselves, meaning that it is our responsibility as a government to provide as many options as possible for Canadians so that they can take these deeply personal choices and make them their own. This means that we must work with the provinces and territories to develop a flexible, integrated model of palliative health care delivery that takes into account Canada's geographic, regional, and cultural diversity, along with a funding strategy for implementation.

As was mentioned earlier, we have to work out how we work with provinces and territories on how we can deliver these services together. This system must be responsive to the needs of patients and create an environment that creates comfort and reassurance.

As discussed in the report, a hierarchy of care environments is an excellent example of how palliative care can adapt to the needs of patients and their caregivers. These environments offer a range of choices, from one to eight.

It is not the quality of care that determines why level 1 is better than level 3. For many people, level 1 or 2 is the best location, since it keeps them at home, where they can receive good physical, emotional, and spiritual support as well as informational care.

Level 7 is a more traditional hospital environment with more involved and expert care, which comes at the expense of a familiar environment for the patient. Patients have described being removed from their preferred surroundings as in itself a kind of dying, because removing what is valued increases the expectation that they will die sooner rather than later.

This system provides an appropriate space for terminally ill patients so that they can have access to the support they need and the dignity they deserve while retaining as much of their home environment as possible.

It is crucial that this palliative care framework provide for the medical, emotional, practical, and spiritual needs of patients. These are the four pillars of hospice palliative care.

Canada has played a proud role in developing modern hospice palliative care. Even the word “palliative” is a Canadian invention, developed in Montreal in the 1970s. Now we must take the final steps needed to make hospice palliative care available to all Canadians.

Many here in this House have heard me speak at length about the importance of innovation, and here too it has a role to play. Innovation can do more than grow our economy. It can also revolutionize how we protect and care for the most vulnerable in our society, including first nations and people who have difficulty getting to care.

A perfect example is the virtual hospice, an online exchange where ordinary people communicate with palliative care professionals to improve care. The virtual hospice uses readily available technologies to help Canadians living in remote areas access the medical professionals they need while remaining in the comfort and security of their own homes and their own communities.

Dr. Valerie Schulz, of the Schulich School of Medicine and Dentistry in London, Ontario, has developed a simple and effective way to get medical students interested in palliative care. Each year, 12 students from the undergraduate program become hospice volunteers. Each student undergoes 30 hours of training and is mentored by an experienced hospice volunteer. The experience is priceless for the future doctors, as it gives them a chance to meet and converse with people outside the clinical environment and without the need to bring a clinical perspective to the relationship. Thankfully, this practice has taken root with great success in hospices across Ontario. It develops the relationships that future doctors will have with their patients facing similar challenges.

Students relate to the hospice clients as persons, learning how they feel about and react to the prospect of dying. Friendships are formed and lessons are learned, which will be of lifelong value to the future doctors. The clients also are transformed, touched that a future doctor cares enough to spend time with them in a companion role. This program is worth emulation and broader application.

In my riding of Guelph, Hospice Wellington has been in existence for over 30 years. Their residential program is noted for being one of the best performing, if not the best, in the province. It serves over 300 individuals and their families. It is my hope that this bill will allow terminally ill patients to receive this kind of care from coast to coast to coast.

I am proud of the work the government and this Parliament have initiated with respect to end-of-life issues. Bill C-277 will provide Canadian patients with a comprehensive system of palliative care as a first option before they consider other options, such as medical assistance in dying.

Additionally, this approach emphasizes the importance of living with dignity before dying with dignity. By creating a national framework for end-of-life treatment, Canada will plug the gap in its medicare program, ensuring that all Canadians, from the very beginning until the very end, have access to the compassionate care they are entitled to under our Charter of Rights and Freedoms.

I thank the member for Sarnia—Lambton for bringing this forward for us. I will be supporting this bill as it comes forward with amendments.

[The Assistant Deputy Speaker, Liberal, Anthony Rota]

The hon. member for Berthier—Maskinongé has two minutes. That is all the time remaining. My apologies.

[Ruth Ellen Brosseau, NDP, Berthier—Maskinongé, QC]

Mr. Speaker, it is an honour to rise to speak even though I have only two minutes.

Obviously, I intend to vote in favour of Bill C-277. I want to congratulate and thank the member for Sarnia—Lambton for her bill, which seeks to develop a framework on palliative care in Canada.

This bill is very important and all Canadians have been waiting for it for a long time. Many Canadians are suffering because of the lack of clear national standards. There is also a lack of funding for palliative care.

In 2014, my colleague from Timmins—James Bay moved a very important motion calling for the creation of a pan-Canadian strategy for palliative and end-of-life care.

The population in my riding is aging. Approximately 17,800 people are over the age of 65, so people have been waiting for this bill for a long time. However, now we need to walk the talk and take meaningful action. We need to develop a national framework and ensure that there is funding for it. We must be proactive. I consulted my constituents and I know that family caregivers do extraordinary work. I recently lost my grandfather and I was able to see the excellent work that is being done in the area of palliative care, but again we need to support family caregivers.

I want to once again congratulate the member for Sarnia—Lambton. We are really proud of her. We are also pleased to see that the Conservative Party has woken up and seen the importance of providing palliative and end-of-life care in Canada. Congratulations and thank you.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Mr. Speaker, Canadians need palliative care services now more than ever. Fewer than 30% of Canadians have access to this vital service that allows them to choose to live as well as they can for as long as they can. Bill C-277 is the next action required to define the services to be covered, to bring standard training requirements to the various levels of care providers, to come with a plan and mechanism to ensure consistent access for all Canadians, and to collect the data to ensure success.

Canada has an ever-growing number of individuals of all ages experiencing chronic and terminal conditions. Good palliative care covers a wide range of services, as we have heard, such as acute care, hospice care, home care, crisis care, and spiritual and psychological counselling. A palliative philosophy of care is needed to address a wide variety of needs through an adapted and patient-centred process.

Use of more home care and hospice care will bring a fourfold reduction in health care costs compared to acute and palliative hospital care. The creation and implementation of a palliative care framework would give Canadians access to consistent, high-quality palliative care through hospitals, home care, long-term care facilities, and residential hospices.

The bill is timely, as we have heard, since the special committee that studied the Carter decision on medically assisted dying said that without good quality palliative care, there really is no true choice, and we want Canadians to have a choice.

I want to thank many organizations. We heard them mentioned before. They are the Canadian Medical Association, the Canadian Cancer Society, the Canadian Nurses Association, the Canadian Society of Palliative Care Physicians, Pallium Canada, ARPA, the Canadian Hospice Palliative Care Association, many of the member hospices, Heart & Stroke, the Kidney Foundation, the ALS Society, the Canadian Association of Occupational Therapists, more than 50 organization members of the Coalition for Quality Care, and many faith organizations, including the Canadian Conference of Catholic Bishops.

There are so many Canadians who have said that they support this bill, and it is through organizations and groups like these that we can integrate palliative care into the current health care system and make a true difference for Canadians.

I want to thank everyone for their support and for continuing to bring awareness to this. I thank the all-party committee that studied this subject and assisted me in bringing forward this bill with these recommendations. I want to thank colleagues on all sides of the House, who have spoken passionately and in support of this bill, and the thousands of Canadians who have written letters to MPs and the Prime Minister and sent 84 petitions to the House asking for palliative care.

Some hon. members have indicated that they are prepared to support referring this bill to committee for amendment. I have heard the members' input on getting the balance right between what is under provincial jurisdiction and what is under federal jurisdiction.

I know that areas such as education are under provincial jurisdiction. However, with the provinces beginning to roll out services in fragmented ways, the federal government has an opportunity to provide the leadership needed to leverage best practices and to fill the possible gaps, because the work does not end with one plan.

We must develop the infrastructure we need in order to provide palliative care beds and hospice care. With our aging demographic, we are going to have to increase the number of home support workers, personal caregivers, registered psychiatric nurses, palliative care specialists, and those providing support services. The promise that the government made in its 2016 budget to allocate $3 billion for this is a good start.

I am happy to see this bill go to committee, with the hope that we will find a way to accelerate the process of making this framework a reality. As we begin the new year, we have a chance, as parliamentarians, to come together in a co-operative spirit to do the right thing for Canadians without partisanship.

I urge my colleagues on all sides of the House to support this bill going forward to committee. Give Canadians the palliative care they so desperately need. Let compassion make members' choices, and support Bill C-277.

[The Assistant Deputy Speaker, Liberal, Anthony Rota]

The question is on the motion. Is it the pleasure of the House to adopt the motion?

[Some hon. members]

Agreed.

[The Assistant Deputy Speaker, Liberal, Anthony Rota]

I declare the motion carried. Accordingly, the bill stands referred to the Standing Committee on Health.

(Bill read the second time and referred to a committee)

[For continuation of proceedings see part B]

[Continuation of proceedings from part A]