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

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Mr. Speaker, I am pleased to rise in the House today to speak to Bill C-277, an act providing for the development of a framework on palliative care in Canada. I would like to thank the sponsor of the bill for her work and the members of the Standing Committee on Health for this new version.

The New Democrats have long supported and advocated for the idea of a Canadian palliative care strategy to provide end-of-life care to Canadians. With Canada's aging population taxing our health care system, the need for a coherent, coordinated, nationwide palliative and end-of-life care strategy is becoming more acute. This issue affects and will continue to affect us all directly or indirectly.

I was pleased to see these words in the new version of the bill:

2(1)(g) evaluates the advisability of re-establishing the Department of Health’s Secretariat on Palliative and End-of-Life Care.

I would remind members that we are in this situation because, when the Conservatives were in power, they decided to abolish the secretariat on palliative and end-of-life care and stop work on the palliative and end-of-life care strategy. We therefore missed an opportunity to make incredible advances for the well-being of patients, their families, and our society. Those decisions, combined with 10 years of inaction on this issue, have had a negative impact.

I hope that, with this bill, the Liberals will take this opportunity to restore the secretariat on palliative and end-of-life care and that it will be given adequate funding. I also hope that health care professionals will have the resources needed so that they can provide services across the country, because as we all know, there is a great and ever-increasing need.

I was able to gauge the extent of these needs when I had the opportunity to sit with my colleagues from the House and the other chamber on the Special Joint Committee on Physician-Assisted Dying. At the hearings, the vast majority of witnesses and experts told us how vitally important accessible and good quality palliative care is to Canadians. I was made aware of the fact that across the country only 16% of Canadians have access to quality palliative care. Thus, one in ten Canadians have access to quality palliative care. One in ten is too little, far too little.

The NDP respects the fact that a good part of health services are provided by the provinces. However, the federal government has a fundamental role to play when working with them. For that reason, we have been asking for a long time for a national palliative care strategy that respects provincial and territorial jurisdiction, but that seeks to find way to provide adequate palliative care services for everyone.

At the Special Joint Committee on Physician-Assisted Dying, we made informed and necessary recommendations on palliative care that called for reestablishing the secretariat on palliative care and funding, creating a properly funded national palliative and end-of-life care strategy, and support for family caregivers and better compassionate care benefits.

These recommendations have to be considered. They respond to the concerns of Canadians. As everyone probably knows, National Palliative Care Week is from May 7 to 13. It is happening right now.

I want to take this opportunity to thank all those who work with our constituents day after day. I am talking about health professionals and volunteers who devote their time to this. Their commitment is essential and I thank them from the bottom of my heart. I want to take this opportunity to specifically thank the health professionals, agencies, and organizations, and the many volunteers in the riding of Saint-Hyacinthe—Bagot who work directly or indirectly with the patients. The role these people play in providing high quality palliative care cannot be measured. They provide patients and their families the support they so desperately need during one of the most difficult times in their lives. The palliative care that they provide whether at home, a palliative care centre, or a hospital, is indispensable.

In my riding, Saint-Hyacinthe—Bagot, countless organizations do exceptional work.

These organizations offer palliative and respite care. Others raise funds to ensure that those who need quality palliative care can get it. One of these is the Hôtel-Dieu-de-Saint-Hyacinthe. The centre's palliative care team has been providing palliative care for 30 years. Hundreds of people go to the nursing home to live out their last days. It is around 500. The hospital has hundreds of beds, but only 12 palliative care beds.

In Acton Vale, the Centre d'hébergement de la MRC-d'Acton has just one palliative care bed. All of the people who work with patients and their families, on user committees and elsewhere, are doing exceptional work, and I am deeply grateful to them.

In support of Hôtel-Dieu residents, the Fondation Aline-Letendre will be holding a spaghetti supper and “Rock à la Sylvain Lussier” party on Saturday, May 13, at 7 p.m. in the Centre communautaire Douville in memory of Lucie-Anna Gaucher and Jeanne Palardy, who both received palliative care at the Hôtel-Dieu-de-Saint-Hyacinthe.

This Saint-Hyacinthe organization does crucial work in our community. I want to recognize the incredible work of its executive director, Christine Poirier, its volunteers, and its board members. Since it was created over 20 years ago, Fondation Aline-Letendre has given over $7 million to the Hôtel-Dieu-de-Saint-Hyacinthe. I am also thinking of the staff and volunteers at Les Amis du crépuscule, a community organization that provides assistance to people receiving palliative care and later to their grieving families. We also have the Maison Marie-Luce-Labossière, which provides support and assistance, as well as accommodations, in a safe, peaceful environment to people suffering from “preterminal” cancer, among others. The Maison Marie-Luce-Labossière also has spaces for short-term stays in order to allow caregivers a period of respite during the summer months.

Like me, the members of these organizations believe that a national palliative care strategy would have a positive impact on patients and their families, and that it is high time Canada developed such a framework for palliative care.

The growing demand for palliative and end-of-life care poses a major challenge for our society. The bill before us today encourages us to think about existing frameworks, strategies, and best practices in palliative care. In that regard, I would like to acknowledge the exceptional work that Quebec has been doing for the past several years to deal with this reality and provide appropriate services to Quebeckers. Quebec created a palliative and end-of-life care development plan in 2015, which builds on other existing measures, such as the end-of-life palliative care policy. Quebec is a leader in this area and we should learn from its example. There is also another inspiring initiative in this regard, and that is Motion No. 456, which was moved by my NDP colleague on October 31, 2013. The motion sought to create a pan-Canadian strategy on palliative and end-of-life care in co-operation with the provinces and territories.

New Democrats have been working with many stakeholders and organizations for a long time in order to develop and implement a palliative care strategy. We are proud that the member revisited the NPD's motion on palliative care, which was adopted in 2014. The motion was adopted in the House three years ago, but no real progress has been made on this vitally important issue since then.

That is why it is high time that we move forward without delay. The federal government must demonstrate leadership and take immediate action to establish a palliative care framework that will give all Canadians better access to quality palliative care.

I would like to once again thank the sponsor of this bill, which I urge all of my colleagues to support. We should be in unanimous agreement in the House on this subject.

[Joël Lightbound, Liberal, Parliamentary Secretary to the Minister of Health]

Mr. Speaker, I am pleased to be here today to express support for Bill C-277, an act providing for the development of a framework on palliative care in Canada.

Our government believes that Bill C-277 provides us with a timely opportunity to take a leadership role on this issue. I would also like to recognize the efforts of the member for Sarnia—Lambton, who had the class and the elegance to send flowers to the minister with whom I feel fortunate to work. I would like to return the favour. I think she did an excellent job on this issue and has put forward a very thoughtful proposal. I sincerely congratulate her.

I also want to congratulate the members who served on the Standing Committee on Health and who studied this bill with a great deal of attention and care.

Our government understands that palliative care is a critically important part of our health care system, providing much needed support to patients and their families at one of the most difficult times of their lives. We also know that Canadians overwhelmingly support a palliative approach to care at the end of life.

Still, studies have reported that as few as 16% to 30% of Canadians have access to palliative care, depending on where they live in Canada.

There is no question that we must improve palliative and end of life care so that Canadians, irrespective of where they live, have access to timely, high-quality care at the end of their lives. If we are going to be successful in achieving this goal, however, it is paramount that the federal government collaborate with the provinces and territories and draw on the considerable expertise that key stakeholders, health care providers, and caregivers have to offer.

I would now like to take this opportunity to speak to some of the amendments made by the Standing Committee on Health, which I believe strengthen the bill.

The Standing Committee on Health received a number of briefs from key stakeholders on Bill C-277, including the Canadian Society of Palliative Care Physicians of Canada, the Canadian Cancer Society, the Canadian Nurses Association, and Pallium Canada. All of these organizations expressed strong support for the implementation of a federal framework on palliative care. However, they also indicated that a significant amount of work had already been done and should be leveraged in the development of any federal framework on palliative care.

For example, most provincial and territorial governments already have a palliative care strategy, plan or framework in place to support palliative care. Several of the briefs submitted to the committee also identified the Canadian Hospice Palliative Care Association’s “The Way Forward: Towards Community-Integrated Hospice Palliative Care in Canada” as a key resource that could be built upon.

Funded by Health Canada, “The Way Forward” Framework was developed through an extensive consultation process with health care providers, experts, key stakeholders and all levels of government. It provides guidance, best practices, and other resources to help communities and organizations adopt a palliative approach across all settings of care.

Organizations across Canada, including the Government of Alberta, the Canadian Home Care Association, the Canadian Nurses Association, the Canadian Medical Association, have used the framework to guide their efforts to implement an integrated palliative care approach.

I was pleased that the members of the Standing Committee on Health acknowledged this significant body of work and that it will be studied when developing any future framework.

A number of stakeholders also expressed their support for the priority areas identified in the framework, including palliative care education and training, support for care providers, and data collection and research. Each of these elements is widely understood to be essential in improving access to high-quality palliative care services by patients and their families.

Our government has been very clear in expressing its support on these issues. For example, the government has provided $3 million in funding to Pallium Canada to support training in palliative care to front-line health care providers. This initiative has developed a range of educational materials, trained trainers, and facilitated sessions to increase the palliative care capacity of health care providers.

We also recognize the critical role that unpaid caregivers play in the care of so many Canadians.

As announced in budget 2017, the introduction of the new Canada caregiver credit and a new EI caregiving benefit will provide additional support to Canadians caring for critically ill or injured family members.

Supporting the development of a solid evidence base has also been a clear priority for our government. Through the government's research funding arm, the Canadian Frailty Network centre of excellence is receiving $23.9 million in support over the next five years to facilitate evidence-based research, knowledge sharing, and clinical practices that improve health care outcomes for frail older Canadians, their families, and caregivers. It is my sincere hope that these foundational investments can be leveraged to guide future work in this area.

Our government is also committed to working co-operatively with provincial and territorial governments to improve the quality and availability of palliative care for Canadians.

While the federal government can provide leadership through the implementation of a framework to help support and unify efforts to make positive change, it is the provinces and territories that have primary responsibility for the delivery of health care services, including palliative care.

When first introduced in the House, Bill C-277 called 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. The bill is significantly strengthened by the changes made at committee to indicate that the federal framework on palliative care developed through Bill C-277 would support improved access to these services by Canadians. While the federal government is well positioned to complement and bolster the important work under way across the country by provincial and territorial governments, this wording better reflects the constitutional realities of the Canadian health care system, as it is the provinces that deliver the services on a daily basis.

The amended bill being considered by the House today no longer requires an evaluation of “the advisability of amending the Canada Health Act to include palliative care services provided through home care, long-term care facilitates and residential hospices”.

While this would no doubt highlight the importance of palliative care within the health care system, I would agree with the briefs sent to the Standing Committee on Health by the Canadian Nursing Association and the Canadian Society of Palliative Care Physicians, expressing concern over potential amendments to the Canada Health Act as part of this bill.

Given the complexity of the Canada Health Act, there is a real risk that this measure would lead to lengthy delays in the implementation of the framework, when more immediate action is needed. That is definitely not our objective, nor that of the member for Sarnia—Lambton, I am sure.

These organizations also expressed concern that the review on the state of palliative care, as prescribed by section 4 of this bill, may not necessarily result in increased access to community and home-based palliative care services, services for which Canadians have expressed the greatest support.

With these considerations in mind, the removal of this point will focus attention to where it is most needed, the development of a framework which would support provinces, territories, and stakeholders in their front-line efforts to improve palliative care.

I would like to thank the House for the opportunity to reflect on some of the important changes that were made to Bill C-277, which I believe significantly strengthen the proposed framework.

I will conclude as I started by thanking the member for Sarnia—Lambton for putting forward such a well-considered proposal, and offer my support and the government's support for the amended bill currently before the House.

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

moved that the bill be read the third time and passed.

Mr. Speaker, I am so pleased to be standing in the House today at third reading of my private member's bill, Bill C-277, an act providing for the development of a framework on palliative care in Canada.

The need for palliative care is increasing in our country. What began as a seed with the all-party parliamentary committee on palliative and compassionate care that studied this issue in the 2011 session and brought forward a report, recommendations, and motion to the House, grew into this bill, which has been supported both here and at committee, and is now ready for final consideration in the House.

Canadians need palliative care services now more than ever. Less than 30% of Canadians have access to this vital service, which 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 for 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. Through the amendments at committee, it will also consider re-establishing the palliative care secretariat.

A growing number of individuals of all ages in Canada suffer from chronic pain or deadly diseases. Palliative care services can replace a wide ranges of services, such as short-term care, home care, crisis care, and psychological or spiritual assistance services.

A palliative care philosophy is needed to meet all sorts of needs through a process that is adapted and patient-centric. Increased demand for home and palliative care will split the cost of health care in four, compared to the cost of short-term care or palliative care in hospitals.

The creation and implementation of a palliative care framework would provide consistent access to high quality palliative care in hospitals, at home, in long-term care facilities, and in nursing homes.

The bill is timely, since the special committee that studied the Carter decision on medical assisted dying legislation said that without good quality palliative care there would be no true choice. We want Canadians to have a choice.

During discussion in committee, we heard testimony from some of the outstanding Canadians who pioneer in palliative care, people like Dr. David Henderson, a lead physician in palliative care, and Dr. Pereira, another pioneer in palliative care. We heard from national organizations of nurses, hospices, and other palliative care experts. As a result of their testimony, several amendments were brought.

The first amendment tasks the federal government with developing a palliative care framework though the provinces are responsible for implementing it. Of course the federal government will support the provinces in this, and I was pleased to see the $11-billion investment in palliative and mental health care in budget 2017.

The second amendment clarifies the wording of the provision dealing with the training of palliative care providers. Many individuals are active in this field, including health care providers, volunteers in a variety of settings, and family caregivers. The committee felt it was important to better define training for health care providers and other people involved, so it amended the wording of the provision accordingly.

The committee also requested that the provision amending the Canada Health Act to include palliative care as a protected service be removed.

From what the witnesses told us, there were clearly other mechanisms that the federal government was already considering, such as health accords, infrastructure spending reviews, and programs for palliative care and home care.

The focus of the bill was on developing a plan, and there are many ways to do that.

One of the amendments brought forward at committee was that the proposed framework designed to support improved access for Canadians to palliative care evaluate the advisability of re-establishing the Department of Health secretariat on palliative and end-of-life care. In June 2001, the secretariat on palliative and end-of-life care was established as the first step in Health Canada's work to co-ordinate a national strategy on palliative and end-of-life care.

Nearly a year later, the secretariat brought together over 150 national, provincial, and territorial specialists in the field. This included practitioners, researchers, and those making decisions in palliative and end-of-life care. This summit, the national action planning workshop on end-of-life care, resulted in the establishment of the main priorities or working groups deemed as essential for quality palliative and end-of-life care in Canada.

These five working groups led to the beginnings of the Canadian strategy on palliative and end-of-life care and focused on best practices and quality care, education for formal caregivers, public information and awareness, research, and surveillance. I am very interested to see what an entity similar to the Department of Health secretariat on palliative and end-of-life care could look like today.

The bill now outlines the advisability of re-establishing this secretariat, which could be discussed at length. However, I would like to elaborate on what such a secretariat or regulatory body might look like.

It would be known as the central entity for palliative care information, education, and accessibility in Canada. Setting a national standard, or a national framework, would create consistent care across the country through a variety of mechanisms. Virtual care, home care, palliative care, and hospice care are only a few of the current possibilities.

Working all of these types of different care into community networks would be beneficial to all Canadians and would facilitate the process of finding and transitioning into palliative care. At the heart of these operations would be our health care workers, our nurses, doctors, palliative care physicians, and all the many other caregivers that exist.

An amendment to improve the wording of the need to provide research and collect data on palliative care was approved, as well as an amendment to remove ongoing responsibility for measuring the performance of the framework, since the provinces would have metrics in this regard.

The committee felt that the wording of the bill was adequately clear to cover all Canadians and, as such, no further amendments were required. I want to thank the committee members for their diligent consideration of the bill.

I was able to tell the committee what I would like to see happen when the framework was implemented. In terms of covered services, I would like to see the covered services include pain control, crisis intervention, spiritual and emotional counselling, as well as all services provided in home care and hospice. In an overall patient-oriented palliative care approach, these things are brought forward when needed and do not necessarily apply to the circumstances of every patient.

I would like to see the government leveraging training on palliative care that is already available through organizations like Pallium Canada and many universities. I would like to see us encourage more palliative care specialists to work in Canada, since we only have 200 versus the current need of 600.

I have heard a lot of innovative ideas that have been implemented to accelerate getting palliative care in more remote parts of Canada. For example, there are places where they have trained paramedics and home care workers, and then they are connected to a virtual call centre with palliative care specialists who can guide the care providers. Training at this level really accelerates the actual care that can be provided in remote communities, which is currently a real challenge.

An excellent example of palliative care done right can be found right at home in my riding of Sarnia—Lambton. With an increasingly aging population, Sarnia—Lambton has done incredible work by creating and continuing to expand its senior care network in our communities. With 20 palliative care beds, five palliative care physicians, and our integrated network of home care and hospice care, I believe Sarnia—Lambton is ahead of the pack.

I am proud to say that St. Joseph's Hospice in my riding survives on fundraising currently of $1 million a year, so hopefully we can have the government provide support for these hospices, which provide such a great service. I would like to thank Dr. Glen Maddison who, along with his many colleagues at St. Joseph's Hospice, provided input on this bill.

I believe all Canadians should have access to consistent and quality care, such as is available in my riding. I would like to thank Sarnia—Lambton's many institutions and groups that support and deliver palliative care, such as the St. Joseph's Health Care Society, Bluewater Health Palliative Care Unit, the Erie St. Clair Community Care Access Centre, and of course, St. Joseph's Hospice. Unfortunately, these resources are not abundant everywhere, so I am doing everything in my power to create them in the rest of Canada.

I would also like to have the data we need to take improved action on palliative care over time. We know, for example, that palliative care in home care settings costs about $200 a day versus $1,200 a day for an acute care hospital bed, but we do not know how much the true cost of palliative care averages. Because of the numerous ways people receive palliative care, and the many who have no access, there is a clear lack of information about what the true demand is. Knowledge about which treatments are more effective or are more cost-efficient are also needed. Knowing how many hospices we would need to adequately address the demand is equally important. There are only 30 hospices in Canada versus 1,300 in the U.S., so there is definitely a need.

Using some of the infrastructure money that the government has announced, I would like to see it spent to create Canadian jobs and to build palliative care infrastructure. That would certainly be money well spent. The palliative care framework in Bill C-277 will contain the plan, and the government will then determine the pace of spending and where it will be focused.

There has been so much interest in this subject, and such great support from the many arenas, I hope that when I thank people I will not forget anyone.

I want to thank the many organizations that have supported this bill through its journey, such as 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, with many of their member hospices, like Bruyère continuing care, St. Joseph's Hospice in my own riding, and West Island Palliative Care Residence. I want to also thank the Heart and Stroke Foundation, the Kidney Foundation, the ALS Society, the Canadian Association of Occupational Therapists, the more than 50 organization members of the Quality End-of-Life Care Coalition, and the interfaith groups, including the Centre for Israel and Jewish Affairs, the Canadian Conference of Catholic Bishops, the Canadian Council of Imams, the Evangelical Fellowship of Canada, the Armenian Prelacy of Canada, the Canadian Conference of Orthodox Bishops, the Ottawa Main Mosque and the Ottawa Muslim Association 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.

I also want to thank my colleagues on all sides of the House who have spoken passionately, and in support of this bill.

I want to thank the thousands of Canadians who have written letters to MPs and the Prime Minister, and who sent more than 84 petitions to this House asking for palliative care.

I want to thank the Minister of Health for her advocacy on this issue with the provinces, and for putting dollars into the budget to begin the journey to ensure that all Canadians have access to palliative care so they can choose to live as well as they can for as long as they can.

The time is right. This bill has been another fine example of how political parties can come together and work for the common good of Canadians, and it has been an amazing experience being part of it.

With that, I encourage each member of this House to support this bill. People in their ridings and people all across our nation desperately need access to good quality palliative care. This bill is another step in the right direction.

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

moved that C-277, An Act providing for the development of a framework on palliative care in Canada, as amended, be concurred in.

The House proceeded to the consideration of Bill C-277, An Act providing for the development of a framework on palliative care in Canada, as reported (with amendments) from the committee.

Hospice Palliative Care

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

Mr. Speaker, I am honoured to stand today in support of National Hospice Palliative Care Week 2017.

Hospice palliative care is about living well right to the end. Seventy per cent of Canadians have no access to such services, but we have the power to change that. My private member's bill on palliative care comes back to the House tonight for third reading. This bill has been supported by all parties in the House and I hope to have members' support again this evening.

Bill C-277 would create a framework that would define the services to be covered, the training needed for different levels of care provision, the data and research needed, support for caregivers, as well as a comprehensive plan to get access for all Canadians to palliative care so that each of us can choose to live as well as we can for as long as we can.

[The Chair, Liberal, Bill Casey]

I call the meeting to order. This is our first meeting on M-47.

I also want to say that we tabled Bill C-277 this morning, and that went smoothly. Congratulations. That's the eighth report of our committee.

We are starting M-47 today, and we have a bit of a change in our witness list from the schedule. One witness is not able to be here, for personal reasons. I understand we are also having technical difficulties with Pennsylvania.

In any case, we're going to start. We have Professor Jacqueline Gahagan, interim director and assistant dean in the Faculty of Health Professions at Dalhousie University. Welcome. We also have Kathleen Hare, doctoral student in the department of language and literacy education at the University of British Columbia. We have both ends of the country represented here, and we are very pleased to have you.

Eventually, we are hoping to have Dr. Mary Anne Layden, director of the sexual trauma and pychopathology program in the department of psychiatry at the University of Pennsylvania, but we have not successfully made the hookup yet.

I want to welcome you to our committee. Each of you has a 10-minute opening statement.

I understand that Ms. Hare is going to start.

Health

[Bill Casey, Liberal, Cumberland—Colchester, NS]

Mr. Speaker, I have the honour to present, in both official languages, the eighth report of the Standing Committee on Health in relation to Bill C-277, An Act providing for the development of a framework on palliative care in Canada. The committee has studied the bill and has decided to report the bill back to the House, with amendments.

I want to thank the MP for Sarnia—Lambton for her good work on this. This bill had all-party support. It is timely and very much appreciated by all. Certainly, I am very pleased and proud to present the report.

[Sonia Sidhu, Liberal, Brampton South, ON]

Good morning, Mr. Chair.

I want to amend Bill C-277 in clause 2 by replacing lines 21 and 22 on page 1 with the following:

care providers, develop a framework designed to support improved access for Canadians to palliative care—pro-

[The Chair, Liberal, Bill Casey]

I call this meeting to order.

We're here to do clause-by-clause on Bill C-277, a very controversial and difficult bill that everybody's had a lot of trouble with.

At any rate, we're going to do clause-by-clause on this and we have some proposed amendments.

Pursuant to Standing Order 75(1), we will postpone consideration of the preamble and the short title and go right to clause 2.

(On clause 2)

We have a Liberal amendment proposed by Ms. Sidhu.

Ms. Sidhu.

[The Chair, Liberal, Bill Casey]

We'll discuss that, but thank you very much.

Now we have a little committee business we have to do, as quickly as we can. We have all-party agreement, I think, on changing the schedule. The next meeting is going to be clause-by-clause. That's settled. The meeting after that will be on M-47, on March 23.

Would somebody move the adoption of the budget for Bill C-277, to help pay our witnesses?

That's moved by Dr. Carrie.

(Motion agreed to)

Thanks for that.

Just before we leave, one last thing. We need to adopt the work plan for M-47. Everybody has a copy of it. Do I have a motion to adopt the work plan for M-47?

Thank you, Mr. Viersen.

(Motion agreed to)

That's it. The meeting is adjourned.

[Dr. J. David Henderson]

We need the leadership and somebody holding the rudder of the ship, so with Bill C-277, it's having a secretariat, starting to form a work group. We can have that oversight to start to put in the standards, to make sure the indicators and so on are in place so that we can gather the proper data so that we can see where the real gaps are, and then really start to fill those.

We have a lot of recommendations on how the gaps can be filled, but we need that oversight and the authority to start saying, “Okay, this has to happen.” There has to be an investment of some monies, and I know there have been promises of monies going towards home care.

I was in Nova Scotia when the last health report came around and there was the basket of services. Within that, there was supposed to be a fair bit of money for palliative care issues within the provinces. I know in Atlantic Canada it was years before we saw anything happen. We did eventually, in Nova Scotia, start to see some improvements in the amount that home care patients with palliative care needs could have. It was just two years ago that we actually had medications, what we call palliative care medication entitlement, in place, so it was that long after to get anything happening.

Those are very basic things. We haven't had any increase in staffing for our programs since 2004 despite having a 400% increase in referrals. We need human resources. We need the specialty teams who can then start to work out, fan out, provide the education, the mentorship, the capacity building to raise the tide so that all the ships rise and we can all do this better.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

Dr. Chasen, I had an opportunity to go to the Brampton Civic Hospital where you work. I also toured the geriatric ward. Can you share some of the challenges faced by a palliative care unit on the front line at Brampton Civic, which would provide a useful tool for making Bill C-277 and the future national palliative care plan?

[Dr. Martin Chasen, Medical Director of Palliative Care, Brampton Civic Hospital, William Osler Health System]

Good afternoon to all of you.

I am a clinician in the trenches, and I think that what I'm going to say to you will answer a lot of those questions, because I'm going to show you that it's all practically possible and it delivers good results.

I'll present myself. I am from South Africa. I came here in 2004, to McGill, initially. Then I went to Ottawa, and I'm now in Brampton. I am a qualified internal medicine specialist, as well as a medical oncologist, and I also have a degree in palliative medicine.

In South Africa, which has the reputation of having the most hospices in Africa, we indeed have a recognized university degree. I was in the first class that got it, in 2004. We do see that having it formally recognized changed a lot of government policy.

I'm going to reference two documents. The first is Bill C-277, which clearly says that in order for a patient to have a proper...and to really have a voluntary decision to participate in medically assisted dying, he must be given the choice of palliative care. I think that has motivated me a lot to develop what we've done.

I'm not sure if any of you know about the 2015 quality of death index. It's a report by The Economist's intelligence unit, and I think it is enough motivation to say that Canada is at number 11 on the list. This is not good enough. Before I got to Canada, I did read that the Honourable Irwin Cotler, in 2002, when he was justice minister, said that palliative care is a basic human right, and I think we should move forward on that one.

You may have heard many definitions of palliative care as an approach that looks at patients who have life-limiting disease and their families, and that is impeccable symptom management. It definitely involves the psychosocial, spiritual, physical, and every other domain of a human being. It's holistic care.

In the World Health Organization definition, there are little attachments that people don't know about, and I'm going to speak specifically about three of these attachments.

First, palliative care “affirms life and regards dying as a normal process”. It doesn't “hasten”, nor does it “postpone” death. It “offers a [full] support system to help patients live [as long as possible and] as actively as possible”, keeping people as comfortable as possible for as long as possible. It has a goal of enhancing quality of life, and once again, it is “applicable early in the course of illness”.

This is not just about end-of-life care. We now know from many clinical trials in patients.... The most topical one is in patients with metastatic lung cancer. The patients who were randomly assigned to receive palliative care and normal chemotherapy had less chemotherapy and lived longer.

This is the model that we put together, initially in Ottawa and now in Brampton. What it looks at is the four pillars. This is a model where we start with an in-patient palliative care service for those patients requiring specialist palliative care: terrible pain that's not controlled, extreme anxiety, or existential issues, so the patient needs to come into hospital to be treated in a palliative care unit.

We also have a consultative service in our hospital, where patients are referred to us from the different wards—orthopaedic, medical, geriatric, internal medicine—and I'll show you that. Patients are seen and treated in conjunction with the most responsible physician. We cannot see all the patients. There are more than enough patients, so our aim is to build capacity. I'm surprised that nobody is speaking about building capacity at such a great level, but we have an enormous obligation to build capacity.

Then, what we recently started is the ambulatory outpatient clinic; we have patients who are able to come to the clinic and are seen. We also—I'm going to show you some results of this—have a robust community service. We have patients being seen in their home by a physician, as well as a nurse. We work as a dyad.

Around the centre of these four pillars, we are embedded within education, because without education we will never be able to build capacity. In our specific area in the LHIN, we have made it a goal to have as many of the LEAP courses as we can to build capacity. I'm sure you've heard of that, learning essential approaches to palliative care, with the Pallium project.

Then, of course, we all need to know that research is important. Why is it important? Because research allows you to have that margin of error. It tells you you're not doing as well as what you want to do, that you need to research this to get better. It's a self-audit. Let's use our model, and it works.

Since I started this program in Brampton, these are the patients who have been referred to us as new patients, and you will notice that the majority, more than 765 patients have been referred to us from general internal medicine. Palliative care is not only about patients with cancer, and I will once again ask you to please not call them palliative care patients. They're patients with cancer, cardiac failure, renal failure, chronic obstructive airways disease. They're patients with a terminal disease.

We're getting patients from all spheres, and this brings in the question: how do we bring it in earlier? How do we start the earlier goals of care discussion? From the ER, we've had 104 patients referred directly to us. How do we start the discussion of advance care directives, not necessarily saying that a DNR doesn't mean any treatment? I like the term ANC, allowing natural causes, but, of course, explaining to a patient that it means that everything possible that can be done will be done to keep them as comfortable as possible for as long as possible.

Here are some little graphs that we can show you since we started the palliative care outpatient clinic at the Brampton Civic Hospital, as well as the Etobicoke General Hospital. We only got it going in April of last year, but you can see that we're having more and more patients referred to us on an outpatient basis. We have already admitted 60 patients into the ward directly from the community through the outpatient clinic. They have not gone to wait for a day or two in the ER, where you have 400 to 600 visits a day, where you have people coming from the long-term care facilities who can wait 30 hours there, where you have 300 patients from the long-term care facilities dying in the ER while waiting to see a doctor.

Seeing them in the community, putting them into the outpatient and then, if necessary, admitting the patients.... You will notice, of course, that the last month or two we've had a decrease in palliative care clinic visits, the reason being that we've had more home visits. We're taking the palliative care to the patients where they want it and wherever we can do it as is best, but it's a dyad. This is teamwork. This is about communication. This is not about the patient belonging to me, and that is where I appeal to you to try a funding model that is not fee for service.

If you have a funding model that's not fee for service, everybody can be obliged to do education, to do research, but when you have a fee-for-service model, it's about how many patients I can collect. That is the one recommendation I would say. We move the patients into the community, but of course, we change the funding structure of how people are paid.

The other program I'd like to speak to you about is the palliative rehabilitation program. This program was designed and implemented very successfully here in Ottawa at the Élisabeth Bruyère and the Ottawa Hospital. The goal of palliative rehabilitation is to enhance the physical, psychological, social, and professional well-being of the patient.

Answering the questions that were asked by Mr. Webber about whether we look at the spiritual aspect, each one of our patients gets a spiritual history. You can have a physical history: how is your pain, your nausea, your vomiting, your anxiety, your depression? But for your spiritual history, it's do you have faith? How important is it to you? Do you have a community that you work in? Do you have community support and how would you like me as your physician or your health care provider to provide a spiritual backup for you?

The palliative rehabilitation patients we're seeing here. I'm just going to show you. This was an eight-week program where we had the patient see the OT, the physio, the dietitian, the social worker, the nurse, and the doctor with the patient and the family at the centre of the team. These are values that are taken before the program and eight weeks later, and you can clearly see the statistical significance of the general activity of the patient that's improved, their mood, their working, their relationships with others, their walking, as well as an enjoyment of life. These are validated tests shown statistically significant.

I have to bring you one of these because this is the patient testimony, if we're talking about patient-reported outcomes and what it means to the patient and their family. They said, “I feel I have been remiss in not writing to you sooner. I cannot say enough about how positive I felt being involved with your team. The thing that impressed me most was your profound respect for me. I think that this was only surpassed by the admiration and respect you had for each other. This allowed me to open up and be more trusting. I knew that anything I shared of value and significance was relayed to other team members. My wife and I were no longer on our own.”

None of our patients want to feel helpless, hopeless, and abandoned. It's our job to take that away from a patient. “Simple things seem to take on a profound meaning 'you need to eat more', 'don't feel guilty about resting', 'you don't have to endure the pain, that's why we give you medication” are a few things that come to mind. As I write I realize that the most important thing is that we felt we were part of a team and that made all the difference.”

So how do I see the future? I see the future with public health, billboards at the side of the road saying, “This is palliative care. It is not physician-assisted suicide”. I also say to you palliative medicine specialty training needs to be brought to the fore. It's happening. It needs a push. The funding of hospital and community palliative care rehabilitation teams, which is not an expensive funding model, have been off course to push the leap as well as the Pallium educational sessions and research.

I thank you for your attention.

[Dr. J. David Henderson, President, Canadian Society of Palliative Care Physicians]

Thank you very much.

It's a pleasure to be here. This is such an important issue that we are thrilled to be here to help support this.

To quickly come to the point of the matter, our society certainly recommends the acceptance of Bill C-277. We've been supporting this concept for quite some time. We're thrilled to see this coming forward and to see the uniformity across all parties in understanding this need and the importance of this issue. We're happy that this is moving forward. We're here to help make sure it moves forward, and we'll do what we can to support it.

I know that you have already had several presentations and are getting the big gist of things, but I want to bring us back to a big picture and down to earth a little. Despite Dr. Oz and all the wonderful health care you get through Dr. Google, the world mortality rate unfortunately is still at 100%. We'll all die eventually, so this is really the only issue that is non-partisan. It's non-faith-based. It's women, it's men, and it's children. This is something that affects everyone.

We're all going to be dealing with this at some point, but dealing with this today is different than it was even 50 years ago. With the advent of some of the advances in health care, dying has changed. It has become more complicated and we need to be able to address that.

I think the aging demographics that we're facing have been discussed before. The graph I have here is a nice one to give a good visual of where we are and the urgency with which we need to move these things forward. If you look at where we are on the graph, you'll see a very large jump from 2011 to 2021 in the number of people who are going to be 65 and older. We know we're human beings. We know we have parts that wear out and break down, and we can't get replacement parts very readily, so things are going to happen. This is going to be the largest part of the population that ends up driving the demand for palliative care services. Again, as that baby boomer generation is hitting this age group, we can see very dramatic increases in the numbers, very significantly so.

I've actually put myself on the graph. I'm coming into this, too, so one could say that this is a very self-serving thing for me, because not only do I want to make sure that I can get the care I'm going to need down the road, but I've put in my son, who's now 15, at where he will be at 65, so that coming down the road for my children and my children's children we will have a strong foundation for the type of care they're going to need as well.

As I look around the room, I see a couple of grey hairs here and there, so you know what? If there's no other good reason, folks, this is for all of us sitting in the room, and also, some day, for some of the younger people sitting off to the side.

Where are some of our current gaps? I've broken it down very basically into professional and human resources. We've talked about that a bit, about just the sheer numbers of people with a bit more of that advanced training in palliative medicine, or the specialty training, and that builds into the skilled providers. Along with that aging demographic, it includes those of us working in palliative care. We have an aging demographic of skilled labour as well, and that too needs to be replaced as time goes on.

In the current gaps in terms of public issues, access now has been well documented as a big issue. There are pockets of places where access is pretty good but likely could be better. I know that in our neck of the woods—because on the east coast we do have some of that aging population—we're probably a little bit skewed on the curve. We have wait-lists now to access palliative care services, which is just atrocious, but that's the reality of the world right now.

As I said earlier, people are living longer with multiple comorbidities because we've been able to manage their renal failure and manage their heart failure. As well, they may have a couple of new arteries in their heart, so they're pumping longer. We've advanced some things, but at the end of the day we still have people with more chronic comorbidities that complicate things as they are getting older, and as these organs and parts still continue to wear out.

There's a higher complexity from the physical nature of it, but it's also a higher complexity because of our generation too. We have a lot of people who have been moving back and forth across the country for work opportunities the way our children do, so often there are not as many caregivers around family-wise to help provide the care in the home that we used to have years ago.

Again, with the aging demographic, we have higher numbers requiring care, and because people are living longer, often there are lower numbers of care providers. If someone is 91 and their spouse is 92 and a fair bit of physical care needs to happen, there are limitations, because of that age range, in what they can and cannot provide physically.

As far as informational gaps that we're facing go, again we still don't have national indicators for palliative care across the country. We don't have our national standards. There's no national reporting and there's no national oversight. That's one of the key things I think this bill can actually bring to the table and really needs to bring to the table. We need that large-scale look at how things are going in a unified way so we can start to look at how things are being done across the country and optimize best practices and make sure they get translated across the country so that we can all do better.

Some great work and some great projects have been done. Now is the time to be taking those and implementing those across the country. As I've said in the past, the time of pilot projects should be done. We need to be moving forward.

I'll just very briefly make one statement, and I think maybe Mr. Oliver made a comment on this earlier. Medically assisted dying is not a choice when there is no other choice. Unfortunately, that's the way it is in Canada right now because of the lack of access to palliative care services.

Bill C-277 would fulfill some of the recommendations that were brought forward in the Special Joint Committee on Physician-Assisted Dying. Specifically number 19 was to:

re-establish a Secretariat on Palliative and End-of-Life Care; and that Health Canada work with the provinces and territories and civil society to develop a flexible, integrated model of palliative care by implementing a pan-Canadian palliative and end-of-life strategy.

Number 18 was to:

ensure that culturally and spiritually appropriate end-of-life care services, including palliative care, are available to Indigenous [people].

This bill would also ensure that palliative care is provided to the people the federal government is responsible for providing health care to. The groups under federal jurisdiction include first nations people living on reserves, the Inuit, serving members of the Canadian forces, eligible veterans, inmates in federal penitentiaries, and some groups of refugee claimants. We need to ensure that we have national standards in this for that population as well.

The bill talks a little bit about the Canada Health Act. When we really start to look at the Canada Health Act, we see that it says that all Canadians should have universal complete access to care. Approval of Bill C-277 would ensure that Canada set the standards for access to quality palliative care for all ages including children, all geographies, and all diagnoses.

To ensure that Canadians have access to high-quality palliative care, we have developed a couple of documents recently that we sent to all the members previously and can certainly make available again. The web connection is present there for you. Basically we're stating clearly that we need to look at implementing the palliative approach to care as outlined in the national framework document “The Way Forward”, which you've heard about today and, I think, previously as well. That document is a good foundation for how things should be moving forward. We, along with many other palliative care organizations and other organizations throughout the country, have endorsed that.

Again, we don't need to start from scratch. One of our key messages is that we need to start to work on implementation as opposed to doing further development.

The second document, which we released just a couple of weeks ago, was looking at the cost-effectiveness of palliative care. Very briefly, some of the different studies looked at lowering costs of delivery by up to 30%. Even more importantly when you look at the delivery of this care, it will also help to free up scarce resources in acute care such as beds in intensive care units for patients who truly need them.

When palliative care can be involved early on, you start to have some of those discussions about goals of care and what the patients' wishes are and their understanding of their illness. They can realize that going into the ICU may not be what's really in their best interests. It's not going to fix things. If we can keep people out of the ICU, for whom there really isn't going to be true benefit, that will open up those beds for somebody else who truly can benefit from using up those very limited resources.

Again, we come back to that aging population. There's going to be a bigger demand on everything throughout health care. There are going to be more people who will need those intensive care beds, so we need to be really making sure we utilize our resources as efficiently as possible. At the same time, while we're offering the same type of care, we're improving quality of life and quality of care for patients with serious illnesses and for their families.

Health care costs have been escalating as a consequence of our failure to adapt to the changing demographics of Canadians and advances in chronic disease management, including cancer. Change is now long overdue. Continued failure to invest in palliative care will be a lost opportunity to achieve better efficiencies, improve outcomes, and reallocate budgets to other priorities. The status quo really neither meets Canadians' needs nor is financially sustainable.

What we're recommending certainly is the forward movement and acceptance of Bill C-277. We'd really like to see an established well-funded secretariat, and the formation of a small, nimble, high-level working group made up of key national organizations to start working with the secretariat on implementation.

Focus needs to be on administrative cost containment so that funds can see their way to the delivery of services. We've seen other projects go on and lots of money put into major infrastructure, which unfortunately hasn't translated into a lot of key things hitting...your rubber hitting the road. This is something where there's lots of good work happening across the country. We have shown in the palliative care world that we work well together. We've been doing things on a shoestring for years. This can be done efficiently. We want to see the monies get to providers out in the areas with increased resources so that we can actually make those differences that need to happen.

We need to bring in additional stakeholders, when and where required, to develop the efficiencies, gain the insights, and mobilize strategies. Having another 100-body committee to work on things is going to be very slow and tedious. Again, you see by that demographic curve, we're into it now. We don't have 10 or 15 years to be doing this. Our hospitals are already starting to be overloaded. I know in Nova Scotia they have overcrowding. They're having to develop new terms to label the levels of overcrowding we're having in some of our hospitals because of this aging demographic and the demands.

What is needed? Again, we need to start with what we know. We really need to be collecting standardized national data. That can happen as well through a national secretariat to help move that forward and make sure we're doing this: setting, monitoring, and enforcing national standards and indicators for palliative care in Canada; and making accreditation of health care services both in hospitals, long-term care homes, home care services, etc., all mandatory and contingent on palliative care services being provisioned to nationally accepted standards. We also need to—and my colleague here will be speaking to this, I think, a bit more—standardize and insist on integration of core competencies in the schools of health care professionals.

We had the opportunity to hear from the Canadian Nurses Association today. I know for medicine, for nursing, for social work, and for pharmacy in particular the core competencies are developed. The big challenge has been getting those integrated within the health care professional schools. That is something for which we may need some federal pressure to help make that happen. We've been advocating. We've been trying to get that to happen, but there's so much competition for that time within our professional schools that you have to look to take something out to add some more time in. But, at the end of the day, what we're doing is so fundamental it needs to be there.