Good afternoon, Madam Chair and everyone. Thank you for giving me the opportunity to address the committee today about the use of technology in the management of people with chronic disease.
l am a family doctor and the interim scientific director of the Technology Evaluation in the Elderly Network—that's TVN. We're at Queen's University and the Kingston General Hospital. TVN is a national centre of excellence with $23.8 million of funding to be used over the next five years. Our mission is to improve the care of seriously ill elderly patients and their families through the development, rigorous evaluation, and ethical implementation of health care technologies, ultimately leading to better outcomes for patients and families as well as health care professionals and the health care system as a whole. With researchers from across Canada and partnerships with industry and community organizations, the network is committed to improving care for the seriously ill elderly in Canada through solution-driven research and partnerships.
We are working to foster research and dissemination of information to ensure appropriate use of life-saving technology at the end of life that fulfills patients' wishes. We will also train students in this area to continue the development of a better way to care for the elderly at the end of life. Specifically, we are looking for impact in four areas: improved care of the sick elderly; improved efficiency of the health care system; evidence-informed policy and practice; and reduced moral distress for patients, families, and caregivers.
Here are a couple of examples of the research projects that we have recently funded. One was done by Dr. Karen Burns, entitled “Practices in End of Life Care and in Discontinuing Mechanical Ventilation in Elderly Critically Ill Patients”. Another project was done by Dr. Francis Lau and Dr. Doris Barwich, entitled “A Knowledge Translation Project on Benchmarking End of Life Care Practices for the Elderly in Primary Care”. A final example is Dr. Sean Bagshaw and Dr. Ron Wald's “OPTIMAL Selection For and Timing to Start Renal Replacement in Critically Ill Older Patients with Acute Kidney Injury”.
The national networks of centres of excellence program is a federally funded program through the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council, and the Social Sciences and Humanities Research Council. The goal of the NCE is to mobilize Canada's research talent in the academic, private, public, and not-for-profit sectors and apply it to the task of developing the economy and improving the quality of life of Canadians. Its other goal is for the mobilization of research knowledge and commercialization of technology.
I'll focus my comments on the use of technology in the sick elderly today. TVN has defined technology in a very broad sense, from low-tech things like data collection tools to very high-tech, life-preserving machines, diagnostic tests, and treatment. As you have heard from others, there are many ways to use technology to improve the care of patients with chronic disease. As one example, I also lead a national primary care chronic disease surveillance network that collects patient health information from electronic medical records. We use this information for chronic disease surveillance, quality improvement, and research. EMRs have great promise in improving chronic disease management in primary care.
But what happens when those chronic diseases progress until the end of life is inevitable, despite all our efforts, and the patient becomes very sick? We know from previous studies that Canadians' values about their health are often at odds with how they experience their health care. The focus on technology in acute care often results in elderly people being treated in ways that are not consistent with their values, may prolong suffering without improving quality of life, and often puts health professionals in positions that are at odds with their own values.
The increase in the absolute numbers of older Canadians dying and the concomitant rise in the use of life-sustaining technologies have really created a paradox in modern medicine at the end of life.
Although most elderly patients prefer less aggressive treatments, they often have these life-sustaining technologies used in the final stages of illness and dying.
Currently in the western world, one in five elderly people who die in hospital, actually die in the intensive care unit. The proportion of patients 80 years or older who are admitted to the ICU in Canada has increased from 10%, in the mid-1990s, to nearly 20% today. Most older patients value quality of life and avoiding unnecessary prolongation of life through the use of technology. Yet aggressive life supports are often provided to patients during the final months of life, even when the patient or family prefer comfort care. An example of this is that rates of using cardiopulmonary resuscitation before death are increasing in hospitalized patients.
It's questions like these. Do I put a breathing tube into an elderly patient with emphysema who develops pneumonia and needs ventilation? Do I put a pacemaker in an elderly patient with dementia who has a heart rhythm irregularity? Do I start an elderly patient with multiple chronic diseases on kidney dialysis? These questions are faced daily by doctors, patients, and families. Often the right questions are not asked, the technology is started without discussion, and everyone ends up in a place they don't want to be.
Although technology can be extremely beneficial to support Canadians to live better and longer with chronic disease, there is a serious and immediate need to improve the care of seriously ill elderly patients and their families through the development of some sort of rigorous evaluation and ethical implementation of health care technologies. There is mounting evidence that the unwanted use of technology at the end of life is associated with worse ratings of quality of life for both patients and families, and result in increased family ratings of anxiety and depression. This is a fundamental issue for us with existing and future uses of technology. There is an urgent need to improve communication and decision-making about the use of these life-sustaining technologies. In particular, this includes communication among health care professionals, particularly at care transition points; communication of information about a patient's health and wishes; and communication among professionals and patients and family.
A couple of recommendations I'd like to suggest are that we need to spread the word about the very low-tech approaches, such as advanced care planning. What would it be like if all Canadians had an advanced care plan so that when they entered a hospital, family and health professionals would know their wishes? What if each of us had an advanced care plan as a smartphone app and could carry it around with us? The federal government can encourage this dialogue on advanced care planning at times of life transitions, and consider including such information in mail-outs for CPP applications.
We must develop an ethical framework about how technology should be used in the sick, elderly patient at the end of life so that they are getting the appropriate care at the right time. The federal government should make it a priority to engage provincial and territorial ministers of health in discussion of the best practices and the common metrics of care and standards.
Health care information must be available to whoever is providing the care. It needs to be timely and it needs to be easily accessible. While Canada has spent billions of dollars on the development of electronic health records, we need to continue to invest in this to get to where we want to go.
Finally, the federal government must continue to invest in national programs like the NCE to foster world-class research and the dissemination of knowledge and commercialization of technology.
Thank you.