Health Committee on March 7th, 2017

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Thank you for being with us today.

I have a two-part question about the national Secretariat on Palliative and End-of-Life Care that operated between 2001 and 2006. My dual question is, did that secretariat do productive work, in your view, in advancing palliative care in Canada, and if so, would you recommend that the government re-establish that secretariat?

[Dr. José Pereira]

As with any new program, some fantastic work was done, and there were also some failures. We need to learn from those failures.

I'll give you an example of what I think was fantastic work.

I happened to be co-chairing the education working group. There were five working groups in total, and I chaired the education one. The work we did as an interprofessional team went to the implementation of a project called Educating Future Physicians in Palliative and End-of-Life Care, or EFPPEC. With the funding we received from that, we were able to put teams in place across all the 17 medical schools to start mapping out the curricula and start implementing palliative care in the curricula. Some of those schools now are amongst world leaders, the University of Ottawa being one of them, in palliative care-related education.

There were examples of successes. We tried to do same EFPPEC type of project for nursing, and unfortunately by the time we got to that, there was no further funding, which is again an example of not having the sustained funding that we needed.

There was another working group that I was very disappointed did not continue. It was one that was looking at measures, performance indicators, and standards. I believe that had that work been funded properly and moved forward, today we would have had much richer data on this topic to inform us and guide us in terms of planning the health care services at regional and provincial levels, and also at the federal level.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm not sure that I got an answer to my second question. I think the secretariat cost about $1 million to $1.5 million a year. Would you recommend that we re-establish that secretariat?

[Dr. José Pereira]

I would strongly recommend that we re-establish a secretariat or office or framework—

[Don Davies, NDP, Vancouver Kingsway, BC]

Something.

[Dr. José Pereira]

—building on the successes that we had earlier on—

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

[Dr. José Pereira]

—but adding much more to that.

[Don Davies, NDP, Vancouver Kingsway, BC]

Part of the proposed palliative framework involved in this bill involves collecting research and data on palliative care. I think you've well covered that there's some exciting and very valuable work being done in the area. I wonder, Mr. Pereira, if you could advise us if there are any specific gaps or really critical areas that you would like to see research dollars or efforts directed at that would be helpful.

[Dr. José Pereira]

Certainly. There are two or three. One of them relates to identifying the patients who need palliative care going forward and tracking them on a large scale across a whole region to see where they are going, what services they are using, and what the impact is of different models .

I've been having meetings, for example, in the Durham region. If we implement these things throughout the region and do the work to see the impact and how we can learn from that.... The whole concept of using models, studying models, and the impact of different models and different decisions on large-scale deployment is an important area.

One of the challenges we face is that in the data that we have—large databases across the provinces—it is difficult to identify who is a palliative patient. We don't have very robust data.

I've been meeting, for example, with colleagues at the Canadian Institute for Health Information, CIHI, and there are gaps there that we need to address. If organizations like that were given additional resources, they would be able to start studying in more detail the palliative care needs across the country and how services are being used.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

I'm not sure if you know the answer to this or not, or if you could get it for us, but I am interested in where Canada is situated internationally in terms of our allocation of public funding to palliative care. Do you know where Canada ranks?

[Dr. José Pereira]

It's variable. Canada has many different health care systems provincially, so it varies a lot within Canada. There are different organizations that have looked at and tried to rank Canada according to different parameters. We rate sort of in the middle of the field in terms of the top 12 or 14 OECD countries, but in some areas it is much lower and in some areas it is higher. By and large, I think that we have a lot of catching up to do with some of the leaders in the world, such as Australia and the United Kingdom.

[Don Davies, NDP, Vancouver Kingsway, BC]

How am I doing for time, Mr. Chair?

[The Chair, Liberal, Bill Casey]

You have one minute and 49 seconds.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

I think the whole doctor-assisted, physician-assisted death debate offered an opportunity for us in Parliament and all Canadians to consider some of the very profoundly difficult questions that surround end-of-life care. Of course, we had the Supreme Court of Canada decision that required us to come up with a framework of some type.

Mr. Pereira, I think that you have indicated some concerns about assisted suicide. I note that in a 2011 National Post article, you are quoted as saying:

Legalizing euthanasia and assisted suicide places people at risk, affects the values of society over time and does not provide controls and safeguards....

What we really need is good palliative care that addresses the issues, suffering and fears that surround terminal disease.

I think death has become something that is very alien to our culture.... We seem to have forgotten that it is a normal, natural process and we have projected our fears onto it.

I think that sums up some of the essential issues involved in this difficult discussion. Are you suggesting that palliative care and physician-assisted dying are mutually exclusive approaches, or can they co-exist as part of a comprehensive end-of-life care strategy?

[Dr. José Pereira]

As a citizen with my own views on it, I will share my view that it's not right to legalize euthanasia and assisted suicide, but I also live in a democratic country and I respect the democratic processes. I, personally, will not do it.

I want to focus on all the other work that I've been doing in terms of addressing the palliative care needs. That is my focus today, and it's my focus in the work that I do now with palliative care. How can we improve palliative care to make sure that every Canadian has access to it when he or she needs it?

[Don Davies, NDP, Vancouver Kingsway, BC]

I think that we all share that. I think everybody agrees that having top-notch palliative care that all Canadians can access is a sound policy that we all want.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Mr. Kang, you are going to share your time with Dr. Eyolfson.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Mr. Chair.

Mr. Pereira, there was a big debate in Alberta about the patients who were in need of, say, acute care or palliative care and were in the hospitals. The argument was that if those people, those patients, were moved out of the hospitals, it would cost us a lot less, and the emergency wait times.... Because they were holding those beds in the hospital, it would really streamline our system.

In your view, what kind of difference will it make if we invest more money into palliative care? Do you think that in the long run it's going to save us money and improve our health care?

[Dr. José Pereira]

That is a fantastic question, and I think it speaks in a very poignant way to what we're talking about here. We often hear that the majority of Canadians, over 75%, want to die at home. It is true that we can improve the number of home deaths, given resources and processes that we can put in place, but we cannot forget the other components of the health care system.

I always use the analogy of a car. If we go into a dealership and we say we want a car with a fantastic right front tire and forget about the other tires, that car is not going to go anywhere. It's the same thing with the health care system. We know that patients experience different palliative care needs across the illness trajectory, from diagnosis to the very end. Sometimes they are basic needs that can be addressed by a generalist, and sometimes their needs are very complex. We do know that we can't just focus on home care. We need to improve home care, but there are some patients who don't want to die at home, and there are other patients who can't die at home. There are patients who find themselves in hospital.

In Edmonton there was some wonderful work done when I was working there in the first regional palliative care program in Canada at the time. We were making sure we put in place the different components in the right proportions. We improved home care services significantly. We made sure there were enough beds in the palliative care unit, so that those patients across the illness trajectory with very complex needs could get the best care possible by highly trained specialists. We made sure there were enough hospice beds. In fact, we used the formula that's known quite well across the world, which is that for every 100,000 population, we need two or three palliative care unit beds and about six or seven hospice beds. We put all of that in place. Within a few years, we showed not only improved care of patients but also a significant lowering of cost to the health care system.

There was a very well-known paper published in 2005 by researchers in Edmonton and Calgary, who showed that putting in all the components in the right proportion, not neglecting one or the other, helped patients and saved the system lots of dollars.

So yes, we can do a better job in improving home care and palliative home care, but we cannot neglect the other components of the system.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

In your opinion, is the health care system working in silos, then?

[Dr. José Pereira]

That is one of the problems, health care professionals working in silos. We have to break those silos.

With our palliative course, for example, we bring people together from different professions and different settings to start speaking to each other and working with each other so we can start breaking those silos.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Chair. I'll pass it on.

[The Chair, Liberal, Bill Casey]

Thank you. Go ahead, Dr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

We talked about the regional disparities across Canada and mentioned that there are some centres of excellence. In your view, in which centres do we find these centres of excellence and the best palliative care?