Health Committee on March 7th, 2017

[Colin Carrie, Conservative, Oshawa, ON]

I have one more question. You and all members around the table will remember all the work that was done on Bill C-14. We had a lot of concerns from people around the country. There were concerns about lack of palliative care and end-of-life options. There was a lot of deliberation on the fact that if you have an efficient palliative care program, many people don't choose to go into assisted suicide or take options along that line.

Do you think the government should have made an investment into palliative care and home care in conjunction with or prior to Bill C-14? Do you think we're being tardy here?

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

Well, certainly the special committee that studied the Carter decision did recommend that you needed to have palliative care in order to have a choice. I can't speculate, but Bill C-14 was a criminal bill, so it may be that the government preferred not to muddy the waters and put health things into the criminal bill. That's why this bill is such a great idea for the government. It will be able to do palliative care, which was clearly a recommended outcome from the special committee.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Mr. Davies, you have seven minutes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Ms. Gladu, thank you for your work on this issue. I think it's a very important issue, and I applaud you for bringing it before our Parliament.

I want to start with the education of physicians. I read a couple of quotes in preparing for this meeting. One of them was from Dr. David Henderson from the Canadian Society of Palliative Care Physicians. He said, “When we plotted out people who had received their palliative care competencies, there was one physician in all of northern Canada.”

Dr. Robin Fainsinger, a professor in the division of palliative care medicine at the University of Alberta, said, “Every primary care physician should be able to do palliative care, have an understanding of the basics of care provision and access to palliative care specialist services.”

Finally, Dr. Stephen Singh, a co-chair with the Canadian Society of Palliative Care Physicians, said, “There are huge gaps in terms of the education family physicians are currently receiving...versus their own comfort level when they get out in practice. We’d like to see that everyone graduating from any residency has the basics.”

I wonder if you have any comment on whether we should be addressing this issue of physician competency in palliative care.

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

Yes. I've met with a number of the people you cited, including Dr. Henderson, who gave me the evolution of what general practitioners used to receive. Keep in mind that palliative care is evolving. They're learning more and more about different cocktails for pain control and different methods to bring comfort to people.

I do think there's an opportunity to revisit this issue. The Canadian Medical Association is willing to continually update the curriculum that the doctors are going into. They should receive palliative care...because when you think about the shortage we have of palliative care specialists—we're short 400 specialists—you realize it's not a “press a button” thing.

What can we do with our existing resources, just by training our existing GPs who are out there today? There are training programs available through Pallium Canada and through universities across the country. You could increase exponentially the amount of palliative care that's delivered.

[Don Davies, NDP, Vancouver Kingsway, BC]

Would you like to see every physician graduating from medical school have some basic training in palliative care?

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

I would, because I think that will provide care, especially in these remote areas where they may have a GP but they have nothing else that would be useful in providing the resource.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Your bill calls for a number of things, including a definition of palliative care. I'm curious why you would like to see a definition when we know that the WHO and other organizations have definitions. What are some of the definitional issues or cleavages that you've identified in your research?

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

You're correct. The World Health Organization has a definition of palliative care. The Canadian Palliative Care Association has a definition of palliative care. Those two are not quite the same, although they're similar.

The problematic point in the definition is that some people only want to look at end-of-life care. They only want to look at those last two weeks, when really palliative care can begin one or two years earlier. That's one point of contention.

Another point has to do with long-term care. Some people see long-term care as more of a seniors health care issue as opposed to a palliative care issue and would like to separate those two.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

We have International Women's Day coming up this week, so I'm going to ask a question on gender. My understanding, Ms. Gladu, is that currently family caregivers provide more than 80% of care needed by individuals with long-term conditions, whether at home, in long-term facilities, or even in the hospital sometimes.

Also, according to I think a pretty broad consensus in the literature, palliative family caregiving for older adults is gendered. Essentially, the responsibility to provide end-of-life care predominantly and disproportionately falls on women and is predominantly unpaid. I'm wondering if you have any comments, as we face International Women's Day, about how we can address this imbalance in the way this care is being delivered now.

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

Absolutely. What you are saying is true.

As the chair of Status of Women, I know we are currently studying the economic status of women, and one of the testimonies we've heard several times is about how more than 80% of care is given by women, causing them to lose the opportunity to work, etc.

In addition to that, I would say that we've heard testimony about the emotional strain this takes. Consider women who are working. They're also providing care to their children, plus caring for a dying or palliative-state parent or relative. This is where some of the caring for caregivers part of this bill comes forward. Today what's covered in some of the provinces is four hours of respite every week, which may be insufficient, especially if you live far away from a grocery store. If you have to go get groceries and come back home, that could take the whole four hours of your break, so it's definitely of concern.

[Don Davies, NDP, Vancouver Kingsway, BC]

I think Mr. Kang touched on this, and I want to follow up with this question.

Many people want to provide care for their family members, and that's a good thing, and perhaps it's also an intimate thing at the end of life. Obviously, if we're going to provide more palliative care professionally in Canada, that's going to cost some money, particularly if we transfer some of this unpaid care by women onto more professional paid workers. Do you have any idea how much money that would cost or what we should be allocating as a country to increase palliative care services?

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

I think those are harder numbers to know. It's easier to know how much for the infrastructure. It's easier to know how much for the average population to get home care. Those are easier numbers.

Today, because we don't know how many people are doing unpaid care and there's no set wage equivalent for that, it would be a hard number to calculate. I would say that in the beginning, one way of providing the resources that are needed for palliative care is potentially to provide families with a mechanism to encourage them to care for their own relatives who are in the palliative state through tax incentives or other government mechanisms. That's beyond the scope of my bill, obviously.

[The Chair, Liberal, Bill Casey]

Your time is up, but thank you very much.

Mr. Ayoub is next.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you, Mr. Chair.

Thank you, Ms. Gladu, for this excellent bill, which focuses on the patient and not the administrative aspects. It is important, however, for me to properly understand the definitions. You were talking about that earlier with Mr. Davies. In the case of a number of definitions, they pull in opposite directions and ultimately cast a very wide net.

In terms of palliative care, it involves addressing something. For example, there could be a patient who does not require care or daily monitoring for their quality of life. The term “palliative care” often refers to end-of-life care. Its purpose is to improve a patient's quality of life at the end of their life when they are suffering from a serious illness that is difficult to control or whose outcome is known.

That is why this is naturally, although not systematically, related to Bill C-14, which pertains to medically-assisted dying. I would like to hear your understanding of the term. Care for the elderly is one thing, but palliative care is something else, and end-of-life care is something else again.

What is your understanding of it?

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

Thank you.

In terms of the definition of the services to be covered, it's for the government to choose. I'm recommending something that's beyond just the end-of-life care. I'm saying we should have pain control from even one to two years before, and I think we want to have hospital care for palliative services, hospice care, and home care as covered services. I'd like to see these fully covered.

I also believe we need to cover spiritual and emotional counselling, which is something that is a little controversial as well, but to me very important. If I look at the model in Sarnia—Lambton, we have palliative care specialists who are working out of the hospice with a crisis response team, with spiritual and emotional counselling integrated into a home network. This is the same model that's in the West Island hospice in Montreal and in a number of what I would consider the leading-edge hospices.

Those are the services that I believe should be defined.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you.

We are talking about home care. This is important and will obviously be important in the years to come. The population is aging and people with chronic illnesses want to be treated at home, whenever possible. This is especially true in the case of grave illnesses that can be treated at home.

The report provided to us summarizes the bill. It says that family physicians are the primarily care providers. I would like to talk about the first responders because I have some questions in this regard. I understand the idea about family physicians, but at a centre, there is a whole range of health professionals, including nurse clinicians, who are involved in palliative care. Even in family medicine, there are occupational therapists and other kinds of professionals.

I would like to know why we should train all these physicians when the range of services offered—not only by doctors—includes specialized care.

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

It's very true that the service is not just provided by doctors. In fact, I would argue it should not just be provided by doctors, because it is extremely expensive.

In order to innovate in the health care dollars and optimize the spending, you should have people do the most that they can with their training level. If personal support workers have palliative care training, they may be able to administer pain control drugs and work in that area. It's the same thing for nurses. Nurses, especially in remote areas, can rise to the occasion and be walked through how to administer palliative care from a palliative care specialist, and then physicians could take over. The gap today with palliative care specialists is so great that it will not be closed for some years.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you. We touched on provincial jurisdiction for health. Federal jurisdiction is also important.

What role do you see for the federal government in areas of provincial jurisdiction that are not dealt with the same way across the country?

A Canadian is a Canadian, but right now, there are inequalities among the provinces.

Should the federal government step in and impose an approach so that palliative care patients receive balanced treatment from one province to the next, right across the country?

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

I think it's clear from a jurisdictional point of view that the province will execute whatever the federal government decides is the service they're going to provide transfer payments for. That said, I do think the federal government has a role in ensuring standardization. Think about skilled trades areas: welders can weld in Ontario, but they can't weld in Alberta because the standards of training have been prescribed differently and they're not recognized across provinces.

Right now we have provinces starting to train in palliative care and starting to determine and develop jargon. The federal government has a role in ensuring that there is a standardization across the country so that there's a common understanding of terminology, a common set of requirements as we move forward. It is for the provinces to execute those. I'm certain that the provinces would be looking for government assistance if the dollar value of delivering those services increases.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

You mentioned basic training in palliative care for a physician. How many hours of basic training would it take to give a family physician some level of confidence?

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

The family physicians are usually getting two months of training now as part of their medical degree. Because of the evolution in palliative care, there are week-long seminars offered at McGill University, for example, through Pallium Canada, through the Center to Advance Palliative Care.

I would say it would take a week, plus access to web-based materials that allow them to up their game on palliative care.

[The Chair, Liberal, Bill Casey]

That's not a lot.