Health Committee on March 9th, 2017

[Sharon Baxter]

CHPCA was the co-lead on the EFPPEC project that is educating future physicians in end-of-life care and trying to get palliative care education into the curriculum of family physicians. It ran for five years. It was a federally funded program. We had about 40 hours of training in the schools of medicine, and that has been decreased over time. It has not increased; it has actually decreased.

We also ran the SCOPE project, which was creating the social work curriculum. I'm actually a social worker by training. We created national social work training, but there was no funding to carry it on. To this day, none of the schools of social work actually offer it as a full package. We've done some of the preliminary work of creating these core competencies and curriculum, but we haven't been able to push it out. It's a growing need.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

I have a number of questions, but before I do, I have to correct the record because Mr. Webber has misled the committee here.

There's been no cut by the Notley government of any spiritual specialists. I've just quickly Googled it. There was a decision to cut a specialist position at the Tom Baker Cancer Centre, which was made by the director of that centre. It was not a decision of the Notley government whatsoever.

As a matter of fact, I'll quote, “Alberta's Health Minister said [the centre] reassured her office that patients seeking spiritual guidance or comfort in the TBCC will receive it.”

In her quote, Minister Sarah Hoffman said, “Access to spiritual support can not only be crucial on a personal level to a patient, it can also have a meaningful effect on the patient's recovery and well being.” She added that Alberta Health “will be following up with AHS to monitor the transition” to ensure that spiritual services are provided.

I just wanted to clarify in case anybody was misled by Mr. Webber's comment.

What is true, though, is that the Conservative Party, which Mr. Webber is a member of.... One of the first acts of the Harper government was to eliminate the federally funded national secretariat on palliative and end-of-life care when they first took office in 2006. That cut the budget $1 million to $1.5 million from that secretariat. Over the last 11 years we've been without that funding.

I think it was you, Ms. Roussel, who referenced that it would be your advice that the government should re-establish a national secretariat to coordinate a national palliative care strategy.

[Josette Roussel]

CNA would support the reinstatement of the secretariat, given all the progress and needs that we currently have in developing a national framework.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Ms. Baxter, pardon me if you've answered this, but I want to be clear. You pointed out that there are fewer than 85 residential hospices in the whole country, with an average capacity of only nine beds. You stated that we're talking about hundreds of beds, not thousands of beds. In your view, approximately how many new hospice beds would we need to make available in Canada in order to adequately address this shortage?

[Sharon Baxter]

It's all about providing the right level of care and the right setting of care for the right patient at the right time. Residential hospices are terrific to provide care for those who are dying with a cancer diagnosis or something that's complex, and we need more than what we have.

However, in a rural community, having one residential hospice in a jurisdiction that has 200 miles of travel doesn't make sense. We need to look at all the models of care. Residential hospices are important, and we could do much better. We need more. I won't put a number on how many—

[Don Davies, NDP, Vancouver Kingsway, BC]

Has there been any work done on a number? That's the purpose of my question, to get an idea of a number.

[Sharon Baxter]

There is not a firm number.

Here's the thing with residential hospices. In Ontario, the Ontario government has invested money to build more residential hospices, but because their funding model is not 100% funded, they really need the support of the community to be successful. They need them to be driven by the community.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Ms. Roussel, I want to come back to you about nurse practitioners.

The CNA's 2010 submission to the parliamentary committee on palliative and compassionate care argued that the federal government should remove federal barriers that prevent nurse practitioners and other health professionals from practising to their full scope of practice in relation to end-of-life care.

Do those federal restrictions still exist, and if so, what advice would you give this committee to improve that situation?

[Josette Roussel]

Since 2010, we've had progress on a federal barrier that was affecting palliative care. It was related to the prescription of controlled drugs and substances. The regulations were in place in 2013.

The remaining federal barriers to a full scope of practice for nurse practitioners are in relation to federal policies and forms of different departments. We've been meeting with several officials, members of Parliament, and ministers on this issue in the past eight months. We are progressing well. Everyone understands the issue and is in agreement that these barriers should be removed in order have an optimal workforce and use of that team approach.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thanks, Ms. Baxter. I probably have time for one question.

Ms. Roussel, if you want to answer this after Ms. Baxter....

Ms. Baxter, in a letter published in the Toronto Star last year, you wrote:

We are at a crossroads: Awareness of hospice palliative care in Canada has never been higher with the recent media spotlight on assisted dying. We can either focus on making HPC a guaranteed right in the next Health Accord being negotiated right now, or we can engage in a re-branding exercise. We are largely a death-denying society and no matter its name, hospice palliative care will continue to be the pariah in the room until it is made a healthcare priority.

I think those were wise words.

In your view, should the federal government propose stand-alone funding for palliative care in the current health accord negotiations, rather than grouping it in the much broader home care envelope?

[Sharon Baxter]

The charge from the Prime Minister in the letter to the health minister was $3 billion for home care, including palliative care. They've stopped the “including palliative care” in some of their notifications, which is a concern for some of us.

We just need to make it a priority. It can't just be home care that we make a priority because Canadians die in many settings. Home care is a big issue. If you ask Canadians where they want to die or where they want to live for as long as they can, it's going to be at home. We can do a much better job. If we fail at keeping them at home, they end up in an acute-care hospital bed, which is the most expensive part of our health care system. We can do a much better job. The level of patient-centred care in a hospital when somebody is lying there dying is not great. In some cases, they have to be there because they need more nursing care than what can be provided at home. We need to find the balance. It needs to look at all those settings of care. It's really important that we do that. I'm not bent on that having to be under the home care dollars, but it needs to be funded in a comprehensive manner.

[Don Davies, NDP, Vancouver Kingsway, BC]

Ms. Roussel, do you have any opinion?

[Josette Roussel]

We think it's a matter of discussions between the provinces and territories and the federal government. We were vocal around the better home care aspect. We have an action plan around advance care planning, which I brought.

As Sharon said, it's a matter of having sufficient access to it in home care and in hospitals when it's needed. It's a matter of having options for Canadians. Right now, they don't have sufficient options.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay, good. Thank you.

Mr. Chair...?

[The Chair, Liberal, Bill Casey]

No, you're done. Thank you very much.

Dr. Eyolfson, you're up.

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

All right. Thank you, Mr. Chair.

Thank you both for coming. I practised medicine for almost 20 years in emergency departments, so much of what you say is resonating quite loudly with me. In the emergency department, we see holes in the system from just about every angle coming into our department, and one of them is our palliative care system, or more often, the lack thereof. People come into the emergency department and what they obviously need, from the state of their illness, is palliative care.

One our of frustrations is that very often when the specialist, very often an oncologist, has said there's nothing more that can be done, the patient is put back into the hands of the primary care provider. Primary care providers don't always understand what's involved and how to access that system. You may have alluded to this, but should a national education program of all health care providers be provided, particularly addressing when to bring this subject up?

[Sharon Baxter]

That's what “The Way Forward” is about. It's about the palliative approach to care, so it's less about the specialists' care and more about the family physicians, the emergency wards, and whatnot being able to have the right conversation with the patient, know where they can refer to if they need to refer, and find the right level of care.

We really haven't really done that much.... This is new for Canada, and we really haven't done that. We did an Ipsos Reid poll of physicians and nurses in this country as part of “The Way Forward” project two or three years ago, and we found great receptivity—these were people not working in hospice palliative care—about knowing more about palliative care, being willing, and citing this as a gap in their care. The sky is the limit on being able to roll this out, but we haven't rolled it out yet.

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

Further to education, one of the frustrations we also have is that there are patients who obviously need palliative care, their care providers know this, but for many patients and their families, there's a misunderstanding of what palliative care means. All they understand about palliative care is that they're giving up. As Mr. Davies so eloquently said, we are a death-denying society. We are.

I have had patients come in and they're not plugged into palliative care when they obviously should be, and it's at an hour when I can get hold of their primary care provider, who tells me, “I've been talking until I'm blue in the face; they won't accept palliative care because they think it's giving up.”

This is even more of an issue in patients who are a different cultural group, a different diaspora, or recent immigrants who are having trouble understanding so much of our society. They think that everyone is just giving up on them, but they don't want to give up.

Should there also be a push to educate the general public about this, so that people generally have this on their radar before any diagnosis even comes up, before they even think that they need it, so that they have some idea of what this is and what it can provide?

[Josette Roussel]

It's very, very true. We see this first-hand as registered nurses, and it's a whole culture shift about having a conversation and explaining what it means in words that are not so definite. It's a shift that we've done recently. I worked in Ottawa as a registered nurse at Bruyère, and we've had these conversations with the patients and family and explained that, as their wish is that treatments will continue, we're here to support them and ensure that their quality of life will remain. That's true that there's a lack of knowledge and understanding on what it means, and as providers, we're not giving up.

[Sharon Baxter]

There's a national program called “Speak Up: Start the Conversation about End-of-Life Care”, which is run by my association. It's part of the advance care planning in Canada project. One of the things we found is that nurses and physicians and others who work in the field, but don't work specifically in palliative care, have a hard time having those conversations. There are a lot of tools that have been available that are now available to some of the health care providers to start having those conversations. Canadians are being encouraged to have those conversations, as well, within their families around what they want, what they think they want, and all these sorts of things. It's becoming more and more important to do this as we get to be an aging population so that we know what our loved ones want. We encourage that to be picked up too.

Again, it's been meagrely funded. How do you roll some of this stuff out? It becomes important that we have these conversations with Canadians.

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

Yes. This is more a comment than a question. From my own experience the shift in earlier medical terminology—and, of course, in medicine we love our terminology—we sometimes will mean something in a benign way, but it doesn't come across benignly to the patients.

Everyone remembers the days when it was common to say DNR for “do not resuscitate”. That term strikes terror into patients and families. If you say DNR they think someone's being put in a back room and forgotten about. Since we've changed the terminology of levels of care, we're doing the same thing, but explaining. We're doing everything that can be done up to this point, and that one type of care isn't appropriate. We can get people to accept that, which is exactly the same as a DNR, but again it's just not in those brutal terms.

I think the medical profession needs to do a better job in getting terminology out there that people understand and are more accepting of, and making sure that people understand what these terms mean. I think that could be part of the training and part of the conversation that would help to facilitate a lot of patients into accepting and embracing palliative care.

[Sharon Baxter]

Agreed.

[Josette Roussel]

The Speak Up campaign has a lot of tools. We've had great success in providing general education and giving access to these great tools.

[Sharon Baxter]

All the provinces have instituted some sort of legislative framework around advance care planning, advance directives, whatever they are calling them in each province, so it's starting. But how do you get to Canadians? It's a big issue.