Health Committee on March 9th, 2017

[The Chair, Liberal, Bill Casey]

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Dr. Henderson, I take it the prime lesson we have to take from this is that none of us are getting out of this alive. Is that right?

[Dr. J. David Henderson]

Absolutely correct.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay.

First of all, I want to thank both of you for taking the time to be here. I've learned a lot from both of you. I have a number of questions.

You made reference to the wait-list, Dr. Henderson. Can you give us an idea of generally how long the wait-list to access palliative care is in Canada?

[Dr. J. David Henderson]

In Canada? No, I can't tell you that. A lot of places choose not to have a wait-list. They'll keep trying to see people just as quickly as they can, which means the caseload for their staff ends up becoming kind of monumental. Even within Nova Scotia, there are caseloads where, based on the nurses' caseload, they could have 80 to 90 to 100 patients on their caseload. You can't see most of those people, so how many of them need to be on the caseload? They are just not getting the attention they need to be able to be kept from needing those extra emergency room visits and so on.

In our district, we have chosen to keep a reasonable caseload per nurse of about 25 so that they are able to make the contacts. The 25 is constantly changing.

[Don Davies, NDP, Vancouver Kingsway, BC]

You made a reference to wait-lists. I'm trying to find out. It's your term—

[Dr. J. David Henderson]

We've been up close to a two-month wait-list—

[Don Davies, NDP, Vancouver Kingsway, BC]

Two months.

[Dr. J. David Henderson]

—when the average life expectancy is about six months.

[Don Davies, NDP, Vancouver Kingsway, BC]

I've seen some references to the number of people who would like to access palliative care but end up not getting it. Do we have a general idea of how many people are actually getting quality palliative care and how many are not?

[Dr. Martin Chasen]

The often-quoted figure in the Auditor General's report is about 35%.

[Don Davies, NDP, Vancouver Kingsway, BC]

The 35% are receiving palliative care.

[Dr. Martin Chasen]

They have access to it, yes.

Cancer Care Ontario has a provincial standard in cancer centres of having a palliative care patient seen within two weeks, but that's in a cancer centre in a specialized centre, which I do believe is not where the majority of patients are going to be seen.

In order for us to do what we've done and see those patients in the community, we've had to employ doctors. I will say that palliative care is actually very cost-effective, because those doctors don't cost the hospital any money at all, other than maybe a computer, and hopefully they can get a place to hang their coat up. Those doctors are not ordering blood tests. They're not ordering X-rays. They are admitting patients and trying to get the patients back into the community. We can't really see where that saving comes, but we do know, for instance, that 60 patients didn't go to the ER and wait there. They went straight into hospital.

It's very difficult to understand how to measure the savings, when all of it goes into the black hole of the exchequer.

[Don Davies, NDP, Vancouver Kingsway, BC]

Dr. Chasen, in the last meeting, we had some testimony around the need to maybe increase palliative care education for physicians in medical school. I'm getting the sense from you that it's a whole specialized field, a specialty in and of itself, but what can you tell us about what you'd like to see in Canadian medical schools in terms of the amount of time and training they give to each graduate of medical school on palliative care?

Dr. Henderson, you might prefer to answer.

[Dr. J. David Henderson]

Actually, we just got the green light to go ahead and do a refresh of the EFPPEC, educating future physicians. I think Sharon Baxter mentioned it today.

The core competencies were developed, I think in 2004 or 2005, and the problem was getting those core competencies integrated within the medical schools. What we've seen through some recent research is that the number of hours of this baseline undergraduate education has actually diminished in most schools to a point where it's really quite low.

The core competencies are developed. We need to get them implemented within the schools. We are going to look at refreshing them, but there won't need to be that many changes in them. That's there for physicians. Core competencies are developed for nursing, and again they're having a harder time getting this education into their core curriculum, because there are that many more nursing schools. Again, it's a challenge. They only have so much time, so if you're trying to get something else in, it means you have to take something else out.

Everybody has their own baby that they want to hug and keep in there. It's a huge challenge. The reality is that this education crosses so much. You don't even have to call it palliative care education, because it's applicable to everything you do in health care. So much of it is about communication, effective communication, listening to the patients, understanding the goals of care. Even if they're coming in for gall bladder surgery, if you can do pain management better and nausea management better, you're going to do well.

[Don Davies, NDP, Vancouver Kingsway, BC]

I want to end with two questions and let you tell us your opinions. Dr. Henderson, in an editorial you co-authored in The Globe and Mail last May, you said the lack of end-of-life care in Canada:

...is a national failure to address dying with dignity from an ethical, funding and continuum-of-care perspective. This failure must be acknowledged and corrected in the current discussions around a new health accord between Ottawa, the provinces and territories and our indigenous peoples.

What would you like to see in the new health accord to correct that failure? I'll ask either of you.

Basically, the last question I have is this. What is the most basic, fundamental, and profoundly important advice you would give us as federal representatives to help address this important issue?

[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.

[Don Davies, NDP, Vancouver Kingsway, BC]

The time's up.

[Dr. Martin Chasen]

I speak often to David, who is the president of our association, but it really needs to come onto the front burner. That's what we need. Palliative care is not an add-on. It is part and parcel of what medicine is. It needs to be brought right onto the front burner with a vision, with the implementation, with the auditing, and with continual improvement.

[The Chair, Liberal, Bill Casey]

Mr. Ayoub.

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

Thank you, gentlemen.

That is very worrisome and your presentations were very informative.

How long do I have? How many minutes?

[The Chair, Liberal, Bill Casey]

You have seven minutes.

[John Oliver, Liberal, Oakville, ON]

I think it was my round.

[The Chair, Liberal, Bill Casey]

Do you want to...?

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

I don't mind. If you have more, go ahead.