Health Committee on March 9th, 2020

[Marcel Saulnier]

I can start.

Yes, for sure, EMS and paramedic services are increasingly becoming a very important extension of the health care service delivery model in several jurisdictions, particularly those with rural and remote populations forming a big part of their population. I think some of the best examples in Canada have come up. It started in Prince Edward Island and Nova Scotia, where all of the EMS providers are being trained to deliver palliative care services and are being deployed throughout those jurisdictions. As you know, both of those jurisdictions have very large rural populations. That model is also in place in Alberta and is increasingly being taken up across the country. I think it's a very good example of innovation that is showing strong promise of being deployed across the country.

[Christina Lawand]

Yes, I think the example that Mr. Saulnier is speaking to is highlighted in our report as well. There's the Canadian Foundation of Health Care Improvement, which has highlighted some of the most exciting, innovative practices out there, and this one of offering emergency medical services is really making a measurable difference in the jurisdictions that have implemented it in preventing unnecessary emergency room visits at the end of life and allowing people to get the care at home.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Right, and taking those dollars to put them where.... We can look at EMS services versus the time that's taken up tying up hospitals, etc.

You also both talked a little bit about the training of the practitioners and how little palliative care is in the medical training and the nursing training, etc. Would you agree that it's imperative upon the professional bodies to incorporate that part, not only in the accredited college training, but also in their post-graduate training for their practitioners in every aspect? When you look at all the professions that you listed, I suspect that every one of them.... It behooves us to be telling them that they should be educating their practitioners on the issues of palliative care and how we want to assist people in their homes.

[Marcel Saulnier]

Yes, I think there's progress being made in that area as well. The Royal College of Physicians and Surgeons has extended the training required for palliative care specialty. Quite apart from the College of Physicians and Surgeons and other nurses and providers, there is really effective training being made available through organizations like Pallium Canada, which has trained 20,000 providers since its inception, so that's really making a very strong contribution to training and competencies out there in the system.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Ms. Lawand, do you have anything you might want to add?

[Christina Lawand]

At the time of our report, we cited some information from the Canadian Partnership Against Cancer survey of medical schools, which did, indeed, find there were potentially some training gaps. While 90% of medical curricula had lectures related to palliative care, just 12% of students were required to participate in mandatory clinical rotations, for example. They found that hands-on experience to be lacking, but promising initiatives like LEAP, which is a program to train people who are already working, are helping to fill some of that gap for sure.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Kitchen.

I go now to Mr. Van Bynen for five minutes.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

Thank you. I appreciate your being here and giving us the information we've heard thus far. I want to carry on a little further from a question that was raised by Mr. Kitchen, and that is the cost of health care and the cost of critical care beds that are being occupied by people who should be receiving palliative care. Is there a mechanism or some way that we can actually define the cost of palliative care in critical care beds across Canada, across a province or across a hospital?

[Christina Lawand]

It's a really interesting question. We took the costing piece out of the scope of our report because it was a more complicated question and we needed more time to work on it, but it's something we could potentially look at, for sure, in terms of analyzing those costs. We know, generally speaking, that end-of-life costs are one of the largest expenses in health care. The last year of life is one of the most expensive times in a person's life.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

One of the goals of Health Canada's action plan on palliative care is to raise awareness about how advance care planning, end-of-life care discussions and palliative care can improve the quality of life of Canadians with life-limiting illness. Can you tell me what role public awareness and education play in improving the access to palliative care in Canada?

[Sharon Harper]

I'm sorry, could you repeat the last part of your question?

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

What role do public awareness and education play in improving access to palliative care in Canada?

[Sharon Harper]

Actually, that's a very important question. Information about palliative care and understanding about palliative care is a huge question because a lot of Canadians do not understand what palliative care is, and what they do understand is very worrisome to them. That creates a barrier to early referral to palliative care because they believe that curative care and palliative care cannot coexist, that if they're referred to palliative care there's nothing else that can be done for them.

End-of-life care planning is arguably something we should all do in terms of planning for the care we want at the end of our lives, being clear and explicit about that with our families, our health care providers and everyone we can explain it to, so we're sure we get the care we want at the end of life. However, naturally, it is something I think most people put off a little too long. It's another area we are focusing on in the action plan, to make sure people have conversations about what they want at the end of life.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

I've been a director of a bereavement centre in Newmarket, and the concern there is that conversations about death and dying simply aren't happening early enough. However, I know the Salvation Army, Doane House Hospice and the Margaret Bahen Hospice have taken on programs like death cafés. Have you been involved in any of these programs, and/or are you interested in partnering with these organizations so these conversations get started early enough?

[Sharon Harper]

Yes, death cafés are a way of making people aware and getting them more comfortable talking about end of life. In fact, our official languages program has developed a series of micro grants that serve to help people who want to create things like death cafés in order to encourage this kind of conversation. They would receive some funding through Health Canada in order to do that for official languages minority communities. Also, Pallium Canada has created kits for people who want to create compassionate communities, which would also help to focus attention on these discussions, as well as create community capacity to care for people at the end of life.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

Thank you. What are the initiatives the federal government will be undertaking as part of this framework on palliative care in Canada to support equitable access to palliative care in Canada? We've heard a lot about the inequities in how that's delivered. What initiatives are being planned or have been planned?

[Sharon Harper]

That's a very interesting question. Right now, the ones we can talk about are the ones that are already in play. We talked about increasing the capacity to have end-of-life care conversations in South Asian communities, and that is one way to increase the equitable access. There are a number of other projects that are under consideration, but they have not yet been approved, so I can't really speak to them at this point.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Van Bynen.

Mr. Thériault, you have two and a half minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

Earlier, after your excellent answer, I realized that, basically, we would have much to gain from working to integrate care. When the curative treatment is completed, patients are in a no man's land, waiting for an appointment with their general practitioner and for the specialist who treated their cancer, for example, to coordinate cessation of care. Then suddenly, that doctor tells the patient that their work is done and advises them to seek palliative care.

You are saying that, if we could integrate care between the end of the curative phase and the palliative care continuum, we would save a lot of money, and in doing so, we would improve accessibility to that care, because we would have more resources.

You are also saying that palliative care units in hospitals are reserved for extreme cases, when someone is admitted to the emergency room and will not be discharged. I understand that we need to be able to provide that palliative care setting. However, ideally, we should be able to offer home care as much as possible. That's what I understand from your answer earlier.

Do I understand correctly?

[Christina Lawand]

Yes, I said that earlier identification would mean the services could be set up in the community. As you said, there needs to be better integration of palliative care when a patient is receiving curative care and they are diagnosed with a terminal illness.

[Luc Thériault, Bloc, Montcalm, QC]

That does not mean that a request for physician-assisted dying cannot emerge from a situation where the best palliative care is provided. It means that palliative care and physician-assisted dying should not be mutually exclusive. It is not a failure of palliative care when someone receiving palliative care requests physician-assisted dying.

[Christina Lawand]

All I can tell you is that, according to our data, patients who received medical assistance to die had also received palliative care. So one doesn't preclude the other. They are two different concepts and two different choices at the end of life.

[The Chair, Liberal, Ron McKinnon]

Thank you, sir.

Mr. Davies, you have two and a half minutes, please.

[Don Davies, NDP, Vancouver Kingsway, BC]

Mr. Saulnier, according to the framework on palliative care in Canada, the time frame of the framework development process did not allow for a thorough engagement process with indigenous people around palliative care. I think you touched on that. We know Health Canada has pledged that it will engage in ongoing discussions with national indigenous organizations about indigenous-led engagement processes towards the development of a distinctions-based palliative care framework for indigenous peoples. Can you update the committee on the progress of those discussions and when you might expect to publish a distinctions-based palliative care framework for indigenous peoples?

[Marcel Saulnier]

Sharon?