Evidence of meeting #19 for Medical Assistance in Dying in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was patients.
A video is available from Parliament.
Family Doctor, As an Individual
The data you're talking about is Canadian.
Surprisingly, in Quebec, despite the fact that a report was produced four years after the Act respecting end-of-life care was adopted, no data is available on comprehensive palliative care. We know whether nurses are involved or not, but that's it.
We couldn't even answer your question in Quebec, and I think that's a shame.
Liberal
The Joint Chair Liberal Marc Garneau
We will now go to questions from Senator Martin.
Senator, you have the floor for three minutes.
The Joint Chair Hon. Yonah Martin
Thank you very much. Thank you to all of our witnesses.
Dr. Dechêne, you've really helped me and us understand the importance of quality home care, especially quality home care and palliative care.
I want to give you the rest of my time to go into any of the key recommendations that you would have for our committee to ensure that people aren't being pushed to access MAID due to a lack of access to home care, palliative care, chronic pain services and mental health services.
Would you go into the key recommendations that you have for our committee?
Family Doctor, As an Individual
Thank you for that really great question.
I have a dream that comprehensive palliative care will one day be available Canada-wide, not just in Quebec, and therefore, all the professionals I just mentioned will be present. As Dr. Downar was saying, the physician can provide care in the home or over the telephone, but we need comprehensive teams so that patients at the end of life have access to medical and nursing care as well as the full range of other professional care they need. I want to make it clear that access to this care is critical whether or not cancer is involved, because non-cancer diseases are always overlooked and they account for half of deaths. Everyone should have access to that care, both those who need more and those who need less.
I'd like to reiterate that MAiD is a complement to good palliative care, not a continuum of care. Also, I believe that more people will request MAiD. We have an average of 3.4% medically assisted deaths in Quebec. So that has gone up and I think it will continue to go up. Quebec is ahead of several Canadian provinces in that respect. I'm not making any value judgements because I feel the most important thing is that we respond to patient requests.
The Joint Chair Hon. Yonah Martin
I saw Dr. Downar's hand. Did you want to add something to that?
Professor and Head, Division of Palliative Care, University of Ottawa, As an Individual
I wanted to respond to something Mr. Hawkswell said previously. I'm sorry; I don't know if this is a good time for that.
The Joint Chair Hon. Yonah Martin
Dr. Dechêne, it seems that what's happening in Quebec in terms of home care and palliative care is about the fact that there's a lack of access and not enough specialists. Are you aware if this is a problem across Canada?
Family Doctor, As an Individual
No, I'm not aware. I'm just speaking for Quebec. I have not studied the other provinces.
Nothing is perfect anywhere in Canada, but obviously the figures we have of the number of patients dying at home show that Quebec is far worse as far as access to palliative care is concerned.
Our guess—but the government is not working on this data, unfortunately—is that 85%, maybe even 90%, of all patients in their last year of life who are unable to go to a hospital or clinic to have their medical care have no medical care at home. That's a lot.
The Joint Chair Hon. Yonah Martin
I would think the same issues are prevalent in other provinces and territories as well.
Thank you very much.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Senator.
Unfortunately, time is going by so quickly and we're now at the end of our first panel. I'd like to thank the witnesses for appearing this morning.
Thank you, Dr. Dechêne, Dr. Downar and Mr. Hawkswell.
Thank you for coming and providing testimony this morning and answering our questions. We very much appreciate it.
With that, committee, we will suspend for a few minutes to move to our next panel.
Senator, Nova Scotia, ISG
Thank you.
Dr. Downar was wanting to make a comment.
Professor and Head, Division of Palliative Care, University of Ottawa, As an Individual
It's a very quick one. I promise.
Senator, Nova Scotia, ISG
You can say it or put it in writing to us. Either way is good.
Liberal
The Joint Chair Liberal Marc Garneau
I think probably it's best to put in writing.
We would appreciate it, Dr. Downar. We have to stay within the protocols of this meeting. Please send it to the committee.
Professor and Head, Division of Palliative Care, University of Ottawa, As an Individual
Thank you. It's about regulations.
Liberal
The Joint Chair Liberal Marc Garneau
Hello again.
We will now resume our work with our second group of witnesses.
I would like to make a few comments for the benefit of our new witnesses. These are housekeeping rules.
Before speaking, please wait until one of the co-chairs recognizes you by name.
This is a reminder that all comments should be addressed through the joint chairs.
When speaking, please speak slowly and clearly. This is for the benefit of our interpreters. Interpretation in this video conference will work like an in-person committee meeting. If you're remote, you have the choice at the bottom of your screen of floor, English or French. The little globe is the interpretation button. When you're not speaking, please keep your microphone on mute.
With that, I would like to welcome our witnesses for the second panel. Again, we're looking at palliative care.
We have online with us Dr. José Pereira, professor and the director of the division of palliative care at the department of family medicine at McMaster University. We have in the room with us Mr. Mike Kekewich, director of the Champlain Regional MAID Network and the Champlain Centre for Health Care Ethics.
I'm not sure I see him yet, but we're hoping to have Dr. Louis Roy.
Dr. Roy represents the Collège des médecins du Québec. He should be arriving any minute now.
With that, thank you all for joining us.
We will start with opening remarks from our three witnesses. We will start with Dr. Pereira. Each witness will have five minutes for opening comments before we go to questions.
Dr. Pereira, you have the microphone for five minutes.
Dr. José Pereira Professor and Director, Division of Palliative Care, Department of Family Medicine, McMaster University, As an Individual
Thank you, honourable chairs, and thank you to the committee for the invitation to discuss palliative care in Canada.
As you've heard, I'm professor and director of palliative care at McMaster University, and I'm also co-founder and scientific officer of Pallium Canada.
I have dedicated most of my career to improving palliative care in Canada and abroad, and I've worked in different clinical, education, research and leadership roles in several Canadian jurisdictions. I am pleased to appear before you to share my experiences in the science on palliative care.
I'd like to briefly highlight three areas related to palliative care in our country: access and availability, education, and funding.
While we have seen noteworthy improvements across all three areas in the last two decades, many gaps still exist. We cannot say today that all Canadians have access to palliative care. In fact, many still do not. The good news is that there are examples of excellence in all these areas across the country, and there are solutions as well.
Let me start with access to palliative care and palliative care services.
On average, only about 30% to 50% of Canadians who need palliative care have access to it or receive it, whether it is delivered by palliative care specialists or by other health care professionals. On average, only about 15% to 25% of patients have access to specialist palliative care teams to address more complex needs. In many rural and remote areas of the country, there is no access to specialist palliative care, and many of the health care professionals serving those populations, just like their urban colleagues, lack core palliative care skills.
A growing body of research shows that palliative care should be initiated early in the illness, not just in the last days or weeks of life. It improves quality of life and reduces anxiety and depression, caregiver distress, hospitalizations and, importantly, health care costs.
Despite this, we consistently see palliative care activated very late in the illness. I see that often in my clinical practice, and studies confirm this.
Whether you'll get the palliative care you need depends largely on where you live, what you're dying from and how close you are to death. Some areas have excellent access; others have almost nothing. You're also less likely to receive palliative care if you're poor, indigenous, homeless or incarcerated.
The availability of access to key palliative care services is still a patchwork across our country. For example, experts propose at least 10 palliative care in-patient beds for every 100,000 inhabitants. This includes palliative care units and hospice beds. Many jurisdictions across the country do not attain these standards. Some do; many don't. Many hospitals across the country do not have sufficient palliative care physicians and nurses, and many communities do not have adequately staffed palliative care specialist teams to support family physicians and home care nurses to provide home and community-based palliative care.
The COVID-19 pandemic has had a major impact on the home care workforce. We struggle to discharge patients from hospital, because there is a lack of home care with palliative care supports. Canadians need assistance in living and supports. This is a crisis.
The pandemic has also highlighted chronic deficiencies in the integration of palliative care into long-term care homes, but again there are centres of excellence.
In the area of education, we have too few palliative care specialists in the country and too few training positions for new palliative care specialists. However, all the palliative care needs of a population cannot be met by palliative care specialists alone.
We must train our professionals in primary care and across many specialty areas to provide a palliative care approach. This has been highlighted in the government's 2018 framework on palliative care.
Many learners across the health professions are still graduating without core skills. In Canada, for example, fewer than one in three medical students completes palliative care clinical rotations during their training. In residency training, only 60% of family medicine trainees completed clinical rotations, and the numbers are low in other specialty areas.
Many practising professionals in primary care and across different specialty areas do not have core palliative care skills. Interestingly, in a study of 10 OECD countries, only 42% of primary care practices in Canada felt prepared to provide palliative care. The number was 80% in the U.K.
To help address this gap, Pallium Canada, a non-profit organization that I co-founded 22 years ago, has trained over 40,000 health care professionals across the country on the palliative care approach. We also now train carers and help build compassion community programs. This still represents less than 6% of the workforce.
Funding is needed to spread these initiatives. The public also needs to be educated on what palliative care actually is and what it can offer.
This finally brings me to funding. Sustained and adequate funding by federal, provincial and territorial governments is needed to ensure access to palliative care services and education. Too often, it's piecemeal.
We applaud some provincial governments, such as the Government of Alberta, which has recently invested in palliative care training en masse, and the Nova Scotia government, which is training PSWs on a large scale.
Federal funding is required to provide the necessary infrastructure and resources to implement the key priorities outlined in the “Framework on Palliative Care in Canada”.
Thank you very much, honourable chairs.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Dr. Pereira.
We will now hear from Dr. Louis Roy, who will deliver his opening remarks.
Dr. Roy, you have the floor for five minutes.
Dr. Louis Roy Physician, Collège des médecins du Québec
Good morning. Thank you for having me. I'm sorry I'm a little late. I was having some minor technical issues.
I'm here today to share the thoughts of the Collège des médecins du Québec, where I've been working for the past year and a half.