Palliative Care in Canada: History, Vision and Challenges

1. Palliative Care in Canada:History, Vision and Challenges S. Lawrence Librach MD,CCFP,FCFP Professor and Head, Division of Palliative Care, Sun Life Financial Chair and director Joint Centre for Bioethics, University of Toronto

2. The Canadian Context

3. Geography • Canada is a large country 10 provinces & 3 northern territories • 90% of the Canadian population lives within 10 km of the American border

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6. Canadian Population Data • 33,000,000 • 60% in largest provinces of Ontario & Quebec • Our population is aging • Multicultural population • We have areas of population that are quite remote with access only by air or sea

7. Political Structure • British parliamentary system nationally and provincially • Prime minister & federal cabinet • Provincial premiers & cabinets • Elections every 4 years

8. Health Care System • Federal government responsible for overall policy & transfer of some tax revenue • Provincial ministries of health responsible for implementation & adding provincial tax revenue • Regionalized care • About 50% of provincial budgets spent on health care

9. Health Care System • National health care scheme • Private health care not “legal” • Costs about 50% of provincial budgets • Drug costs covered over age 65 & those who are poor or disabled

10. Health Care System

11. Health Care System-Physicians • # of active physicians 65,440 in 2009 • About ½ family physicians but shortages • Overall physician-to-population ratio 195 per 100,000 in 2008, though ratios and growth rates varied among provinces, territories and health regions • 17 medical schools • #of new medical students 9,640 in 2007

12. Health Care System-Nursing • 250,000 nurses in Canada • Numbers decreasing & aging • Significant shortages particularly in community care • 91 nursing schools

13. Health Care System • Institutions • All hospitals publicly owned & funded • Nursing homes-half privately owned & partially funded by government & patient • All accredited

14. Health Care System • Other disciplines • Occupational therapy • Physiotherapy • Pharmacy • Social workers

15. Health Care System • Home care • Not part of Canada Health Act • Varies from province to province but most provide a wide range of services & equipment • Medications provided with special palliative care formularies • Wide variety of opioids available

16. Palliative Care System • Began in 1976 • Now over 1200 programs or services • Limited government funding but improving • Donated funds important • Based in hospitals, cancer centres & community • All hospitals must have palliative care services

17. Palliative Care System • Specialist physicians • Recognized specialty • Residency & fellowship programs • About 250 full and major part-time • Need is increasing rapidly • Nursing certification • Over 800 nurses have taken certification • Need for clinical nurses specialists

18. Palliative Care System • Community volunteer hospices • Palliative care units • Most in hospitals • Residential hospices

19. Palliative Care System • About 25-30% of dying cancer patient access palliative care • In some well organized regions, this reaches almost 100% • 80% of palliative care patients are cancer patients • Those dying of non-cancer illnesses just starting to be part of the system

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21. Why a Standardized Approach? • To ensure that all Canadians have access to consistent, high quality care • Ensure all caregivers and staff are knowledgeable and skilled, and have the support they need to fulfill their roles

22. Why a National Model for Hospice Palliative Care? • Guide for: • patient and family care provided by both primary & expert caregivers • development & function of hospice palliative care organizations • educational competencies • accreditation & QI • research

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26. Practical Outcomes from the Model • Adopted across Canada by consensus building • Used by national & provincial health planners • Services • Funding • Used by Accreditation Canada, national hospital & health agency accreditors

27. Practical Outcomes from the Model • Framework for the Quality End of Life Care Coalition of Canada, a group of 30 influential organizations, to use to approach governments • Framework for educational efforts like the Educating Future Physicians in Palliative & End of Life Care Project, new nursing curriculum effort

28. Common or Core Competencies • Address & manage pain and symptoms • Address psychosocial & spiritual needs • Address end of life decision-making and planning • Collaborate as a member of an interdisciplinary team • Communicate effectively • Attend to suffering

29. Care coordination Pain management needs improvement Symptom management priority Psychosocial & spiritual care Preparation for dying Enhancing home care ACP Increasing awareness of HPC Remaining Challenges for Canada

30. Awareness of Palliative Care • Canadians more aware than even 5 years ago • More exposed to palliative care • More media attention • Living Lessons campaign

31. Summary • Our system has the right components • We do have the basic foundations of the Model • Not perfect but growing stronger quickly