palliative care in canada: history, vision and challenges

Palliative Care in Palliative Care in Canada:Canada:History, Vision and History, Vision and ChallengesChallengesS. Lawrence Librach S. Lawrence Librach MD,CCFP,FCFPMD,CCFP,FCFPProfessor and Professor and Head, Division of Palliative Head, Division of Palliative Care, Care,

Sun Life Financial Chair and director Joint Sun Life Financial Chair and director Joint Centre for Bioethics, Centre for Bioethics, University of TorontoUniversity of Toronto

Temmy Latner CentreTemmy Latner Centre 22

The Canadian ContextThe Canadian Context


GeographyGeography

• Canada is a large country 10 Canada is a large country 10 provinces & 3 northern provinces & 3 northern territoriesterritories

• 90% of the Canadian population 90% of the Canadian population lives within 10 km of the lives within 10 km of the American borderAmerican border

Temmy Latner CentreTemmy Latner Centre 44Dr. Larry Librach Temmy Latner Centre for

Palliative Care 4


Canadian Population Canadian Population DataData

• 33,000,00033,000,00060% in largest provinces of 60% in largest provinces of

Ontario & QuebecOntario & Quebec• Our population is agingOur population is aging• Multicultural populationMulticultural population• We have areas of population that We have areas of population that

are quite remote with access are quite remote with access only by air or seaonly by air or sea


Political StructurePolitical Structure

• British parliamentary system British parliamentary system nationally and provinciallynationally and provincially

• Prime minister & federal cabinetPrime minister & federal cabinet• Provincial premiers & cabinetsProvincial premiers & cabinets• Elections every 4 yearsElections every 4 years


Health Care SystemHealth Care System• Federal government responsible Federal government responsible

for overall policy & transfer of for overall policy & transfer of some tax revenuesome tax revenue

• Provincial ministries of health Provincial ministries of health responsible for implementation responsible for implementation & adding provincial tax revenue& adding provincial tax revenueRegionalized careRegionalized care

• About 50% of provincial budgets About 50% of provincial budgets spent on health carespent on health care


Health Care SystemHealth Care System

• National health care schemeNational health care schemePrivate health care not “legal” Private health care not “legal” CostsCosts about 50% of provincial about 50% of provincial

budgetsbudgets• Drug costs covered over age 65 Drug costs covered over age 65

& those who are poor or disabled& those who are poor or disabled


Health Care System-Health Care System-PhysiciansPhysicians• # of active physicians 65,440 in 2009# of active physicians 65,440 in 2009

About ½ family physicians but About ½ family physicians but shortagesshortages

• Overall physician-to-population ratio Overall physician-to-population ratio 195 per 100,000 in 2008, though ratios 195 per 100,000 in 2008, though ratios and growth rates varied among and growth rates varied among provinces, territories and health provinces, territories and health regionsregions

• 17 medical schools17 medical schools#of new medical students 9,640 in #of new medical students 9,640 in

20072007


Health Care System-Health Care System-NursingNursing

• 250,000 nurses in Canada250,000 nurses in CanadaNumbers decreasing & agingNumbers decreasing & aging

• Significant shortages particularly Significant shortages particularly in community carein community care

• 91 nursing schools91 nursing schools



• InstitutionsInstitutionsAll hospitals publicly owned & All hospitals publicly owned &

fundedfundedNursing homes-half privately Nursing homes-half privately

owned & partially funded by owned & partially funded by government & patientgovernment & patient

All accreditedAll accredited



• Other disciplinesOther disciplinesOccupational therapyOccupational therapyPhysiotherapyPhysiotherapyPharmacyPharmacySocial workersSocial workers



• Home careHome careNot part of Canada Health ActNot part of Canada Health ActVaries from province to province Varies from province to province

but most provide a wide range of but most provide a wide range of services & equipmentservices & equipment

Medications provided with special Medications provided with special palliative care formulariespalliative care formularies•Wide variety of opioids availableWide variety of opioids available


Palliative Care SystemPalliative Care System• Began in 1976Began in 1976

Now over 1200 programs or servicesNow over 1200 programs or services• Limited government funding but Limited government funding but

improvingimprovingDonated funds importantDonated funds important

• Based in hospitals, cancer centres & Based in hospitals, cancer centres & communitycommunityAll hospitals must have palliative All hospitals must have palliative

care servicescare services


Palliative Care SystemPalliative Care System• Specialist physiciansSpecialist physicians

Recognized specialtyRecognized specialtyResidency & fellowship programsResidency & fellowship programsAbout 250 full and major part-timeAbout 250 full and major part-timeNeed is increasing rapidlyNeed is increasing rapidly

• Nursing certificationNursing certificationOver 800 nurses have taken Over 800 nurses have taken

certificationcertificationNeed for clinical nurses specialistsNeed for clinical nurses specialists


Palliative Care SystemPalliative Care System

• Community volunteer hospicesCommunity volunteer hospices• Palliative care unitsPalliative care units

Most in hospitalsMost in hospitalsResidential hospicesResidential hospices


Palliative Care SystemPalliative Care System

• About 25-30% of dying cancer About 25-30% of dying cancer patient access palliative carepatient access palliative careIn some well organized regions, In some well organized regions,

this reaches almost 100%this reaches almost 100%80% of palliative care patients 80% of palliative care patients

are cancer patientsare cancer patients• Those dying of non-cancer Those dying of non-cancer

illnesses just starting to be part of illnesses just starting to be part of the systemthe system


• www.chpca.netwww.chpca.net

Dr. Larry Librach Temmy Latner Centre for Palliative Care

22


Why a Standardized Why a Standardized Approach?Approach?

• To ensure that all Canadians To ensure that all Canadians have access to consistent, high have access to consistent, high quality carequality care

• Ensure all caregivers and staff Ensure all caregivers and staff are knowledgeable and skilled, are knowledgeable and skilled, and have the support they need and have the support they need to fulfill their rolesto fulfill their roles


Why a National Model for Why a National Model for Hospice Palliative Care? Hospice Palliative Care? • Guide for:Guide for:

patient and family care provided patient and family care provided by both primary & expert by both primary & expert caregiverscaregivers

development & function of hospice development & function of hospice palliative care organizationspalliative care organizations

educational competencieseducational competenciesaccreditation & QIaccreditation & QIresearchresearch


Palliative Care 25


Palliative Care 26


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Practical Outcomes from Practical Outcomes from the Modelthe Model

• Adopted across Canada by consensus Adopted across Canada by consensus buildingbuilding

• Used by national & provincial health Used by national & provincial health plannersplannersServicesServicesFundingFunding

• Used by Accreditation Canada, Used by Accreditation Canada, national hospital & health agency national hospital & health agency accreditorsaccreditors


Practical Outcomes from Practical Outcomes from the Modelthe Model

• Framework for the Quality End of Framework for the Quality End of Life Care Coalition of Canada, a Life Care Coalition of Canada, a group of 30 influential group of 30 influential organizations, to use to approach organizations, to use to approach governmentsgovernments

• Framework for educational efforts Framework for educational efforts like the Educating Future Physicians like the Educating Future Physicians in Palliative & End of Life Care in Palliative & End of Life Care Project, new nursing curriculum Project, new nursing curriculum efforteffort


Common or Core Common or Core Competencies Competencies

• Address & manage pain and Address & manage pain and symptomssymptoms

• Address psychosocial & spiritual Address psychosocial & spiritual needsneeds

• Address end of life decision-making Address end of life decision-making and planningand planning

• Collaborate as a member of an Collaborate as a member of an interdisciplinary teaminterdisciplinary team

• Communicate effectivelyCommunicate effectively• Attend to sufferingAttend to suffering

Remaining Challenges Remaining Challenges for Canadafor Canada

• Care coordinationCare coordination• Pain management needs Pain management needs

improvementimprovement• Symptom management prioritySymptom management priority• Psychosocial & spiritual carePsychosocial & spiritual care• Preparation for dyingPreparation for dying• Enhancing home careEnhancing home care• ACPACP• Increasing awareness of HPCIncreasing awareness of HPC


Awareness of Palliative Awareness of Palliative CareCare

• Canadians more aware than even Canadians more aware than even 5 years ago5 years agoMore exposed to palliative careMore exposed to palliative careMore media attentionMore media attentionLiving Lessons campaignLiving Lessons campaign


SummarySummary

• Our system has the right Our system has the right componentscomponents

• We do have the basic We do have the basic foundations of the Modelfoundations of the Model

• Not perfect but growing stronger Not perfect but growing stronger quicklyquickly

palliative care in canada: history, vision and challenges

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