Hunter Prize: Improving end-of-life care is the compassionate and cost-effective solution to Canada’s health crisis

Prioritizing hospice care is the dignified, comfortable, and compassionate approach to end-of-life care
Kevin Ackroyd sits on the patio at Kensington Hospice with his housing worker and close friend Starr Dedam, in Toronto, Tuesday, June 6, 2023. Chris Young/The Canadian Press.

The Hub’s first annual Hunter Prize for Public Policy, generously supported by the Hunter Family Foundation, focused on solving the problem of long wait times in Canada’s health-care system. A diverse group of ten finalists have been chosen from nearly 200 entries, with the finalists and winners chosen by an esteemed panel of judges, including Robert Asselin, Dr. Adam Kassam, Amanda Lang, Karen Restoule, and Trevor Tombe. The Hub is pleased to run essays from each finalist this week that lay out their plans to help solve this persistent policy problem. The winners of the first-ever Hunter Prize for Public Policy will be announced on Friday, September 29.

Canada’s health-care system has long been a source of pride, standing as a testament to the nation’s commitment to providing quality medical care for all. However, in recent years, the cracks in our system have become increasingly apparent. 

Wait times across the health system continue to escalate, leaving patients and families frustrated and health-care providers overwhelmed. 

This is further exacerbated by a growing shortage of health-care professionals, especially nurses and personal support workers. 

These factors will soon amount to a perfect storm.

There is one area of health care in which a disproportionate amount of resources are spent, and is intimately tied with patients’ journeys: end-of-life care.

Most Canadians do not want to die in a hospital. In 2020, 54.7 percent of Canadians died in hospital. In addition to contradicting the preferences of most Canadians, the impact of dying in hospital has stark financial and systems-wide implications.

Comparing the last six months of life, Canada’s average hospital expenses (USD $21,840) surpass those of England ($9,352), the Netherlands ($10,936), and the U.S. ($18,500). This cost and care discrepancy in Canada is linked to the heavy reliance on hospitals for end-of-life care delivery, impacting both expense and quality.

The national average hospital length of stay in 2021 was 7.2 days. Patients admitted for palliative care had an average length of stay in hospital of 12 days, and 17 days for those patients with admissions with palliative care. Of these days, patients receiving palliative care remained in hospital waiting for admission to another facility for a median number of 10 alternate level of care (ALC) days per patient. The proportion of admissions with reported ALC days was only 5.8 percent nationally in 2021 (129,764 admissions). Extrapolating from this, patients admitted for palliative care represent a 33.9 percent share of patients with reported ALC days. Nearly half of patients receiving palliative care who were waiting for care in a more appropriate setting died before they could be discharged to one (13). 

Hospices have become an important, alternative level of care setting designed for end-of-life care. Care is provided at hospices with a palliative approach, which has been recognized in literature to increase quality of life and satisfaction with care.

There are significant cost savings when shifting care from an acute hospital bed (~$1000/day) to a residential hospice (~$400/day). These savings are accrued via shortening hospital stays, decreasing the frequency of ICU admissions, and decreasing unnecessary diagnostic tests and treatments. 

While hospices provide a valuable option, the limited availability of hospice beds poses a critical operational bottleneck.

In 2014, the Auditor General of Ontario recommended between 945 and 1,350 hospice beds, yet the reality falls drastically short, and the shortage continues to grow. The shortage of hospice beds is particularly glaring in certain rural regions of the country. 

The 2023 CIHI report found that 49 percent of hospices were always or usually operating at full capacity. Around 50 percent of operating costs are raised yearly by the hospices through charitable organizations, while the other portion is funded by government sources. Hospices also rely significantly on the assistance of volunteers—most importantly patient’s families and friends providing informal care. 

Build more beds

Canada Health Transfers, which are the federal government’s method of funding province’s health-care budgets, should be utilized and earmarked for building more hospice beds. Priority should be given to underserved communities to expand existing facilities and build new ones to meet the growing demand for hospice beds. Such an investment will make hospice care more accessible and reduce the strain on local, acute care hospitals. 

According to Residential Hospice Working Group, in 2010 the average 10-bed hospice had a projected annual budget of $1.6 million, with provincial government support only covering nursing & personnel salaries at $900,000, with non-clinical staff and operational costs covered through donations/fundraising. Some provinces such as Ontario are now recognizing the value of hospice care and are increasing operating budgets.

Per a CD Howe report on palliative care, if the costs associated with end-of-life ALC days in acute care were spent instead on the beds where the patients were waiting for residual care, the savings in Ontario would be $161 million annually, and if extrapolated to the rest of Canada, then $400 million per year, just by moving patients to a bed in the location they are waiting for. While this would not present directly as a cost-saving, we believe that this would relieve in-hospital waiting lists: alleviating burdens in the emergency room, acute medical wards, surgical wait lists, and in-hospital services (radiology, laboratory work, among others) and encourage an acute care system that is more fit for purpose.

Staff these beds

With more hospice bed capacity, the staffing of health-care workers at these facilities needs to increase, too. However, health-care staffing shortages continue to pose a human resource constraint, worsening with increasing reports of health-care worker burnout and attrition. 

To directly increase the Canadian hospice workforce, we should leverage Canada’s progressive immigration policies to make it easier to hire and immigrate foreign-trained health-care workers. Existing preferential skilled immigration programs, like the Government of Canada’s Global Skills Strategy (GSS) can be expanded to allow hospice-focused health-care professionals access to expedited visa and work permit processing. 

By increasing the hospice workforce, we stand to improve wait times in hospitals by reducing the burden of ALC patients and making Canada’s end-of-life services resilient to the demands of an aging population.

Dignified, comfortable, and compassionate

As our society continues to age, the demand for end-of-life care will only intensify. By prioritizing hospice care, building hospice beds, expanding the health-care workforce, and increasing funding transfers, we can transform the landscape of end-of-life care in Canada. This initiative is a call to action that will usher in meaningful change, improving wait times and ensuring a dignified, comfortable, and compassionate journey for patients nearing the end of life. 

Rick Firth, the president and CEO of Hospice Palliative Care Ontario notes, “While there is a growing understanding of the complex needs of the dying and their families and how quality of life can be extended to last breaths with appropriate hospice palliative care, we still have much work to do to truly demonstrate the compassion and humanity of our society by caring for families in a most difficult chapter of life”.

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