February 27, 2017 - We save for retirement. We draw up wills. But how many of us invest the same resources into planning for our own end of life care? For such a significant event in our lives, death is one we appear to give little thought to. In a culture of self-improvement, we seem fixated with living our best lives, but are less concerned with how we are going to die. Perhaps it is because we naively assume that we will die at home or perhaps we are fearful of death and avoid thinking about the topic. Whatever the reason, with an aging population and a financially strained healthcare system, it is one we need to address.
Although most people wish to die at home, this is often impractical or unrealistic. Indeed, in 2012 for example, approximately 63% of Canadians died in hospital. But unless those admitted require hospital level care, their admission is problematic. Hospitals, often overcrowded, underfunded and short-staffed, can cause unnecessary stress to people living out their final days. Some would even argue that the very mandate of the hospital as a life-saving institution makes it ill-suited to serve the needs of the departing. In addition, hospital care is expensive. Indeed estimates suggest that an acute care bed costs upwards of $1,100 a day in Ontario. Thus, shifting the terminally ill out of hospital beds into more appropriate care settings would therefore be wise from both a social and economic standpoint.
One such alternative care option is the hospice, home-like residences that provide end-of-life care to those with three months or less to live. Residents are admitted to a hospice when they are unable or no longer wish to remain at home, but do not require hospital-based medical care. Similar to hospitals, hospices provide round the clock care to their residents, but unlike hospitals they also offer unrestricted visiting hours, bereavement support to the family, and have a different care focus - maximizing patient comfort rather than prolonging life. Hospices have been found to deliver higher levels of care to patients and receive higher satisfaction ratings from bereaved families.
Ontario has a hospice bed shortage. The Fraser Health Authority in British Columbia, widely considered a leader in residential hospices in Canada, provides 8 hospice beds per 100,000 people; Ontario sits well below this benchmark at 1.54 beds per 100,000. Northern Ontario sits close to the provincial average, but this masks the significant disparity between its two regions. In 2015, Northeastern Ontario had 3.53 beds per 100,000 population while Northwestern Ontario had none. In order to reach the recommended number of hospice beds in Ontario - between 755 and 1,080 according to the 2014 Ontario Auditor General Report - with the current stock of 271 beds and 196 beds in the works, Ontario would have to commit to constructing an additional 388 to 613 beds. The question is can Ontario afford to make this investment?
Healthcare spending is already the largest provincial expenditure, accounting for approximately 42 percent of all program spending in Ontario in 2015. Indeed, in Canada, 45% of all public health care dollars are consumed by Canadians 65 and over, despite the fact that they make up less than 15% of the population. Furthermore, spending on seniors is only expected to increase as shifting demographics increase the size of this segment of the population. In Northeastern Ontario, for example, seniors are expected to make up 31.3% of the population by 2041, up from 18.8% in 2013. Thus, carving out money for future hospices from the already strained, and soon to be even more strained, provincial healthcare budget will require that hospices demonstrate a certain level of cost-effectiveness.
Though there is some evidence that hospices may be cost-effective, not enough research has been conducted to definitively support this claim. The biggest savings would likely result from shifting patients out of hospitals and into hospice beds. According to the 2014 Ontario Auditor General’s report, hospice beds are estimated to cost less than half of acute care hospital beds. While an acute care bed costs approximately $1,100 per day, hospice beds cost only $460 per day. However, given that acute-care beds are often in short supply, it is likely that these beds would be filled by other patients and therefore the cost savings may not manifest themselves. In other words, the potential savings resulting from shifting individuals out of hospitals into hospices may not come to fruition as these beds would be quickly filled by other patients requiring hospital-based care. Thus, one of the main benefits of hospices may instead be reducing wait times for others to access hospital beds and ensuring that those who require hospital based care are the ones receiving it. Overall, experts agree that more research needs to be done on residential hospices to determine their cost-effectiveness.
Ultimately, Ontario needs to develop and implement a comprehensive end-of-life care approach that allows its citizens to die with dignity, without overstretching the provincial healthcare budget. As the population ages, the importance of finding a solution will only heighten. Hospices represent part of this overarching solution. Knowing how large a role hospices will play requires further research into their cost-effectiveness.
 Authors calculation based on CANSIM Table 102-0509, Statistics Canada, Retrieved from: http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=1020509
 In Britain hospices were found to deliver higher levels of care than palliative care wards even though hospice staff were faced with higher workloads according to https://www.nursingtimes.net/clinical-archive/end-of-life-and-palliative-care/hospice-wards-better-staffed-and-better-quality/5031983.fullarticle
 Residential hospice beds are beds that are housed in standalone hospice institutions. This definition excludes hospice beds that exist within hospitals. In Northwestern Ontario, Thunder Bay has 10 hospice beds in St. Joseph’s hospital. See http://www.cbc.ca/news/canada/thunder-bay/thunder-bay-hospice-unveils-renovated-rooms-1.1876096 for more.
Lauren Rainsford is a former policy intern at Northern Policy Institute.
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