S. Lawrence Librach, MD.

2011 State of the Union for theToronto Central Palliative Care Network


Toronto - Part of the living process is the dying process. In Canada 90 percent of the population willdie from non-cancer related illnesses. These patients are not just the elderly, in Toronto alone 170children die from chronic diseases each year and most of those die away from home in a hospitalsetting. Today the 2011 State of the Union for the Toronto Central Palliative Care Network tookplace at the University of Toronto headed by S. Lawrence Librach, MD.


Very few of us in Canada will die from an accident. Most will live a long life and near the end of lifedeal with one or more chronic illnesses. One in five Canadians have three or more chronic diseases.Ninety percent of disability related costs are related to chronic disease. The reality is that as we ageas a society more people will die at a greater rate. What will the end of life care be like for us? Unlesschanges are made end of life care will be chaotic and patients will deal with invasive measures thatare unwarranted instead of their pain being dealt with effectively. Improvements are needed in thereferral process to palliative care and hospice services and the waiting times need from ER to hospice needs to improve.


When we think of how health care dollars are spent it's often thought that the elderly place a highburden on society. The truth is the majority of health care dollars is used by Ontarians who are 30 to50 years old. Most elderly Ontarians are healthy until their last two years prior to death. For far toomany palliative care could be introduced far too late in the dying process. Some will never hear whatpalliative care they could be offered as the medical profession fights to save their lives. This fact ishighlighted when you consider that 10 percent of those who die in hospital do not have a record oftheir death being in hospital. Palliative care is the specialized area of healthcare that focuses onrelieving the suffering of patients. This care can come at any stage of treatment including thosenearing the end of life and emphasizes the quality of life for the patient and their loved ones.


For the Toronto Central Palliative Care Network's State of the Union the focus was on the end of lifefor those in Ontario. Despite the fact that most people, excluding cancer patients, will have morethan one chronic illness at the time of their death the medical profession as a whole at times appearsto be in denial about the end of life. The medical practice has become so good at treating illnesses inthe past century that death is rarely discussed. This is across the board when you consider thatchronic disease plans out of Ottawa do not mention dying. Yet the fact is we all die.


"We need to look beyond hospital beds. There is a need to look at the home level." Palliative carecan improve the quality of life of patients. Instead of focusing on treating late stage disease patientscan focus on living without pain. So why are patients not being served at a better rate at the end oflife? For one the funding dollars are tight and for another many of those who would be best cared forin the palliative setting are being cared for at home until a medical crisis. Another hindrance is thateven for professionals navigating through the system is difficult. Patients have a slew of casemanagers as their diseases progress. At some point the question becomes who will coordinate the managers of a patient's care so that their best options at a good quality of life while dying is achieved.


The goal of palliative care is to reduce the need of emergency room visits. This action alone wouldsave Canadians millions of dollars yet there is a lack of palliative care staff for many. The ministry ofhealth says there is no money for more positions within palliative care medicine. Many of the patientsthat could benefit the most from palliative care live in home settings which include Long Term Carefacilities. When using mobile ER nursing services instead of emergency room visits those in this typeof setting can avoid being admitted to hospital which often hastens a person's death. Yet the medicalcommunity is not referring patients to palliative at a good rate.


Instead patients are placed in nursing homes where there isn't a palliative care approach andsuffering because of it. Simply consider pain management. In nursing homes around the clock painmedication can not be delivered for all patients in the time periods that these patients require it.


We don't know the clear numbers of how many chronically ill patients in need of hospice care bedsthere are in Ontario. The numbers are not being tracked other than in cancer care. Those in need ofthese beds are often not simple patient cases, non-cancer patients are generally sicker and have ashorter period of life compared to cancer patients. These patients include the young. In Canadapediatric palliative care is 15 years behind adult care in terms of research. Children's end of life careneeds though differs from adults. Ontario has basically ignored the mental health of dying children."These are the needs of the people," Librach stressed to the audience.


So how do we as Ontarians address these needs? Librach said that when the public begins todemand good palliative services and hospice care they will get it. If the concerns are not demandedthen we will remain in a system where only 30 percent of cancer patients receive palliative care.Marian Walsh, CEO of Bridgepoint Health Care Centre, said our emergency rooms are under siege.These visits are the main entry point to hospital and the beginning of the waiting period for LongTerm Care. "In the beginning people died young from infectious diseases. During the beginning ofthe last century we started controlling infectious diseases. It wasn't until the 1950's that studies onaging began. Today there are not many cures but we are very success at treating diseases. Today'sdying patient often has a number of illnesses they are dealing with at the time of their deaths.


"Seventy percent of health care costs are related to chronic disease. Each year Canadians pay out $80billion dollars for chronic diseases yet the system focuses on acute care, the treat to street approach."As we age the reality is that chances are we will have a variety of chronic illnesses. These illnessescan be complex. The end of life will be a longer period of time and a more medically complex one,"Walsh said, "We need to change health care to bringing palliative care into the forefront to improvethe quality of life. There are more needs than just pain management."

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