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Expensive Endings
Reining In the High Cost of End-of-Life Care in Canada

by Kieran Quinn, Sarina Isenberg and James Downar

Series:Commentary No. 608
ISBN 9781989483725
Publication year: 2021

Cdn: $12.00; US: $12.00
Paperback
Language: English
25 pages
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Despite spending more on medical care delivered at the end-of-life than other high-income countries, Canada performs poorly on most measures of healthcare quality – meaning Canadians are not getting value for their money, according to a new report released by the C.D. Howe Institute.

In Expensive Endings: Reining In the High Cost of End-of-Life Care in Canada, authors Kieran Quinn, Sarina Isenberg and James Downar review the gaps in Canada's healthcare system that lead to costly and low-quality end-of-life practices. They estimate that with a few simple, feasible structural changes in end-of-life care, Canada's healthcare system could save hundreds of millions of dollars annually.

"Most Canadians do not receive palliative care when they would benefit from it," say Quinn, Isenberg and Downar. "Instead, most Canadians facing their end of life receive more expensive, often aggressive, acute care in hospitals and, as a result, the cost of healthcare delivery increases significantly in the final months of life and does so in particular for hospital admissions and emergency room visits."

Canada has among the highest rates of hospitalization in the last three months of life (61 percent), despite the vast majority of Canadians (87 percent) preferring to receive end of life care at home. As well, most Canadians die in hospital (61 percent), far more than in England (47 to 51 percent), the Netherlands (28 to 31 percent) and the United States (20 percent), according to the authors.

Notably, the structural problems identified by the authors that exacerbate the situation include: i) inadequate end-of-life beds and options; ii) the siloing of budgets in healthcare institutions that stymie cost-saving solutions; iii) lack of timely prompts for transition to a palliative approach; and iv) barriers to home and community-care resources, such as constantly changing support workers and lack of supports for caregiving family and friends.

"Fewer days spent in hospital will lead to lower spending on end-of-life care and better alignment with patients' preferences," write the authors, who are palliative care physicians.

Addressing how to increase palliative care and reduce acute care, the authors highlight solutions such as:
  • Creating appropriate and abundant discharge options for patients in acute care who are nearing the end of life;
  • Implementing reliable triggers for adopting a palliative approach;
  • Supporting the unpaid, informal caregiving that is essential for those who are able to receive end-of-life care at home;
  • Identifying and tracking relevant metrics for appropriate end-of-life care; and
  • Empowering the public to initiate conversations about palliative care.
Quinn, Isenberg and Downar also conclude that Canada must stop treating end-of-life care as acute care and provide palliative and end-of-life care across multiple healthcare settings, including at home, in a hospice, or within a hospital. They stress the need for reliable clinical triggers for moving a patient to palliative care settings during the final three to four months of life to improve their quality of care, while achieving the greatest reduction in costly and low-value end-of-life care.

Kieran Quinn is with the Divisions of General Internal Medicine and Palliative Care, Department of Medicine, Sinai Health System, Toronto.

Sarina Isenberg is with the Bruyere Research Institute, Ottawa.

James Downar is with the Division of Palliative Care, Department of Medicine, University of Ottawa.

With Secondary Authors: Amy Hsu, Peter Tanuseputro, Michael Bonares, Kali Barrett, Kwadwo Kyeremanteng, and Konrad Fassbender.
Expensive Endings
Cdn: $12.00; US: $12.00
C.D. Howe Institute / Institut C.D. Howe BookID: 128914 Added: 2021.10.23