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Palliative care

https://policybase.cma.ca/en/permalink/policy11809

Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 2 Policy Resolution GC14-20 – Palliative
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
Text
Palliative care is an approach that aims to relieve suffering and improve the quality of life of those facing life-limiting acute or chronic conditions by means of early identification, assessment, treatment of pain and other symptoms and support of all physical, emotional and spiritual needs. It may coexist with other goals of care, such as prevention, treatment and management of chronic conditions, or it may be the sole focus of care. General principles Goals 1. All Canadian residents should have access to comprehensive, quality palliative care services regardless of age, care setting, diagnosis, ethnicity, language and financial status.1 2. The Canadian Medical Association (CMA) declares that its members should adhere to the principles of palliative care whereby relief of suffering and quality of living are valued equally to other goals of medicine. 3. The CMA believes that all health care professionals should have access to referral for palliative care services and expertise.2 4. The CMA supports the integration of the palliative care approach into the management of life-limiting acute and chronic disease.3 5. The CMA advocates for the integration of accessible, quality palliative care services into acute, community and chronic care service delivery models4 that align with patient and family needs. 6. The CMA supports the implementation of a shared care model, emphasizing collaboration and open communication among physicians and other health care professionals.5 7. The CMA recognizes that the practice of assisted dying as defined by the Supreme Court of Canada is distinct from the practice of palliative care. Access to palliative care services 8. The CMA believes that every person nearing the end of life who wishes to receive palliative care services at home should have access to them. 9. Comprehensive, quality palliative care services must be made available to all Canadians and efforts to broaden the availability of palliative care in Canada should be intensified.6 10. The CMA calls upon the federal government, in cooperation with provincial and territorial governments, to improve access to pediatric palliative care through enhanced funding, training and awareness campaigns.7 11. The CMA will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative care throughout Canada.8 Education 12. All physicians require basic competencies in palliative care and may require enhanced skills appropriate to their practice. 13. The CMA requests that all Canadian faculties of medicine create a training curriculum in palliative care suitable for physicians at all stages of their medical education and relevant to the settings in which they practise.9 Role of governments 14. The CMA calls on governments to work toward a common strategy for palliative care to ensure equitable access to and adequate standards for quality palliative care.10 15. The CMA recommends that all relevant legislation be amended to recognize that any person whose medical condition warrants it is entitled to receive palliative care.11 16. The CMA supports emergency funding for end-of-life care for uninsured people residing in Canada.12 BACKGROUND In Canada, the impact of end-of-life care on both individuals and the health care system is "staggering," and the demand for this care will continue to grow as the population ages.13 It is estimated that the number of Canadians dying each year will increase by 40% to 330,000 by 2026. The well-being of an average of five others will be affected by each of those deaths, or more than 1.6 million people.14 Against this backdrop, the availability of and access to palliative care is an urgent policy and practice imperative. There has been mounting support for, and mounting criticism of the lack of, a national strategy for palliative care.15 The delivery of palliative care varies greatly across Canada due to differences in regional demographics, societal needs, government involvement and funding structures. Similarly, funding and legislation supporting access to palliative care services vary significantly between jurisdictions. A recent survey of Canadian physicians who provide palliative medicine found that: (1) Canada needs an adequate palliative medicine workforce; (2) primary care providers need more support for palliative care education and training; (3) palliative medicine as a distinct discipline must be further developed to better meet the complex needs of patients; and (4) Canada must ensure minimum palliative medicine standards are met.16 In an effort to address the current challenges in palliative care and improve both the quality of care and access to care, the CMA developed recommendations for a national call to action: 1. All patients should have a primary care provider that can support them with their palliative care needs or else refer these patients earlier to a palliative care team to establish goals of care. 2. Physicians should provide leadership at local, regional, provincial/territorial and federal levels to promote the establishment of integrated models of palliative care. 3. All physicians should obtain essential palliative care skills and knowledge to provide basic palliative care services to their patients. 4. Physicians should advocate for adequate and appropriate home palliative care resources so their patients can stay in their homes as long as possible. 5. Physicians should advocate for an adequate number of palliative and/or hospice care beds to meet their communities' needs. 6. Continuing care facilities and long-term care homes should have in-house palliative care physician support on their palliative care teams. 7. Physicians should support the valuable work of hospice volunteers. 8. Medical students are encouraged to look at palliative care as a rewarding career. 9. Practising palliative care physicians are encouraged, if needed, to obtain additional certified training in palliative care from either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. 10. Physicians acknowledge the value of and support the participation of family and friends in caring for their loved ones at the end of life. Integrated palliative approach to care There are four main models of palliative care delivery in Canada: integrated palliative care programs, continuing care and long-term care facilities, residential hospices, and home-based palliative care. Palliative care was originally developed in cancer care to provide patients dying of cancer with care at the very end of life by a specialized palliative care team.17 This model has evolved significantly in response to the increasing occurrence of, and burden posed by, complex chronic disease18. Palliative care is now also provided to patients with multiple co-occurring morbidities who require multiple interventions. It is now recognized to benefit all those living with life-limiting acute or chronic conditions, including, or perhaps especially, when it is initiated earlier in the disease trajectory. Evidence shows that integrated and early provision of palliative care leads to: (1) better outcomes than those obtained with treatment alone (e.g., improvements in symptoms, quality of life and patient satisfaction; positive effects on emotional wellness; decreased suffering; and at times increased longevity) and (2) better use of resources (e.g., less burden on caregivers, more appropriate referrals to hospice palliative care, more effective use of palliative care experts, less use of emergency and intensive interventions and decreased cost of care).19-20-21-22 Taken together, these studies validate the benefits of integrating palliative care services with standard treatment and involving palliative care providers early, a collaborative approach that transcends the conventional view that palliative care is care delivered at the very end of life. At present, there is strong support for the development and implementation of an integrated palliative approach to care. Integration effectively occurs: * throughout the disease trajectory; * across care settings (primary care, acute care, long-term and complex continuing care, residential hospices, shelters, home); * across professions/disciplines and specialties; * between the health care system and communities; and * with changing needs from primary palliative care through to specialist palliative care teams. The integrated palliative approach to care focuses on meeting a person's and family's full range of physical, psychosocial and spiritual needs at all stages of frailty or chronic illness, not just at the end of life.23 It is provided in all health care settings. The palliative approach to care is not delayed until the end stages of an illness but is applied earlier to provide active comfort-focused care and a positive approach to reducing suffering. It also promotes understanding of loss and bereavement (Fig. 1). Figure 1 Specialized palliative units and hospices are essential for end-of-life care for some individuals but are not appropriate for all persons facing life-limiting chronic conditions. When a palliative approach is offered in multiple settings, people and their families can receive better care through the many transitions of chronic conditions like dementia, lung, kidney and heart diseases, and cancer. This requires that all physicians be competent in initiating a primary palliative approach: they must be able to engage in advance care planning discussions, ask about physical and emotional symptoms and make appropriate, timely referrals to other providers and resources. Primary care physicians may need to develop more expertise in palliative care. A cadre of expert palliative care physicians will be required to provide care in complex cases, engage in education and research, and provide support for health professional colleagues providing palliative care in multiple settings. All health professionals must be able to practise competently in an integrated palliative approach to care. At the heart of an integrated palliative approach to care are a patient and family surrounded by a team of multidisciplinary professionals and community providers (Fig. 2). While team members vary depending on the needs of the patients and families, the principles of whole-person care and family care do not change. This allows patients and families to have their symptoms managed, receive care in the setting of their choice, engage in ongoing discussions about their preferences for care and experience a sense of autonomy in living their lives well. Figure 2 A report on The Way Forward, a project of the Quality End-of-Life Coalition of Canada and the Canadian Hospice Palliative Care Association, summarizes the situation as follows: "Only a small proportion of Canadians will need the kind of complex, intensive or tertiary hospice palliative care provided by expert palliative care teams in institutional settings, such as residential hospices and acute care hospitals. However, everyone who is becoming frail or is faced with a chronic illness could benefit from certain key palliative care services. As our population ages, we must ensure that all Canadians have access to palliative services integrated with their other care that will help them manage symptoms, enhance their lives, give them a greater sense of control, and enable them to make informed decisions about the care they want. More equitable access to palliative care integrated with their other care will enable more Canadians to live well with their illness up to the end of life. It will also enable more people to receive care in the setting of their choice and reduce the demand on acute care resources." 24 Access to palliative care services There are currently no reliable data on the number of specialized or semi-specialized palliative care physicians in Canada. It is difficult to count these physicians because palliative care has not historically existed as a specialty. Physicians practising palliative care have a wide variety of backgrounds and training, and many provide palliative care on a part-time basis. The Canadian Society of Palliative Care Physicians is currently working with partner organizations including the CMA, the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada to better define the different types of palliative care physicians to conduct a meaningful count. On the question of access, studies have found that palliative care services are not aligned with patient preferences. For example, while 70% of hospitalized elderly patients reported wanting comfort measures rather than life-prolonging treatment, more than two-thirds were admitted to intensive care units.25 Most patients and caregivers report wanting to die at home26 and in-home palliative team care is a cost-effective intervention,27 but the value of this form of care is not reflected in many provincial policies. Instead, Canadian families frequently shoulder 25% of the total cost of palliative care because they must pay for home-based services,28 such as nursing and personal care services, that are not provided by governments. With the goal of improving the congruence between patient treatment preferences for end-of-life care and the services provided, Health Quality Ontario developed an evidentiary platform to inform public policy on strategies to optimize quality end-of-life care in in-patient and outpatient (community) settings. It identified four domains in which access to end-of-life care should be optimized to align with patient preferences: (1) location (determinants of place of death); (2) communication (patient care planning discussions and end-of-life educational interventions); (3) team-based models of care; and (4) services (cardiopulmonary resuscitation [CPR] and supportive interventions for informal caregivers).29 Education It is well recognized that education in palliative care is lacking in medical school and residency training. In response, the Association of Faculties of Medicine of Canada, in partnership with the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians, conducted the Educating Future Physicians in Palliative and End-of-Life Care Project30 to develop consensus-based competencies for undergraduate medical trainees and a core curriculum that was implemented in all 17 Canadian medical schools. Despite these efforts, a survey conducted by the Canadian Society of Palliative Care Physicians found that the competencies are not being consistently taught in medical schools, as evidenced by the fact that 10 medical schools offered less than 10 hours of teaching on palliative care and two offered none.31 Moreover, evidence suggests that Canadian physicians are not consistently or adequately trained in palliative care. There is a general lack of providers trained in palliative care for service provision, teaching, consultative support to other physicians and research. To fill the observed gap in education, the Royal College of Physicians and Surgeons of Canada is developing Palliative Medicine as a subspecialty, and the College of Family Physicians of Canada is developing a Certificate of Added Competence in Palliative Care. What is more, different levels of palliative care competencies are required for different physicians: * All physicians require basic skills in palliative care. * Palliative consultants and physicians who frequently care for patients with chronic illnesses and/or frail seniors require enhanced skills. * Palliative medicine specialists and palliative medicine educators require expert skills. More broadly, the undergraduate curricula of all health care disciplines should include instruction in the principles and practices of palliative care, including how to access specialized palliative care consultation and services. Role of governments Access to palliative care must be treated with the same consideration as access to all other medical care. Provincial/territorial and federal legislation, however, is vague in this regard and does not recognize access to palliative care as an entitlement. Government funding of community-based hospice palliative care has not increased proportionately to the number of institutionally based palliative care beds that have been cut, leaving a significant gap in the health care system.32 To address this issue, efforts to broaden the availability of and access to palliative care in Canada need to be intensified. It is imperative that governments develop a common palliative care strategy to ensure equitable access to and adequate standards for quality palliative care, including emergency funding for those who are uninsured. Glossary Integrated palliative approach to care: An approach that focuses on quality of life and reduction of suffering as a goal of care. This approach may coexist with other goals of care - prevention, cure, management of chronic illness - or be the sole focus of care. The palliative approach integrates palliative care services throughout the treatment of a person with serious life-limiting illness, not just at the very end of life. Palliative care services: Generally consists of palliative care provided by a multidisciplinary team. The team may include a primary care physician, a palliative care physician, nurses, allied health professionals (as needed), social workers, providers of pastoral care and counselling, bereavement specialists and volunteers. The team members work together in a shared care model. Shared care model: An approach to care that uses the skills and knowledge of a range of health professionals who share joint responsibility for an individual's care. This model involves monitoring and exchanging patient data and sharing skills and knowledge among disciplines.33 References 1 Policy Resolution GC99-87 - Access to end-of-life and palliative care services. Ottawa: Canadian Medical Association; 1999. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 2Policy Resolution GC14-20 - Palliative care services and expertise. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 3Policy Resolution GC13-67 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 4Policy Resolution GC13-66 - Palliative Care Services. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 5 Policy Resolution GC13-80 - Collaborative palliative care model. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 6Policy Document PD15-02 - Euthanasia And Assisted Death (Update 2014). Ottawa: Canadian Medical Association; 2015. Available: https://www.cma.ca/Assets/assetslibrary/document/en/advocacy/EOL/CMA_Policy_Euthanasia_Assisted%20Death_PD15-02-e.pdf#search=Euthanasia%20and (accessed 2015 Nov 26). 7 Policy Resolution GC06-12 - Access to pediatric palliative care. Ottawa: Canadian Medical Association; 2006. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 8Policy Resolution GC14-23 - Delivery of quality palliative end-of-life care throughout Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 9Policy Resolution GC13-71 - Training in palliative care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 10Policy Document PD10-02 - Funding the continuum of care.Ottawa: Canadian Medical Association; 2010. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 11Policy Resolution GC13-70 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 12Policy Resolution GC14-26 - Emergency funding for end-of-life care for uninsured people residing in Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 13 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework. 14 Quality End-of-Life Care Coalition of Canada. Blueprint for action 2010 to 2012. Ottawa: Quality End-of-Life Care Coalition of Canada; 2010. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 15 Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med. 2013;36(3):E127-E32. 16 Canadian Society of Palliative Care Physicians. Highlights from the National Palliative Medicine Survey. Surrey (BC): Canadian Society of Palliative Care Physicians, Human Resources Committee; May 2015. 17 Bacon J. The palliative approach: improving care for Canadians with life-limiting illnesses. Ottawa: Canadian Hospice Palliative Care Association; 2012. Available: http://www.hpcintegration.ca/media/38753/TWF-palliative-approach-report-English-final2.pdf. 18 Ontario Health Technology Advisory Committee OCDM Collaborative. Optimizing chronic disease management in the community (outpatient) setting (OCDM): an evidentiary framework. Toronto: Health Quality Ontario; 2013. Available: www.hqontario.ca/Portals/0/Documents/eds/ohtas/compendium-ocdm-130912-en.pdf. 19 Zimmermann C, Swami N, Krzyzanowska M, Hannon B, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730. 20 Klinger CA, Howell D, Marshall D, Zakus D, et al. Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West end-of-life shared-care project. Palliat Med. 2013;27(2):115-122. 21 Temel JS, Greer JA, Muzikansky MA, Gallagher ER, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010;363:733-742. 22 Bakitas M, Lyons KD, Hegel MT, Balan S, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302:741-749. 23 Quality End-of-Life Care Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for an integrated palliative approach to care. Ottawa: Quality End-of-Life Care Coalition of Canada; 2014. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf 24 Quality End-of-Life Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for the integrated palliative approach to care. Quality End-of-Life Coaltion of Canada; 2014. Available: http://www.hpcintegration.ca/media/60044/TWF-framework-doc-Eng-2015-final-April1.pdf. 25 Cook D, Rocker G. End of life care in Canada: a report from the Canadian Academy of Health Sciences Forum. Clin Invest Med. 2013;36(3):E112-E113. 26 Brazil, K, Howell D, Bedard M, Krueger P, et al. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med. 2005;19(6):492-499. 27 Pham B, Krahn M. End-of-life care interventions: an economic analysis. Ontario Health Quality Technology Assessment Series. 2014;14(18):1-70. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 28 Dumont S, Jacobs P, Fassbender K, Anderson D, et al. Costs associated with resource utilization during the palliative phase of care: a Canadian perspective. Palliat Med. 2009;23(8)708-717. 29 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework 30 Association of Faculties of Medicine of Canada. Educating future physicians in palliative and end-of-life care. Ottawa: Association of Faculties of Medicine of Canada; 2004. Available: http://70.38.66.73/social-educating-physicians-e.php. 31 Daneault S. Undergraduate training in palliative care in Canada in 2011. Montreal: Soins palliatifs, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal; 2012. 32 Canadian Hospice Palliative Care Association. Fact sheet 2012: hospice palliative care in Canada. Available: http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf. 33 Moorehead, R. Sharing care between allied health professional and general practitioners. Aust Fam Physician. 1995;24(11).

Documents

Less detail

Health and health care for an aging population

https://policybase.cma.ca/en/permalink/policy11061

Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Replaces
PD00-03 - Principles for medical care of older persons
Topics
Health care and patient safety
Health systems, system funding and performance
Text
In 2010, 14% of Canada's population was 65 or older. With the aging of the baby boom generation, this proportion is estimated to rise to about 25% in 2036 (1). The aging of Canada's population is expected to have a major impact on the country's economy, society and health care system over the next 25 to 30 years. Though age does not automatically mean ill health or disability, the risk of both does increase as people age. In 2006, 33% of Canadians aged 65 or older had a disability; the proportion climbed to 44% among people aged 75 or older (2). Nearly three-quarters of Canadians over 65 have at least one chronic health condition (3). Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada's population ages. Currently Canadians over 65 consume roughly 44% of provincial and territorial health care budgets (4), and governments are concerned about the health care system's capacity to provide quality services in future. The CMA believes that to provide optimal care and support for Canada's aging population, while taking care to minimize pressure on the health-care system as much as possible, governments at all levels should invest in: * programs and supports to promote healthy aging; * a comprehensive continuum of health services to provide optimal care and support to older Canadians; and * an environment and society that is "age friendly." This policy describes specific actions that could be taken to further these three goals. Its recommendations complement those made in other CMA policies, including those on "Funding the Continuum of Care" (2009), Optimal Prescribing (2010) and Medication Use and Seniors (Update 2011). 2) Providing Optimal Health and Health Care for Older Persons: This section discusses in detail the three general areas in which the CMA believes governments should invest: a) Promotion of "Healthy Aging" The Public Health Agency of Canada (PHAC) defines healthy aging as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life." It is believed that initiatives to promote healthy aging, and enable older Canadians to maintain their health, will help lower health-care costs by reducing the overall burden of disability and chronic disease. Such initiatives could focus on: Physical activity. Being physically active is considered the most important step that older Canadians can take toward improving health, even if they do not start being active until later in life. However in 2008, 57% of seniors reported being physically inactive (5). Injury prevention. Falls are the primary cause of injury among older Canadians; they account for 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures (6). The causes of falls are complex, and both physiology (e.g. effect of illness) and environment (e.g. poorly maintained walkways) can contribute. Most falls can be prevented through a mix of interventions: for the person (such as strength and balance training); and for the person's environment, (such as grab bars and railings, slip-proof floor surfaces, walkways that are cleared of snow and ice in winter.) Nutrition. In 2008, 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less (7). The reasons for nutrition problems among older Canadians are complex; they may be related to insufficient income to purchase healthy foods, or to disabilities that make shopping or preparing meals difficult. Mental health. An estimated 10-15% of seniors report depression, and the rate is higher among those with concomitant physical illness, or those living in long-term care facilities (8). Depression among older people may be under-recognized and under-treated, since it might be dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors. Recommendations: Governments and National Associations The CMA recommends that: 1. Governments at all levels support programs to promote physical activity, nutrition, injury prevention and mental health among older Canadians. Health Service Delivery The CMA recommends that: 2. Older Canadians have access to high-quality, well-funded programs and supports to help them achieve and maintain physical fitness and optimal nutrition. 3. Older Canadians have access to high-quality, well-funded programs aimed at determining the causes and reducing the risk of falls. 4. Older Canadians have access to high-quality, well-funded programs to promote mental health and well-being and reduce social isolation. Physicians and Patients The CMA recommends that: 5. Older Canadians be encouraged to follow current guidelines for healthy living, such as the 2012 Canadian Physical Activity Guidelines for adults 65 and over. 6. Physicians and other health care providers be encouraged to counsel older patients about the importance of maintaining a healthy and balanced life style. 7. All stakeholders assist in developing health literacy tools and resources to support older Canadians and their families in maintaining health. b) A Comprehensive Continuum of Health Services Though, as previously mentioned, age does not automatically mean ill health, utilization of health services does increase with increasing age. Patients over 65 have more family physician visits, more hospital admissions and longer hospital stays than younger Canadians (the overall length of stay in acute inpatient care is about 1.5 times that of non-senior adults) (9). In addition, seniors take more prescription drugs per person than younger adults; 62% of seniors on public drug programs use five or more drug classes, and nearly 30% of those 85 and older have claims for 10 or more prescription drugs (10). Heavy medication use by people over 65 has a number of consequences: * The risk of adverse drug reactions is several-fold higher for seniors than for younger patients. * Medication regimes, particularly for those taking several drugs a day on different dosage schedules, can be confusing and lead to errors or non-adherence. * Patients may receive prescriptions from multiple providers who, if they have not been communicating with each other, may not know what other medications have been prescribed. This increases the risk of harmful drug interactions and medication errors. For seniors who have multiple chronic diseases or disabilities, care needs can be complex and vary greatly from one person to another. This could mean that a number of different physicians, and other health and social-services professionals, may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to clean house and make sure the patient is eating properly, and a social worker to make sure his or her income is sufficient to cover health care and other needs. Complex care needs demand a flexible and responsive health care system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community based health care, (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and footcare), to long-term care and palliative care. Ideally, this continuum should be managed so that the patient can remain at home, out of emergency departments, hospitals and long term care unless appropriate, can easily access the level of care he or she needs, and can make a smooth transition from one level of care to another when needed. Care managers are an essential part of this continuum, working with caregivers and the patient to identify the most appropriate form of care from a menu of alternatives. Care managers can co-ordinate the services of the various health professionals who deliver care to a given patient, and facilitate communication among them so that all work to a common care plan. A family physician who has established a long-standing professional relationship with the patient and is familiar with his or her condition, needs and preference is ideally placed to serve as manager of a patient's overall care, supported by geriatric and other specialists as appropriate. Not all of the patient's caregivers may be health professionals; more than 75% of the care of older Canadians is delivered by unpaid informal caregivers, usually relatives. The role of the family caregiver can be demanding financially, physically and emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more may be required. The Special Senate Committee on Aging has called for a National Caregiving Strategy to help put in place the supports that caregivers need. (11) Finally, many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding of these services varies widely from province to province. Long-term care beds are in short supply; as a result more than 5,000 hospital beds are occupied by patients waiting for long-term care placement (12), making them unavailable for those with acute-care needs. CMA's Health Care Transformation Framework (2010) makes a number of recommendations aimed at improving access to continuing care in Canada. Recommendations: Governments and National Associations The CMA recommends that: 8. Governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. 9. Governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. 10. Governments and other stakeholders work together to develop and implement a National Caregiver Strategy, and expand the support programs currently offered to informal caregivers. 11. All stakeholders work together to develop and implement a national dementia strategy. 12. Governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. 13. Governments work with the health and social services sector, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Medical Education The CMA recommends that: 14. Medical schools enhance the provision, in undergraduate education and in residency training for all physicians, of programs addressing the clinical needs of older patients. 15. Medical students and residents be exposed to specialty programs in geriatric medicine and other disciplines that address the clinical needs of older patients. 16. Continuing education programs on care for older patients be developed and provided to physicians of all specialties, and to other health care providers, on a continuous basis. Health System Planners The CMA recommends that: 17. Health systems promote collaboration and communication among health care providers, through means such as: a. Interdisciplinary primary health care practice settings, that bring a variety of physicians and other health professionals and their expertise into a seamless network; b. Widespread use of the electronic health record; and c. A smooth process for referral between providers. 18. All stakeholders work toward integration of health care along the continuum by addressing the barriers that separate: a. acute care from the community; b. health services from social services; and c. provincially-funded health care services such as physicians and hospitals, from services funded through other sources, such as pharmacare, home care and long term care. 19. Programs be developed and implemented that promote optimal prescribing and medication management for seniors. 20. Research be conducted on a continuous basis to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and health care costs. Physicians in Practice The CMA recommends that: 21. Continuing education, clinical practice guidelines and decision support tools be developed and disseminated on a continuous basis, to help physicians keep abreast of best practices in elder care. c) An Age-Friendly Environment: One of the primary goals of seniors' policy in Canada is to promote the independence of older Canadians in their own homes and communities, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, it is important that governments and society ensure that the social determinants of health care addressed when developing policy that affects them. This includes assuring that the following supports are available to older Canadians: * Adequate Income: Poverty among seniors dropped sharply in the 1970s and 1980s. In 2008, 6% of Canada's seniors were living in low income, as opposed to nearly 30% in 1978. However, there has been a slight increase in poverty levels since 2007, and it may be necessary to guard against an upward trend in future (13). Raising the minimum age for collecting Old Age Security, as has been proposed, may weigh heavily on seniors with lower incomes, and make prescription drugs, dental care and other needed health services unaffordable. * Employment Opportunities: it has been recommended that seniors be encouraged to work beyond age 65 as a means of minimizing a future drain on pension plans (14). Many older Canadians who have not contributed to employee pension plans may be dependent on employment income for survival. However, employment may be difficult to find if workplaces are unwilling to hire older workers. * Housing. Nearly all of Canada's seniors live in their own homes; fewer than 10% live in long-term care facilities. Options are available that permit older Canadians to live independently even with disabilities and health care needs, such as: o Home support for services such as shopping and home maintenance; and o Assisted-living facilities that provide both independent living quarters and support services such as nursing assistance, and cafeterias if desired. * An Age-friendly built environment. To enable seniors to live independently, the World Health Organization's "Age-Friendly Communities" initiative recommends that their needs be taken into consideration by those who design and build communities. For example, buildings could be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation could be provided in neighbourhoods where a large concentration of seniors live. * Protection from Abuse. Elder abuse can take many forms: physical, psychological, financial, or neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported (15). CMA supports awareness programs to bring the attention of elder abuse to the public, as well as programs to intervene with seniors who are abused, and with their abusers. * A Discrimination-Free society. Efforts to boost income and employment security, health care standards and community support for older Canadians are hampered if the pervasive public attitude is that seniors are second-class citizens. An age-friendly society respects the experience, knowledge and capabilities of its older members, and accords them the same worth and dignity as it does other citizens. Recommendations: Governments and National Associations The CMA recommends that: 22. Governments provide older Canadians with access to adequate income support. 23. Governments devote a portion of national infrastructure funding to providing an adequate supply of accessible and affordable housing for seniors. 24. Older Canadians have access to opportunities for meaningful employment if they desire. 25. Communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems and other aspects of the built environment. Health System Planners The CMA recommends that: 26. The health system offer a range of high-quality, well-funded home care and social support services to enable older Canadians to remain independent in the community for as long as possible. 27. Physicians receive advice and education on optimal community supports and resources to keep seniors independent and/or at home. Physicians in Practice The CMA recommends that: 28. Training and programs be provided to physicians and other care providers to enable them to identify elder abuse, and to intervene with abused people and their abusers. 3) Conclusion: Aging is not a disease, but an integral part of the human condition. To maximize the health and well-being of older Canadians, and ensure their continued functionality and independence for as long as possible, CMA believes that the health care system, governments and society should work with older Canadians to promote healthy aging, provide quality patient-centered health care and support services, and build communities that value Canadians of all ages. 1 Public health Agency of Canada. "Growing Older: Adding Life to Years. Annual report on the state of public health in Canada, 2010." Accessed at http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/index-eng.php 2 Statistics Canada: A Portrait of Seniors in Canada (2008). Accessed at http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm 3 Canadian Institute for Health Information. "Seniors and the health care system: What is the impact of multiple chronic conditions?" (January 2011.) Accessed at https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf 4 Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2010. Accessed at http://www.cihi.ca/cihi-ext-portal/internet/en/document/spending+and+health+workforce/spending/release_28oct10 5 PHAC 2010 6 PHAC 2010 7 PHAC 2010 8 Mood Disorders Society of Canada. "Depression in Elderly" (Fact sheet). Accessed at http://www.mooddisorderscanada.ca/documents/Consumer%20and%20Family%20Support/Depression%20in%20Elderly%20edited%20Dec16%202010.pdf 9 Canadian institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Aging. Accessed at https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 10 CIHI 2011 11 Special Senate Committee on Aging. "Canada's Aging Population: Seizing the Opportunity." (April 2009). Accessed at http://www.parl.gc.ca/Content/SEN/Committee/402/agei/rep/AgingFinalReport-e.pdf 12 CIHI 2009 13 PHAC 2010 14 Department of Finance Canada. Economic and fiscal implications of Canada's Aging Population (October 2012). Accessed at http://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp#Toc01. 15 PHAC 2010

Documents

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Around-the-clock services for frail and elderly Canadians living in the community.

https://policybase.cma.ca/en/permalink/policy11600

Date
2015-08-26
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC15-20
The Canadian Medical Association supports improved training, resource allocation and incentives to help primary care physicians develop robust, around-the-clock services for frail and elderly Canadians living in the community.
Policy Type
Policy resolution
Date
2015-08-26
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC15-20
The Canadian Medical Association supports improved training, resource allocation and incentives to help primary care physicians develop robust, around-the-clock services for frail and elderly Canadians living in the community.
Text
The Canadian Medical Association supports improved training, resource allocation and incentives to help primary care physicians develop robust, around-the-clock services for frail and elderly Canadians living in the community.
Less detail

National seniors’ strategy includes evidence-based hospital practices

https://policybase.cma.ca/en/permalink/policy11607

Date
2015-08-26
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC15-27
The Canadian Medical Association recommends that a national seniors’ strategy includes evidence-based hospital practices that better meet seniors’ physical, cognitive and psychosocial needs.
Policy Type
Policy resolution
Date
2015-08-26
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC15-27
The Canadian Medical Association recommends that a national seniors’ strategy includes evidence-based hospital practices that better meet seniors’ physical, cognitive and psychosocial needs.
Text
The Canadian Medical Association recommends that a national seniors’ strategy includes evidence-based hospital practices that better meet seniors’ physical, cognitive and psychosocial needs.
Less detail

Seamless transition through the continuum of care in a national seniors’ strategy

https://policybase.cma.ca/en/permalink/policy11608

Date
2015-08-26
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC15-28
The Canadian Medical Association supports the development of innovative and alternative models/partnerships that can provide services and resources for patients’ seamless transition through the continuum of care in a national seniors’ strategy.
Policy Type
Policy resolution
Date
2015-08-26
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC15-28
The Canadian Medical Association supports the development of innovative and alternative models/partnerships that can provide services and resources for patients’ seamless transition through the continuum of care in a national seniors’ strategy.
Text
The Canadian Medical Association supports the development of innovative and alternative models/partnerships that can provide services and resources for patients’ seamless transition through the continuum of care in a national seniors’ strategy.
Less detail

Palliative care services and expertise

https://policybase.cma.ca/en/permalink/policy11216

Date
2014-08-20
Topics
Ethics and medical professionalism
Physician practice/ compensation/ forms
Resolution
GC14-20
The Canadian Medical Association believes that all health care providers should have access to referral for palliative care services and expertise.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Ethics and medical professionalism
Physician practice/ compensation/ forms
Resolution
GC14-20
The Canadian Medical Association believes that all health care providers should have access to referral for palliative care services and expertise.
Text
The Canadian Medical Association believes that all health care providers should have access to referral for palliative care services and expertise.
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