Canada's 2016 law on medical assistance in dying (MAiD) spurred great interest in efforts to provide alternative treatments that help people cope with terminal illness. Changes in the nation's approach to palliative care have had a long gestation.
In the early 1990s, José Pereira, MBChB, PhD, then a recent graduate of medical school in South Africa, was working as a family physician in a small town in rural Manitoba. A patient in his 50s came with his wife to Pereira's office seeking help in coping with his cancer.
Pereira felt ill prepared. At that time, the young physician feared increasing what he now realizes was an inadequate dose of morphine for the patient because of concerns about addiction. Pereira also didn't know how to address the patient's other symptoms, including fear. Pereira still recalls the patient's parting words. "He said, 'I hope that one day doctors like you are able to look after people like me,'" Pereira told Medscape Medical News.
Shortly after this encounter, Pereira flew to Hamilton, Ontario, Canada, to get training in palliative care, which he knew little about. He later asked the patient with cancer for a second chance and cared for him in his final months.
"I learned that with a little bit of training, a healthcare professional like me can make all the difference," Pereira, now a noted expert on palliative care, said in 2017 testimony for the Health Committee of Canada's House of Commons.
He spoke in favor of a bill that the Parliament passed into law that year, leading to the 2018 establishment of the National Framework on Palliative Care. That framework detailed ways for the federal government to aid provinces and territories as they developed strategies for making palliative care more widely available.
The goal of this initiative is to help all Canadians with serious illness live well until the end of life. This goal extends beyond managing pain and other symptoms of serious illness to understanding the psychological, social, and practical needs of patients who are dying, as well as their caregivers.
Establishing a national framework helped change the perception of this field of medicine, said Hsien Seow, PhD, the Canada research chair in palliative care and health system innovation at McMaster University in Hamilton. "It has allowed us to take away some of the stigma and fear around the words 'palliative care,'" Seow told Medscape Medical News. "They've had public health campaigns and advertising that have brought attention to the human piece of this [aspect of medicine]."
The National Framework also has drawn attention to the need for more clinician training. Seow explored this point in his 2023 book Hope for the Best, Plan for the Rest: 7 Keys for Navigating a Life-Changing Diagnosis, which he wrote with palliative care physician Sammy Winemaker, MD.
Fear and panic can make a patient's final year unnecessarily rocky when clinicians lack knowledge to guide him or her, Seow and Winemaker wrote. Training can help clinicians anticipate what the course of their illness will be, including bouts of vomiting. "Most people rush to the emergency department because they don't understand what's happening," Seow and Winemaker wrote.
Two Status Reports
Two major reports issued last year on palliative care in Canada noted recent gains, while highlighting a need for more clinician training.
Among people who died in Canada, the proportion who did so at home, supported by palliative care, was 13% in 2021-2022 compared with 7% in 2016-2017, according to an April 2023 report by the Canadian Institute for Health Information (CIHI).
Yet, CIHI also reported that only 40% of primary care physicians reported feeling prepared to care for patients with palliative care needs. This result is consistent with the proportion reported in 2019, which was 39%.
In December 2023, Health Canada released an assessment of the state of palliative care since the 2018 creation of the framework. Health Canada has spent about $18.5 million for training and other resources to help clinicians and other caregivers. Its report described how provinces have adapted to local needs and shared information on successful approaches.
For example, one program built on previous work in Alberta, Prince Edward Island, and Nova Scotia to better equip paramedics to perform palliative care. In about 7000 palliative care calls studied, 53% of patients were able to receive care at home instead of in the emergency department, according to the report.
In Alberta, a 24-hour palliative physician on-call program provides specialty support to primary care physicians in managing their patients.
The Health Canada report called for continued training and support for clinicians and caregivers involved in palliative care.
Much of this work is performed by Pallium Canada, a nonprofit organization that Pereira cofounded in 2000. Among the programs highlighted in Health Canada's 5-year report were Pallium's Learning Essential Approaches to Palliative Care courses. They can be taken online, in person, or in a hybrid version.
To date, more than 5520 physicians have taken palliative care training through Pallium, and more than 1500 of them practice family medicine, the organization told Medscape Medical News.
'Family Medicine on Steroids'
Some physicians like Erin Gallagher, MD, decide early in their medical careers to undergo more training in palliative care. In addition to preparing to work in family medicine, Gallagher pursued an extra year of enhanced skills training in palliative care through McMaster University.
"I went into family medicine because I like people and I like the psychosocial aspects" of providing healthcare," Gallagher told Medscape Medical News. "I felt like palliative care was family medicine on steroids. It's a rewarding type of work."
Adding palliative care into family medicine can be a step toward reversing the medicalization of death, which tends to shift this natural and inevitable process away from homes and communities.
Instead, physicians can work with people confronting terminal illness to consider how they want to approach death, said Gallagher, who also is an associate professor of family medicine and palliative care at McMaster University.
Too often, people have seen loved ones suffer with terminal illness without realizing what steps they can take toward a more comfortable passage. Some may consider MAiD, but most people who talk about it don't pursue it, she said. Clinicians' discussions with patients about MAiD are intended to include a review of palliative care options. Physicians thus can help patients manage many of the physical and emotional challenges they face, said Gallagher.
"My hope is that they find the care that they have wanted and that it allows them to maintain as good of a quality of life as possible to the end," she concluded.
Kerry Dooley Young is a freelance journalist based in Washington, DC.