I gave permission to take my dad off life support in 2006, when he was 84. He died minutes later. He had decided to undergo expensive, extensive, elective multiple surgeries, even though he only had 15 per cent heart function. He’d believed the surgeries would extend his life, but I knew he wouldn’t make it. My mom was diagnosed with colon cancer in 2008, when she was 82, and she decided not to do anything. She knew that if cancer didn’t end her life, something else would. So she focused on living her last chapter and checking the remaining items off her bucket list. She died at home, among family, four years later, within a week of accepting morphine to relieve her mounting pain. Two parents, two very different deaths. Both had options on how they wanted to go. And in a matter of weeks, we in Canada will have new options for how we choose to die.
After facing challenges all the way to the Supreme Court, by June 6 2016 Canada’s assisted dying law (Bill C-14) will be law across the country. As presented, the legislation introduced on April 14 addresses all aspects related to assisted dying. While an important new legislation and a welcome option for those in incurable pain and suffering, however, it is incomplete public policy.
We need to step back and ask ourselves: Exactly what problem are we trying to fix?
Let’s review some of the facts stated in the Canadian Institute for Health Information’s report “National Health Expenditure Trends, 1975 to 2015” (October 2015).
- A new period is emerging, with health spending growth failing to keep pace with inflation and population growth (combined). Since 2011, health spending has decreased by an average of 0.6 per cent per year — comparable with decreases during the mid-1990s. It reflects, in large part, Canada’s modest economic growth and fiscal restraint as governments focus on balancing budgetary deficits.
- Across Canada, almost 40 per cent of provincial budgets go toward healthcare. This share has stabilized since 2009.
- Provincial and territorial governments’ per capita health-care spending is highest for seniors and infants. In 2013 (the latest available year for data broken down by age group), the cost for Canadians younger than one year was about, on average, $10,900 per person. For children one to 14 years, per-person average spending on health was $1,408; the equivalent for those 15 to 64 years was $2,637. For those 65 and older it was almost $11,600. Those in the last two decades of life incur the largest share of health-care expenditures, outside of childbirth.
At this unique point in history, Canadians are living longer than ever. These facts, and that we now have more Canadians over the age of 65 than under 15, points to a looming problem of increasing costs of healthcare for at least the next two decades, if not longer. Thus it is no surprise, beyond enhancing personal rights and dying with dignity that Bill C-14 may also serve as a “backdoor” cost management measure. Callous as it may seem, it is this cost factor, implicitly, we are trying to fix.
What Bill C-14 does well is to address an immediate problem — the end of life. But if we consider the Bill from a cost management intent, it maintains much of the status quo in healthcare. First, it barely considers the looming increased cost of healthcare and adequacy of systems to manage emerging problems associated with an aging population. Specifically, Bill C-14 allocates $3-billion for more palliative care over the next four years, but barely begins to address the need for incremental space and services likely required with the demographic bulge presented by aging boomers – the front end of which is now 69 years and already hitting the healthcare system. Second, Bill C-14 maintains the status quo on pharmaceuticals (rightly, at this point). However, considering the premise of cost management, associated pharmaceutical costs omnipresent in the last couple of decades of our lives — many of these medications required for chronic conditions due to longevity itself — will likely increase as well (in 2015, the public sector share was 36.6 per cent of drugs within total health expenditures in Canada). Research has consistently indicated that pharmaceutical companies do prefer investing in and promoting products and treatments for chronic conditions, as opposed to solving or eliminating ailments. And those of us with aging parents and relatives know the costs and trade-offs on medications depending on their level of insurance.
So what will a complete policy solution to complement Bill C-14 look like? Simply, incentivize advanced care directives.
An advance healthcare directive, also known as a living will, is a legal document that specifies what actions should be taken for the subject’s health and well-being if he or she is no longer able to make decisions due to incapacity or illness. In an analysis presented on National Public Radio in 2014, advanced care directives in Lacrosse, Wisconsin were in place for 96 per cent of the adult population. Consider this compared with 30 per cent across the entire United States. Participants readily extolled and appreciated the benefit of completing this legal document. In the analysis, a physician confirmed that the program loses money, but overall it puts potential patients into better situations in these critical last decades, and saves money elsewhere within the healthcare system. According to Jeff Thompson, CEO of Gundersen: “It turns out that if you allow patients to choose and direct their care, then often they choose a course that is much less expensive.” At the time, this action contravened the common American healthcare funding/revenue model. But in November last year, insurers took notice of these positive results in Lacrosse, and are stepping up to cover the funding shortfall — because that is cheaper than covering the costs of extended life care.
Further, when given a choice, few people want to face their twilight years tied up in the healthcare system or hospital. Most want to remain comfortably among loved ones and close to home. This can all be handled in an advanced care directive, and provisions can be made for the healthcare system to adapt to this shift. And there is a subtle shift in this direction – for example, with the Death Café movement participants get together to discuss their demise only to discover how they want to make the most of their finite lives.
So what would an incentivized advanced healthcare directive look like in Canada? Simply a cash or tax incentive to complete one by at least 40 or 50 years old. An incentive can be in the ballpark of $150 to $250 if filed with a provincial healthcare agency to verify its tax-code compliance. This value should be enough, given that the expected lifetime healthcare cost would far exceed the cost of preparing and submitting an advanced care directive. In addition, a simple directive template can be developed online, and verified by a lawyer for approximately half the cost of the incentive.
I applaud Bill C-14 as a first step in dealing with an aging population and a healthcare system challenged to provide a broad range of services to Canadians. But the federal and provincial governments need to step up and promote advanced care directives so that Canadians can have a rational discussion on the type of healthcare we want as we approach the end of our lives. And as individuals, we need only witness the challenges of our aging loved ones to understand that we must consider our end-of-life options rationally and early.