Medically Necessary? the Case for Fully Funded End-of-Life Care

Introduction The current work of provincial and national health commissions, and the release of some preliminary reports, is focussing attention on the issue of health services. This is not the first time that the issue of has been debated. Since the formation of the Canadian health care system in the 1960s, and its reinforcement in 1984 by the Canada Health Act, the concept of medically necessary has broadly defined which health services will be publicly funded. As the concept of could also define which services will not be publicly funded, it stands to reason that the issue of defining health services on the basis of whether they are considered or not is of critical importance to Canadians. Medically health services are all those which physicians deem to be for individual clients. This definition has largely resulted in all Canadians having a wide range of medical and hospital services readily available to them when needed. Yet, at the same time, an illness-oriented, hospital-dominated health system has been the primary outcome of this legislated aim to ensure provinces universally provide, at a minimum, health services. However, our health system has evolved and continues to evolve into a more diverse and community-based system. Obviously, there are other influences on our health system. These influences are illustrated by the physician fee-for-service schedules negotiated by health ministries, and political as well as regional health authority policy-making. In short, there are many influences on what is and what is not in our current basket of publicly-funded health services. In some cases, these additional influences result from technological and educa tional advances, as in the case of laparoscopic procedures replacing many of what were previously major invasive surgeries. The widespread but still variable substitution of day surgery care across Canada, along with a shift in the cost of health care supplies and the responsibility for providing pre- and post-operative care to the home, are among the most common outcomes of this single technological advance. Additional influences have also arisen out of fiscal prudence, as was the case in the 1990s when provinces furthered a shift from inpatient to outpatient care. Still other influences have arisen out of the identification of unmet health care needs. Inner city primary health care programs are but one example. Although laudable, the programs that result from these additional health system influences are often only available in select communities. Home care is one such boutique or designer program, with each province and also each regional health authority determining if home care will be provided, and how it will be funded and delivered to community residents. (1) Although targeted programming assists residents of one community, people in other communities normally have similar health care needs. Universal programming is therefore often indicated. This paper argues for a fully funded home-based palliative care program for dying Canadians. Why is There a Need For This Publicly Funded Health Service? Approximately 220,000 Canadians die each year now, three quarters of whom are aged 65 or older. (2) Most of these 220,000 deaths are not unexpected. Death today most often follows a variable but still notable period of declining health due to advanced aging and/or progressive chronic illness. (3) During an ongoing decline in health to death, it is reasonable to expect that some care needs will occur. (4) A key question is: where does this care take place? A recent study of hospital use by dying Albertans over a five year period found one admission in five years was the most common frequency of hospitalization. (5) As this hospitalization was the one that ended in death, it is remarkable that no admissions to hospital occurred in the five previous years. …

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