Misplaced priorities have harmed our seniors
The alarming Canadian Armed Forces report on Ontario long-term care facilities during COVID-19 has once more exposed the deficiencies of our healthcare system. While public outrage may lead to the current leadership being held to account, it is widely acknowledged that conditions in long-term care have been progressively deteriorating to near-crisis levels for some time.
One of the most important causes of this deterioration is the failure of the Canadian political class, media and general public to have a rational debate about what components of our health and social care systems provide the most value for enhancing the well-being of Canadians.
Suboptimal conditions in long-term care existed long before the COVID-19 crisis. The poor response to the pandemic, with high mortality, suffering and abandonment, was entirely predictable. Comparative underinvestment has left long-term-care homes and the vulnerable patients within them in a state where even the most motivated and capable government would likely have been unable to protect them.
Despite the problems being well known, there has been a sustained lack of interest in improving long-term care. This is the result of decisions we (as Ontarians and Canadians) have made regarding the importance of long-term care in our health-care system.
Over most of the last two decades, we have focused on improving acute care services. Major drives to reduce wait times for hip surgeries were not matched by reducing wait times for long-term care. The Ford government’s major health-care platform was to eliminate “hallway medicine,” but this ignored the fact that residents in nursing homes are often left in hallways, too. Our most vulnerable are now paying for this decision to allocate resources so lopsidedly to the acute end of the spectrum.
These errors are not confined to the distant past. It was mere weeks ago that our major focus of pandemic planning was on acquiring more ventilators for our ICUs. As important as this effort was, in hindsight, might some of that effort not have been more fruitfully applied to training and staffing our LTCs?
This is a reflection of the somewhat misplaced priorities Canadians have within our health-care system, particularly for those in the twilight of life. Put another way, we have undervalued life in long-term care, and often overvalued the resource-intensive prolongation of the dying process in acute care. This likely represents a grave error that the COVID-19 crisis may hopefully now be pushing to the forefront of public consciousness.
Every health system is “designed” to get the results that it does. Our system is designed to provide expansive (and expensive) access to acute care services in hospitals, which depletes the resources needed to secure the needs of nursing home residents. While many other countries have developed mechanisms and political systems that establish reasonable limits to lower-value or even “futile” care, Canadians in general have typically insisted on limitless access to most health-care services.
To illustrate, compare two hypothetical 90-year-old patients — hypothetical in this story, but well-known to any acute care health professional in Ontario.
The first one lives in a nursing home where an inadequate number of staff strive to be compassionate and provide necessary care, but are truly overwhelmed by the number and complexity of patients in their charge. Despite a potential ability to derive enjoyment from their remaining years, this patient suffers poor quality of life.
In contrast, another patient of the same age has spent weeks or months in and out of hospitals with a terminal illness. They have been admitted to an intensive care unit twice. They remain confused and delirious and are again deteriorating. ICU has not previously altered the course of their terminal illness. Their family — perhaps out of a sense of duty, or fear — has refused palliative care and insists on aggressive measures to prolong life at all costs.
From the viewpoint of fundamental justice, is it justifiable to spend thousands of dollars per day on another ICU admission (that will not change a certain outcome) when the daily wages of a PSW in long-term care have always been a small fraction of that? Is it possible to have a productive debate about where our scarce and limited resources provide the most benefit, joy and quality of life?
We are hospital-based physicians who have chosen to make acute care our area of practice, and we recognize the importance of a world-class acute care system. It is from this perspective that we ask: How best do we honour and respect our parents and grandparents, and provide them with the best overall health possible?
We suggest that the answer lies in realigning policy and funding priorities. If there is indeed a “right to health care,” perhaps this right ought to begin with the fundamental and ordinary obligations of feeding the hungry and clothing the naked.
Only when we have satisfied these obligations can we begin to focus on perceived rights to intensive (and sometimes heroic, or extreme) treatments, especially at the end of life. In this way we will provide the best possible standard of care and well-being to the frail and vulnerable while they are still more able to enjoy many of the things that they value.
Dr. Travis Carpenter is an internal medicine physician and health policy specialist at Unity Health Toronto and the University of Toronto. Dr. Lucas Vivas is an internal medicine physician and bioethics specialist at William Osler Health System.