Health — Issue No. 14 — Wednesday, April 29, 2015 (HTML)

Present: Linda Larson, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Donna Barnett, MLA; Dr. Doug Bing, MLA; Sue Hammell, MLA; Richard T. Lee, MLA; Dr. Darryl Plecas, MLA; Jennifer Rice, MLA; Bill Routley, MLA; Dr. Moira Stilwell, MLA

2. The following witnesses appeared before the Committee and answered questions on end of life care:

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH


CONTENTS
Page
Presentations: End-of-Life Care	177
W. Morris
D. Robertson
T. Davies
J. Dimmick
I. Mackenzie

L. Larson (Chair): Good morning, everyone. I’d like to welcome our guests this morning — Wanda Morris and Dr. David Robertson from Dying With Dignity Canada.

Welcome to our committee. We are looking forward to your presentation. I’ll allow our members a quick introduction around the table, just so that you know who’s here. I’ll start with Dr. Stilwell.

D. Barnett: Donna Barnett, MLA, Cariboo-Chilcotin. We had a discussion, and Wanda Morris and I have something in common from about 1995 or ’96, somewhere in there.

J. Darcy (Deputy Chair): Judy Darcy, MLA, New Westminster. We’ve certainly had the chance to meet.

I also just wanted to let the committee know I have to step out at 9:30. I do apologize for that. I will miss parts of this meeting.

W. Morris: On February 6 the Supreme Court of Canada released its decision on physician-assisted dying. They said: “It is a crime in Canada to assist another person in ending her own life. As a result, people who are grievously and irremediably ill cannot seek a physician’s assistance in dying and may be condemned to a life of severe and intolerable suffering. A person facing this prospect has two options. She can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.”

Those were the opening words of a decision that was signed by the nine members of the Supreme Court in their unanimous decision striking down the laws in Canada that prohibit physician-assisted dying.

Last year Dying With Dignity Canada made a submission to this select committee on end-of-life health care. Much of that submission is now out of date. The court has ruled. The debate is over. Now is the time for compassion.

Today I’m here with my colleague Dr. David Robertson, one of the nine physicians from B.C. on our physicians advisory council, to advise you of what is ahead, how B.C. can address the challenges of implementing physician-assisted dying and to review with you five guiding principles that we would like to see adopted in any legislative or regulatory framework.

Now, you may be aware that a majority of Canadians support physician-assisted dying, but are you aware of exactly how strong that support is here in this province? Last October, before the Supreme Court held its hearing, we commissioned a poll from Ipsos-Reid, one of the most reputable polling companies in Canada. The question read as follows: “As long as there are strong safeguards in place, should a doctor be able to assist a terminally ill patient to end their life if they are suffering unbearably and repeatedly ask for assistance to die?”

The results are there before you. B.C. ranked second among all the provinces polled, slightly behind Nova Scotia. Our sample was over 2,500 Canadians, including 400 from this province. While B.C. came second in total support, it was first in the number of people who strongly supported an individual’s right to have access to die.

That support crossed all political boundaries. People who vote are more strongly supportive than people who do not do so. But what we found is that the Liberals came in right at the average of 87 percent, slightly exceeded by the NDP and Green Party. And below the average were those voting “other” or “undecided; would not vote.”

What did, actually, the Supreme Court decide? The Supreme Court ruled at a high level and made some clear findings in terms of eligibility. They decided that to be eligible for physician-assisted dying, an individual must have a “grievous and irremediable medical condition,” which they noted could arise from illness, disease or disability. So they struck ground here perhaps broader than some would have envisioned.

You’ll note that this definition does not restrict access to physician-assisted dying to the terminally ill. They ruled that individuals who are competent adults with unbearable suffering and no treatment acceptable to that individual…. Here, they clearly valued the patient’s autonomy and the patient’s right to determine whether they wanted further treatment or assistance to die.

In terms of the remedy, the court case applied to physician-assisted death, which had been defined as the prescription of medication — to be crystal-clear, what is sometimes called assisted suicide — as well as the admin-
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istration of medication, or what is sometimes known as voluntary euthanasia. Here again the courts cast a pretty broad judgment, not restricting assistance to die to those who are at the very end of life and making sure that individuals like Sue Rodriguez or Gloria Taylor, who would not have been able to self-administer the means to die, would have access to a compassionate and humane death, if that is truly what they chose.

What happens now? The court decision made clear that either the federal government or the provincial governments could legislate. Both could. Neither has to do so. In B.C. there is already an existing regulatory framework of consent legislation so that if no legislation is passed, either federally or provincially, physician-assisted dying would be regulated as are other end-of-life treatments, such as withholding and withdrawal of medical treatment, voluntary stopping of eating and drinking, or terminal palliative sedation.

Will the federal government legislate? We saw in the news — I believe it was just yesterday — Peter MacKay saying that no legislation would be coming before the upcoming federal election. In an earlier article published in Le Devoir, there was an article noting that the federal government will establish a commission to embark on a six-month tour to probe the views of Canadians — the commission being struck in June and reporting in December, neatly bridging the election period. Nobody from the federal government has affirmed that, but it has also not been denied.

If such a commission is indeed going to be struck, it would seem to be so that the federal government could indeed legislate. If they were to legislate, it would likely be under the auspices of the Criminal Code, still leaving the health jurisdiction open to a provincial legislative or regulatory framework.

Will other provinces legislate? Well, you may be aware that Quebec passed a bill last year — An Act respecting end-of-life care, called Bill 52 — which, among other things, made palliative care a right for Quebeckers; which encouraged Quebeckers to create advance care plans and which legalized what that province called medical aid in dying for individuals at end of life, subject to a number of safeguards. That bill is scheduled to come into effect December 31 of this year, and the latest information that we have is that Quebec intends to proceed.

Now, at the moment that bill is not in compliance with the Supreme Court’s ruling, because the eligibility criteria are stricter than what the Supreme Court has allowed. So whether they will amend the legislation or perhaps wait for a court challenge waits to be seen. The remedy arrived at by Quebec, which was the provision of assisted dying by a physician, the administration of medication, or voluntary euthanasia, is consistent with the Supreme Court’s ruling.

Now, if Quebec goes ahead, we could have a situation where we have something still not legal in Canada, because, of course, February 6, 2016…. The Supreme Court gave parliament a year to regulate, but it is unlikely that we would see a challenge to Quebec in that short period between when they enact legislation and when the time period runs out.

Ontario. We have had some meetings in Ontario with individuals in the Health Ministry there. They have indicated an interest, I know, ideally in participating in a Canada-wide solution and avoiding a patchwork of potentially differing legislation by province.

What do key B.C. stakeholders want? The federal government has certainly indicated that physicians will play a significant part in any legislation. Our physicians advisory council tells us that first and foremost they want clarity. They want to know what they are doing that is within the laws, that is legal, and what would cross the bounds. They don’t want to end up in jail for providing compassionate assistance. They also want the right of conscientious objection. Access will be a critical issue for any regulatory framework to resolve.

We, as well as the physicians advisory council, have a disability community advisory council. The members of our disability council…. Just as a quick sidebar, our poll also polled those in the disability community to see what their support was for assisted dying, and 85 percent of the members of that community supported assisted dying.

The disability community wants to see safeguards. They would like to see legislation so that they know nobody will be coerced to accept assisted dying against their will. They would also like to see adequate support for the disabled so that people aren’t choosing assisted dying because the resources in their communities are so dire it is the only option.

What about the 87 percent — the B.C. residents, those who we speak for, who want to see assisted dying? We want to see a regulatory framework that honours the wording and spirit of the Supreme Court’s decision.

In our submission we talked about five guiding principles for end-of-life care. I’m now going to turn over to my colleague Dr. David Robertson to overview those principles.

I do wish to make clear at the outset, just as a brief introduction, that I currently work full-time as an executive medical director for Island Health. However, I am not here for Island Health. I am here for myself as a citizen and as a physician who’s worked for 35 years in anaesthesiology in areas of intensive care units, operating rooms and acute pain control.

The five principles that we laid down in our submission remain the core of our submission. The first of those, patient autonomy, is really the crux, and that’s the crux of the Supreme Court’s decision. I think when historians look back at this era, they will come to the conclusion
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that this change in societal belief that we’re promoting is one that’s driven by the boomers.

The boomers have controlled every aspect of their life as they’ve gone through: school, choice of mate, reproductive history, much in the workplace, gender equality, their pensions. I’m absolutely certain that now they wish to take greater control of the manner of their dying. But it’s not just the boomers. It’s 87 percent of this province who actually think that we need to move forwards.

Any end-of-life care should respect the wishes of the individual and, if they choose, of their families — the values that the individual holds most important. Whether it’s to live as long as possible, whether it’s to experience redemptive suffering — one thinks there of John Paul II — whether it’s to be lucid, even if that means accepting pain — this is my sister, actually — or whether it’s having a gentle death, that should be the individual’s call.

Eight-four percent of Canadians and 87 percent of B.C. residents support physician-assisted dying, including the full spectrum of religious beliefs, age ranges and self-disclosed persons with disabilities.

The Supreme Court ruling clearly states that there must be grievous and irremediable suffering. It must be enduring suffering intolerable to the individual. It is not the role of legislation, we believe, to overturn or to undermine the Supreme Court’s findings.

Thus the ruling does not require that the condition be terminal. There is no requirement that the individual be at life’s end. The ruling does not compel any physician to assist individuals in this way. They’ve left it up to regulators to find a balance between physician and patient rights.

Doctors of B.C. does expect that if a physician is not willing to take part in physician-assisted dying or prescribe medications, then that physician should be required or expected to provided adequate referral and not to proselytize to patients. Our principle at Dying with Dignity is that it is the wishes of the individual that are paramount.

The second of our principles was that of patient-centred care. This actually, as it happens, ties in extremely well with the strategies that have come out from the provincial Ministry of Health regarding patient-centred care and the idea or the notion, the plan, that we should move forward in the province from one that has tended to be facility- and provider-centric to being one that is patient-centric in our health care.

People want to be allowed to die at home in a manner of their own choosing and to be allowed control over the timing of their death. More than 90 percent of people would, frankly, rather die at home. I know I would. We actually fail very badly in that. Approximately 80 percent or more people die in some sort of an institution and have, frankly, very little control over their death.

Our laws and our health system should actually enable this. The Supreme Court of Canada has clearly said that we now have the right to decide as individuals the time and the manner of our death under certain conditions. The Ministry of Health strategies talk about this, and I know that I’m doing a lot of work to try and move Island Health in that direction.

The Supreme Court is completely silent on the issue of advanced-care directives and the authority and power of alternate decision-makers. It’s actually up to you to decide whether there will be any alteration in the Health Care (Consent) Act of 2011, I think, regarding that role.

At Dying with Dignity Canada we believe that laws should be amended to make advanced-care directives actually do what the person wants to do in cases where they don’t. As physicians — and this is me talking on the front line — we believe it when a Jehovah’s Witness has a card that says, “no blood products,” and this certainly results, occasionally, in hastened death for those individuals.

W. Morris: This is a picture of a young woman by the name of Margot Bentley. It’s a particularly poignant picture because it’s her picture on graduating as a nurse, where she went on to work on dementia wards. She was very clear with her family that the last thing she ever wanted was to die a lingering death in a demented state. Unfortunately, today that is where she is.

Those were filmed circumspectly on an iPhone in a care facility where Margot Bentley is currently residing. Her family had repeatedly requested the care facility to respect Margot’s wishes and allow her to be enabled to die. She is being spoon-fed.

You are likely well aware that this was the subject of a court case here in B.C. and an appeal, both of which were overturned, and the care facility was enabled to continue to feed Margot Bentley. The family was trying to make the case, particularly with the second video, that she’s opening her mouth to an empty spoon and is not actually consenting to her death.

Many of our members want physician-assisted dying. But I would say that stronger than that is the urge for them not to end up in a situation like Margot Bentley, where they clearly envisioned a state at which they wanted to not be living but are powerless to have the end that they want.

D. Robertson: So we insist on feeding Margot Bentley. The courts tell us that according to their interpretation of legislation, we must. If that is what our legislation says, then we feel it must be changed.

Individuals who have a long-standing abhorrence of dementia must be able to have the confidence that their
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instructions will be followed. Since Margot Bentley’s case became public as a result of the court case — and I’m sure you well know; it’s been in the news — we have seen suicide notes that have referenced her death. People are dying untimely deaths, in some cases violently, because the system has failed them.

Individuals must be able to leave instructions that cannot be overridden. At Dying With Dignity Canada we believe that Margot Bentley’s legacy should be that no one else need endure as she is enduring. We believe that the laws should state that the last advanced-care directive written before a person became incapable of consenting on their own behalf should endure.

We believe that people like me should have confidence that if demented, I will not be given flu shots or have antibiotics if I develop pneumonia, because actually pneumonia is not a bad way of dying. To me, the threat of being demented is horrifying. In that case, I will have confidence that I will not have to endure the terrified, confused, unwanted dementia that my father went through, which, frankly, he would have considered very degrading and which fell totally against his values of life.

The laws around refusing treatment, we feel, need to be strengthened. Right now individuals can complete a do-not-resuscitate order. But what if someone wants to refuse treatment other than resuscitation? We need to have broader options for refusal of treatment, and our health care providers need to be educated more about respecting them.

The third principle that we’ve outlined was that of adequate pain and symptom control. At Dying With Dignity Canada we understand that adequate pain and symptom control sometimes requires terminal palliative sedation, or physician-assisted dying. This is not wrong. It is a fact of life. It’s something that I’ve known from my work for decades. It’s something that Canadians are now learning.

Individuals should never be forced to endure what they consider as unbearable suffering because someone else is making assumptions about what is for their own good. Whether individuals can request physician-assisted dying by an advanced-care directive is still to be determined, but the abilities for substitute decision-makers to inform regarding terminal palliative sedation in accordance with an individual’s wishes as a means of controlling pain must be part of regulatory frameworks.

In our section on patient autonomy we’ve recognized that it is the individual’s decision to choose their own treatments. Likewise, with pain and symptom control we must trust the individuals to let us know when their pain or their other symptoms are at unacceptable levels. It is not actually for me as a professional to decide that.

Some pain and some symptoms are simply uncontrollable. They will never be controlled. Morphine is a great drug, but it doesn’t do everything. Some palliative care physicians argue this, but the reality is that there is refractory pain that simply cannot be treated.

Palliative care physicians’ work is dedicated to improving the quality of life at the end of life, and they always believe, as individuals, that they can do better. It’s the nature of physicians. We all believe that. They believe that they can always improve the quality of an individual’s life if they have more resources or they work harder.

In theory, yes, they can, and the system, actually, can greatly improve its palliative care. But in practice, for an individual who’s suffering with irremediable pain, that does not actually help the individual at the moment.

We do have an obligation to improve our palliative care system, but we have to recognize that it can never cover everything. The Supreme Court ruling means that the palliative care physicians are no longer, at the moment, the decision-makers in this. It’s no longer up to the caregiver to decide whether or not the control is adequate or has been achieved or could be improved. It’s up to the suffering patient.

All too often in my working life I’ve encountered the approach in my colleagues that says: “Yeah, well, you know, we’ve done everything we can. You can never completely control pain with cancers like these, but we’re doing pretty well with this one.” These colleagues of mine are not actually asking the patient what the patient thinks.

The Supreme Court ruling clearly puts the ball firmly in the patient’s hands. If the pain control is inadequate, if the suffering is untreated and can never be adequately treated, the patient may wish for help to die.

This puts the onus on us all — that’s health care workers and citizens — to ensure that pain and symptom control is as good as it can be. Only then can we, as a society, know that every person who reaches the stage of demanding and receiving physician-assisted dying actually had no other options.

It is this pressure on us that results in improved palliative care in those societies that have allowed physician-assisted dying, because they’ve gone through a societal conversation, and they have paid attention to it. They are confident — much more confident — as citizens that they’re doing everything that they can and that the options have been run out. But it leaves the actual decision about whether or not to request physician-assisted dying firmly in the hands of the suffering individual.

The ministry is already talking about improving care at end of life and making it patient-centric, and it’s important to recognize that improving care also improves the understanding and the ability to access physician-assisted dying when care is simply not possible to improve anymore.

The fourth principle is that of universal access. The Supreme Court ruling means, quite simply, that such a service should be available to any Canadian, irrespective of whether they are at home, in residential care, in a hospice or in a hospital.

The ruling spoke for all Canadians. Under the principle of universal access, any legislation that is enacted should
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ensure that all Canadians actually see the benefit of this. Legislation must require that all health care institutions receiving public funds enable physician-assisted dying. This includes hospitals, residential care, long-term care, assisted living and hospices.

As many of you will be aware, there is something of a patchwork of availability of access to abortion across this country. It is reasonable to expect that someone who is seeking an abortion can move to the next-door town. It is not reasonable to expect that someone who is in unbearable pain and suffering can move to a different institution.

Physicians need to have the option of whether or not to provide. The patient’s right to receive physician-assisted dying must not be prevented by any physician’s views. Physicians who will not take part in providing physician-assisted dying should be required to provide suitable referrals.

All pharmacies should provide information regarding physician-assisted dying. Any individual pharmacist may refuse to fill a prescription for medications that will be used in physician-assisted dying; however, a pharmacist who refuses to fill such a prescription must provide a referral. Pharmacies in public facilities, such as hospitals, must have at least one pharmacist who will fill a prescription for a medication to be used in physician-assisted dying on a timely basis.

L. Larson (Chair): Dr. Robertson, I don’t want to cut you off or speed you up, but I know that in this room there are a ton of questions. I’m watching the clock and knowing that at ten o’clock we have another presentation coming in. I’ll let you do your fifth point, and then can we go to questions at that point?

Patient education and effective communication. It’s well documented that doctors die differently from other people. My knowledge, my experience of how horrific treatment can be will result in me potentially dying a different death from those of many citizens.

All too often at Dying With Dignity Canada we hear patients saying — and I’ve certainly heard it in my work: “If I knew then what I know now, I would never have agreed to this. This is not what my mother wanted.” I’ve been told that I don’t know how often.

Why are we subjecting people to treatment that is, at best, futile, and at worst, torturous? Wouldn’t it be better to invest our health care dollars into a system that puts planning and communication above technology and a default reflex to treat?

Government needs to act in two ways. They need to require that the health care authorities ensure that advanced-care directives become part of electronic health records. That would be an easy fix. They need to make it possible for advanced-care directives to instruct regarding feeding and fluids, whether administered by tube or by mouth.

Then government needs to work to ensure that realistic discussion about end of life actually takes place in society. That’s a matter of leadership rather than legislation.

With that, I’m going to hand it over to Wanda, and we will move pretty quickly, I imagine, on to at least a half-an-hour’s worth of questions.

W. Morris: Our legacy. This is a time for B.C. to move forward. Quebec has taken steps, but B.C. can take centre stage. This issue lives in this province.

The Sue Rodriguez case started here. Evelyn Martens, who was prosecuted for assisting a suicide, was a B.C. resident. Gloria Taylor, who joined the current court case, was a resident in the Interior. Kay Carter — the court case focused on her. She travelled to Switzerland to have an assisted death, and her daughter, Lee Carter, was of course the named plaintiff in the case. Gillian Bennett, a woman from Bowen Island who ended her life because she had a diagnosis of dementia, took medication while she was still able to do so. Margot Bentley still lives a kind of living death, as many of our members would see it.

We have a broad popular support in this province. This select committee is demonstrating a non-partisan approach. A Supreme Court decision grounds us. It is a time for leadership. It is a time for legacy.

L. Larson (Chair): Thank you, Wanda. I know that everybody has more than one question, but I want to make sure we get around the table at least once. I’m going to start and ask the members of this committee to only ask one question this first time round, then if we have time, we can go around, and they can get to their second question.

W. Morris: I’ve got my cards here, and I’m happy to continue conversations afterwards.

L. Larson (Chair): We can also compile a list of questions for you that we don’t get to today.

M. Stilwell: Thank you for the presentation and the information, which is important and helpful.

My question is a bit granular. That is about the concept of suitable referral. My observation is through reproductive right access. Physicians think suitable referral is just to somebody else and sense no obligation to ensure and follow up that the patient received what they wanted.

It’s a statement and a question. Suitable referral to me is not just someone else. Going back to your principle of patient-centred and the patient controlling what happens to them, is there going to be…? How do you see that really being entrenched in a meaningful way, and not just be a way to…?
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W. Morris: You know, Dr. Stilwell, I think that you have put your finger on one of the biggest and most contentious issues that will be determined in legislation.

What we have seen is a number of colleges, the provincial regulatory bodies, saying that doctors have a duty to refer. We’ve heard the CMA talk about the need for doctors to have conscientious objection. The objection in the physicians community is going to be about…. Nobody is interested, certainly not Dying With Dignity Canada, in compelling a physician to provide something they don’t want to provide. The issue is around how we make that referral effective.

Some doctors feel they shouldn’t have to refer to what is called a willing provider, that even that act would make them complicit in something they conscientiously object to.

The CMA has talked about an independent body that could be used to effectively find individuals who would provide. So the doctor isn’t referring to a willing provider. They’re referring to an independent agency.

When we look at Quebec’s Bill 52, they had adopted such a mechanism, so a doctor referred to their institution, as opposed to them trying to find another doctor. We’re not opposed to such a mechanism, but what we are absolutely opposed to is a regulatory framework that just gives a physician the right to refuse an effective referral without putting a mechanism in place that will deal with it.

Just to continue your point, we’ve got the issue with physicians. We’ll have the same issue, potentially, with pharmacists. We want to make sure that the rights of patients are put forward. So absolutely, individuals should have the right of conscientious objection, but that cannot — that must not — be allowed to trump the rights of patients to have access.

L. Larson (Chair): Thank you. What I’m going to do, again because of time, is get your question and ask you to just make a note of it and then to respond to them all at once — all right? That way, we can keep within the time frame.

D. Plecas: Thank you very much for what you do and all you’ve done to help us get to this place. I would say the only problem with the Supreme Court decision is it should have happened decades ago.

My question is: how long, in your minds, should it take us before we get to a place where what we need to have done has happened?

What are some of the safeguards that you would have as a group? There’s talk about the disability community wanting to ensure there are safeguards. What would be the list of potential safeguards that you would want to see included in any legislation?

R. Lee: Usually, the pain is caused by the failure of an organ or some other disorder, and there’s suffering followed by death. Sometimes patients will feel better one day or another, or with some, say, acupuncture, there will be pain relief. What kind of decision-making process for the patient, if it’s patient-centred…? One day the patient may want to die; another day they maybe say: “Well, I can live longer.” Are there any mechanisms to follow that process?

J. Darcy (Deputy Chair): I want to thank you, as well, for the work that you’ve done. It’s an issue that all of us with family members have confronted, with, you know, mother-in-law having one very strong set of views and my father, as he was dying, having very different sets of views. That’s what you were talking about — people’s choice.

I wonder if you could just drill down a little bit more on the B.C. situation. You referred to what exists now in B.C., the existing regulatory framework and what that speaks to. You also talked to…. I was taking notes furiously, but I don’t think I got it all down when you said what government, you believe, needs to do to act now, what the next steps are. If you could put a little bit more meat on those bones so that we are in a position to have a more informed discussion afterwards.

D. Bing: Thank you for your presentation. The issue is very poignant to me today because I was at a memorial service on the weekend. It was an acquaintance who was a war vet, and he surprised everyone, especially his family, by committing suicide because he was in pain.

Anyway, my question is regarding the legislation. I was wondering: if every province was to have their own legislation, would that create a problem, rather than having one solution from the federal government that would apply to the whole country? It seems to me that the provinces do tend to do legislation individually, and it’s often not a total match for people.

D. Barnett: It’s a very difficult topic. Some of us have been through having people die at home — and, fortunately, peacefully — but others are not so fortunate.

My concern is — and this would be part of legislation or whatever — that if it’s not universal across Canada, I think it would create some real issues from province to province. If I have the wish to die with dignity, how could it stop me from going to Alberta, if they have a legislation
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in place that says I can die with dignity? I can see some real issues there if it’s not universal.

The other thing I have a concern with is that we don’t know, if we don’t plan ahead, what is going to happen to our lives. I could wake up tomorrow and the brain could not function. It doesn’t function that good most days, but at least it still functions. If I’ve given somebody my power of attorney, would that then give them the right if there was legislation passed — or would it have to be in there? — that says they can then have the right to say that I need to die with dignity? Or would I have to foresee that ahead of time?

L. Larson (Chair): My questions are fairly similar to Judy’s, and that is that the test for continuing to feed, etc., is, right now, by interpretation. Dr. Robertson, you said that health authorities and so on can interpret that a little bit. I want to know, again: how do we fix the legislation so that there isn’t this type of interpretation that can be passed around a little bit?

The legal documentation that would allow somebody like Margot…. For instance, did she not have a legal document that says: “When I’m at a certain stage, I give somebody the authority to no longer feed me”? Was that not available to her, at her point in life, so she doesn’t have it right now? She doesn’t have that kind of documentation. Is that documentation that legally tight that if I was to do that today and say, “This is the way I want to end my life,” or whatnot, nobody would be able to argue that point, when I was no longer able to communicate?

We’ll turn it over to you and let you quickly try to respond. We’ve got 12 minutes.

In terms of: how long should it take us, and specifically, what needs to happen? And is this a federal issue or a provincial issue? The federal government…. Let’s assume that Le Devoir is correct that there is a panel, that there is going to be some consultation, and that’s going to be to drive some federal legislation, which I think is a good idea. It would be Criminal Code legislation, and it would cover things like eligibility criteria and, likely, safeguards.

There is some sample legislation on our website. Steven Fletcher had a bill. The Senate had a similar bill. Those lay out some of the potential safeguards. What we’re trying to make sure of is that the person is giving informed consent — the presence of an independent witness, two physicians to make sure that that assessment of consent is there, perhaps some type of waiting period to address the issue of…. We don’t want somebody with one spike of pain to make a premature decision. We want to make sure it’s enduring and consistent.

I think many of those would be addressed through federal legislation. Certainly, also, those issues of “let’s make sure the legislation enshrines the wisdom and spirit of the decision” in terms of grievous, not just terminal; access to voluntary euthanasia, not just a prescription an individual may not be able to ingest themselves.

What does that leave the provincial government to do? Do you even need to act? I think there is definitely a space for the provincial government to act. It may not necessarily be through legislation. It could be through regulatory frameworks or in other ways. But when we look at end-of-life care….

I commend the committee for putting this in that context, because physician-assisted dying shouldn’t stand alone. It’s part of a network of, as Quebec has done, ensuring that B.C. residents have access to palliative care. And what a wonderful opportunity to tie those two things together.

Also, the area of advance care planning. Margot Bentley’s situation so horrifically denotes what happens when that goes wrong. I’m not a legal expert, but I’m aware that B.C.’s legislation is different than some in other provinces. Also, institutions have abilities to interpret. We understand that Margot Bentley, in a different institution or perhaps in a different province, may well have had a very different end. Universal access should say that our laws need to be written or regulations tightened in such a way that her wishes are followed.

The issue was raised about what we call non-contemporaneous consent. Advance care plans, advance directives are meant to be binding so that if…. And we see that in the case of Jehovah’s Witnesses, where someone refuses blood products and that refusal is clear and it is honoured and it may hasten a person’s death. How do we get that same clarity around more nuanced situations?

That’s not an easy question, or I think we would be further there than we are, but just because it’s not easy doesn’t mean that it’s avoidable. We need to tackle that and give Margot Bentley and all our seniors or others who are worried about potentially long-term issues, like dementia, a way to have access. That, I think, is going to happen provincially. That’s not going to happen federally.

The Criminal Code can address eligibility. It can address remedy, but it can’t address access. So there’s a clear role here for the province and, I think, probably the regulatory colleges to work with pharmacies and pharmacists, physicians and institutions, long-term-care facilities, residential facilities and home care to make sure that individuals, wherever they are, have access — whether they’re in the urban areas of the Lower Mainland or in the urban interior or north. How can we facilitate that?

Can we have assisted dying through non-contemporaneous consent? The Supreme Court decision does not go there. It doesn’t preclude legislation from going further, but the Supreme Court decision itself doesn’t provide for that.

I can tell you that internationally there are three jurisdictions that allow some form of assisted dying without
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consent at the time of death. Those are the Benelux countries — Belgium, the Netherlands and Luxembourg. In Luxembourg, in Belgium, it’s a very short-term window. If an individual requests assistance to die and during the waiting period they become incompetent, go into a coma, assistance can be rendered. In the Netherlands there is a longer-term provision.

How the B.C. government wants to regulate there…. I can tell you, as well, that this is a huge issue for our members. In a survey we did a number of years ago, 95 percent of individuals that we surveyed — this was our own members and supporters — wanted to be able, in an advanced-care directive, to have assistance to die through an advanced-care plan. Whether that is something that we want to do at this point is a question for the government to decide. I realize that there are many issues involved — ethical, medical and otherwise.

What we do want to ensure, though, is — whether or not it’s through physician-assisted dying — that individuals in that state have clear rights that they can state beforehand so that nobody need be in Margot Bentley’s situation.

In terms of a time frame, I believe that the opportunity is now. You know, it was 20 years that the Rodriguez case came. If we do not take advantage of this now, it could be another two decades before some of these injustices are addressed. The select committee has gotten a jump on it. You’ve already consulted. The window is till February 6, 2016, to introduce some sort of framework, and I encourage you to make this your legacy.

Doug, I just wanted to speak to your point about the war vet. What we know is that once a framework for assisted dying is put in place, less people die violently or die prematurely because conversations can then happen.

Physicians who are otherwise rightly afraid of having a conversation know that now it’s something that can legally happen so that people are much more likely to get assistance and possibly have pain treated, where maybe a physician wasn’t aware previously of the degree of suffering that was going on.

L. Larson (Chair): Thank you very much. You did, fairly quickly, go through those things.

D. Robertson: From the front line there was a question regarding: would it not be preferable to have a flat playing field across the country? From the front line, yes, it would. It is much easier if we have identical regulations, identical legislation from province to province with nationwide access. However, we recognize that that’s maybe not completely likely. We understand that, but the more uniform it is — certainly from the front line — the better it works. That would prevent issues of people wanting to move province at the last minute and all these sorts of things.

W. Morris: Just looking down at my list of questions, Judy, I’m not sure I fully answered yours in terms of what the existing regulatory framework is. We are working in partnership with a group called B.C. Civil Liberties. You may be familiar with them as the co-plaintiffs on the Carter case. They bring the legal expertise, so they’d be in a better position to advise you particularly.

What they have told me is that there have been reviews of the existing provincial health legislation. B.C., and I believe the other province is Ontario…. There are two provinces that actually have a framework right now that’s pretty close to what it needs to be to adopt physician-assisted dying without major legislative changes. I’d be happy to connect you with them and get you that further detail.

The other thing I will just mention: in any legislation or regulatory framework the devil is in the details. One thing to just put on the radar is life insurance. One of the questions that we get asked by our members is: “What happens to life insurance?” In Oregon, in the Netherlands and in Belgium a physician-assisted death is treated as a natural death so that an individual does not have to choose between a gentle death and potentially gutting the estate that they’re leaving to their survivors.

Now, in Oregon that happens because they treat the cause of death on the death certificate as the underlying cause. So if a person has got untreatable cancer pain, then cancer is known as the cause of death. The difficulty with that, then, is it becomes difficult to have oversight data collection when death certificates are coded in that way, and we think oversight is critical. We don’t want this….

We are committed to working with the disability community, with the doctors to being the mainstream, middle-of-the-road organization that supports this, and we want oversight. We want to make sure that what happens is reviewed and that if there are mistakes or errors that happen, we then tighten our regulations and address them so that this can be a part of our legacy going forward.

D. Robertson: Originally you questioned about the patient having a bad day and deciding that’s it. Other legislations do require, most of them, some degree of cooling-off period or repeated interviews between initial request and prescription or physician-assisted dying — all of which is very sensible. However, at the back of it we also have to acknowledge the fact that it’s the patient deciding for themselves. That is very much part of the Supreme Court’s purpose, I believe.
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W. Morris: Yeah, and noting that an individual can refuse or withdraw treatment. So it’s a situation we’re already dealing with.

L. Larson (Chair): Thank you. This committee actually did form a subcommittee to look specifically at the issue that you’ve presented this morning, but there was such a broad interest around this table. That’s why the entire committee is here to hear you today, and because we are looking at the end-of-life care and doing a better job of it. This is definitely part of that path, once you’re there.

The other thing is, too, that from a cultural perspective, we do not talk about death like we should. There are some wonderful hospice organizations that are trying to educate the public and get us to talk about dying. It’s very much…. It’s going to happen to everybody, so we need to have that conversation.

Certainly, the advanced-care planning and your suggestion about the B.C. Civil Liberties — perhaps our subcommittee will connect with them and see what the legalities would be, as well, as we move forward.

Thank you so much. This is a conversation that is very difficult for anybody to have. I thank you for presenting it in such a way that we were comfortable listening to you. You certainly raised a lot of questions and some possibilities for us as well. So thank you very much for being here this morning. I’m sure you’ll hear from us again.

L. Larson (Chair): Good morning. Thank you so much for joining us. I apologize. We’re running about five minutes behind, but we won’t cut you off as a result of that.

Welcome, Tom and Jim, to the committee this morning and to talk to us. We’ll do a quick run around the room so that you have a chance to hear where each individual is from. Then we will turn it over to you. We do have 15 minutes for you to make your presentation and 15 minutes for us to ask questions. If that’s okay, we’ll do that.

We’ll start with you, Tom. Would you like to introduce yourself. Then we’ll just do a quick around the table.

T. Davies: My name is Tom Davies, and I’m a spokesperson for the Federation of Oceanside Residents Associations.

J. Dimmick: I’m Jim Dimmick. I’m a member-at-large, formally representing the Craig Bay community. But I’ve moved to Qualicum Beach.

L. Larson (Chair): We’ll just give Darryl a moment, and he’ll introduce himself.

L. Larson (Chair): Thank you very much for being here, gentleman. I’ll turn it over to you.

T. Davies: My name, again, is Tom Davies. I’ll just introduce what FORA is, and then Jim will be doing the presentation.

In 2009 there was a group of residents associations that was concerned about the shortfalls of delivery of health care in the Oceanside area. So what we decided to do was organize all the residents associations into one group — which included, also, the chamber of commerce and KAIROS and that type of thing — with a group that represented about 25,000 people and do what we could to advocate for delivery of better health services.

Then what we did is we went on a campaign of engaging the MLA Ron Cantelon at the time there. Ron turned out to be just a tremendous supporter and opened many doors for us to meet with the minister at the time and also the Premier and arranged other things to come in. Now Michelle Stilwell is certainly a very strong supporter as well.

We’ve met with the Island Health board many times and introduced ourselves and take the high road in requesting certain things to happen within our area, the result of which was the Oceanside Health Centre in Parksville,
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which is a $16 million facility there that has really ramped up the level and quality of service in that area.

We try to engage with the community. We have what we call mayors breakfast meetings every three months, where we take all the mayors from Parksville, Qualicum, the RDN, Michelle Stilwell, senior executives of the Island Health at the executive director level, division of family practice, and we all get together in the same room, have breakfast, and everybody gets everybody up to speed so that at the end of the day or at the end of the breakfast meeting, everybody leaves the room with the same sort of information about what’s happening with delivery of health in the area. We do that on a three-month basis.

That sort of lays down the foundation. We have an organization in place. We’re engaged with the proper leadership in the community, we believe.

You’ve already read our submission prepared by Jim, and I’ll turn that over to Jim now.

As Tom has said, we come from a community that is really engaged in concerns over its health care. As you can see on the list I’ve provided, members of FORA are plugged into all the other committees — the end-of-life care, the health network and a healthy-living group. There’s a lot of advocacy going on, and concern, because in large part, Oceanside has more seniors in that population than any other area in Canada, certainly in B.C.

With seniors comes, as you would know, a lot of chronic disease load. This community lends itself perfectly for what people have been looking at as the better way of health care delivery, using what we have in our primary care centre at the Oceanside Health Centre as a multidisciplinary team approach to health care delivery. I think that has proved itself to be sustainable, cost-effective and, certainly, has much better outcomes for patients, in particular those who are being treated for chronic diseases — perfect for our population.

We’ve gotten, I think, a long way down the road with the start-up of that health centre, which opened in 2013, but we’re hardly there yet, and so we’re advocating for more progress.

We’ve also had progress in home care, which has expanded, but not to the fullest extent that would make the greatest impact in reducing health care costs in acute care and in emergency. We’re looking at ways to advocate for that.

I should tell you that in the health centre, telemedicine is phenomenally popular — a lot of consultation. I was surprised at this, but especially in the mental health area, they’re having a considerable impact.

There are things like this that are happening. Also, in the end-of-life care, the community is collaborating with the division of family practice and moving ahead with a plan to deal with that in a seamless way, making use of all the groups collaboratively.

We’re getting five mid-level palliative care beds and, with that, our local hospice is actively engaged in providing the other kinds of support that don’t come from the health authority. As you know, hospices — at least, ours — get no stable funding. It’s all run on donations and grants and so on, so it’s precarious. Part of our advocacy is to secure some stable funding, at least in part, for the operation of our hospice, which will make end-of-life care much more successful.

The other aspect of what we’re up to — we receive a lot of concerns from our residents about referrals to specialists. Now, we don’t have…. I guess we do have one or two specialists in our community. Most of us are retired, though, so we’re completely useless. You know, you get approached periodically, but I no longer have a licence, thankfully. Anyway, there are a lot of complaints about people, especially older people, who can’t connect with a specialist easily.

Now, a lot of the local doctors have their favourite specialists to whom they refer. We’re all familiar with that. But what the problem is, is that that may be a failed specialist referral — that happens — or that the specialist is incredibly busy, so it’s delayed and delayed.

One of the things we’d like to have explored and solved is this dilemma. I’m interested in it partly because I just went to Mountain Equipment Co-op on line, and I was looking for a light for my bicycle. You look at the various lights, and then over on the side there’s a thing that says what store has this light available. Well, that struck me as a family doctor’s office saying what gastroenterologist is available. If MEC can do this, surely the province can do it.

The other issue that we’re advocating is in home care. There’s lots of new technology to make home care even better. Website consultations take the patient in the home. Obviously, most of these patients would like to be at home. If they can be cared for at home, then we’re going to save money doing so, and the patient will be healthier and happier in the home. That’s an angle that’s very important.

The last thing I want to say that we’re very, very concerned about and our mayor in Parksville is very concerned about is the economic health of the community, which will fail if our health care in the community stumbles. He’s aware of this, because they’re trying to build small businesses and bring them into Oceanside to improve the economics. If the health care side is failing, then we have older people and young families saying: “Well, I don’t want to come there, or I don’t want to stay there, if I can’t find a doctor.”

Right now the division of family medicine says we have about 4,500 — about 10 percent of our population — with no doctor. What we’re facing — and this is really
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critical — is we have 28 doctors, average age 59. When I wrote this, they were 59. They’re probably average age 60. In three to five years 50 to 80 percent of those are going to be gone. In fact, when I last talked to the division, they said five were going imminently. You can imagine what that does to the unattached numbered. Fairly quickly we’re in a catastrophic situation.

The community is concerned about how to solve that. I think part of the solution is the Oceanside Health Centre. This multidisciplinary primary care approach is an obvious way to deal with a large number of patients — more than a single doctor can deal with — because you have other professionals handling a lot of the problems.

We’re advocating that the one primary team we have be progressively expanded, particularly as we lose private practitioners out of the community. It’s a new way of practice. There are tensions between — as Moira would know — old ways of practising and the new way.

I think the good part about this is that the medical students coming out today are geared to this multidisciplinary way of practising medicine. They’re also less interested in the fee-for-service, less interested in the business side of medicine. They want to spend more time with their patients, probably in part because over half of the medical students are female — sometimes more sensible than male medical students — and they want to have that effect and that relationship on an ongoing basis with their patients.

That’s perfect for our situation. It’s perfect for our primary care centre. I think the primary care centre, the Oceanside Health Centre, should be used as a recruitment and retention tool.

Part of the reason physicians don’t go to rural areas. There’s a recent review out of UBC, and it says two reasons. One, they don’t know anything about the rural areas. They’re from the big city, and they’re raised in hospitals, so they don’t know anything about it. Two, if they do go there, they want to feel like there’s a collegial system support mechanism around them. That is lacking in many of the small one-doctor, two-doctor practices.

The Oceanside Health Centre, with its primary care unit, can provide that atmosphere. It lends itself to the new way of practising. It provides a system support mechanism. And if done right, that centre should be affiliated with the university so that we can have trainees, who then have experience in the rural areas and, more than likely, will stay. That’s why the med school expanded to Prince George successfully.

I think we’re asking for the same thing there: make sure our curriculum works so that the students can come and spend some time. Some will stick. So those are the things we’re advocating.

The health centre opened in 2013. In the planning leading up to it, it was portrayed as the model of the future for rural areas. It seems to have stalled. Now, we’re impatient; we’re only a year and a half out, okay? But the urgent care side was thought to be able to handle…. The speculation was there would be 8,000 to 10,000 attendees. Last year there were 27,000.

Now, a lot of those people are unattached. They’re using an urgent care centre inappropriately, but they have nowhere to go. The answer, obviously, is to expand the primary care.

Some would say: “Well, private practitioners can be replaced.” That’s a real tough task, as you all know, in rural areas. And practices are not sold anymore. No one wants them. So communities have to do something else.

Oceanside has an advantage in having the Oceanside Health Centre as a way of luring younger practitioners who know and feel comfortable in a team practice approach. I think that’s where we have to go.

What we’ll do is similar to what we did at our last session. I’m going to go around the room, let everybody put one question on the table for you. If you can just take note of those, there are probably some that will have similarities, and then we’ll get you to answer them all together, all at once. Hopefully, within the next 15 minutes we’ll be able to work our way through them.

I’m going to start with Bill this time. Throw your question out there, and we’ll just get going.

B. Routley: Thank you for your presentation. I’m a bit shocked that a beautiful community like yours would have trouble attracting doctors. On the other hand, we went through it in the Cowichan Valley and Lake Cowichan, which is a spectacular lake.

I think it is very concerning to all of us that are looking at the problems in health care. The fact that so many doctors are…. Well, I guess we shouldn’t be surprised. They’re part of the boomers generation as well. I agree with you that we do need a new model.

I guess if you could comment on the multidisciplinary approach. I’ve heard so much about it. I believe that it’s kind of the new wave, but I was concerned when you said, “Well, it’s not quite there or perfect” — at least, that’s what I thought you were inferring.

Could you give us some ideas on what things you think could improve that? Do you have nurse practitioners, for example?

S. Hammell: It’s a reoccurring question, but is there conflict between the fee-for-service and the holistic, or the integrated disciplinary team, in terms of being able to service people with perhaps a cost to them that is not either covered or covered by some kind of health care insurance, or people have to come up with money from their own pockets to get some of the services?

J. Darcy (Deputy Chair): Thank you for your presentation, Dr. Dimmick.
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You’ve mentioned younger med students. We had the opportunity, many of us, to meet with UBC Medical Undergraduate Society just a couple of days ago. What you’ve said is exactly what they said. They’re looking for different ways of practising, and they’re very much more open to team-based care. It was very encouraging.

I wanted to also drill down a bit more about how things work and what the funding model is for the Oceanside Health Centre. Are the physicians on fee-for-service or not? There are different models of team-based care, as you’re well aware. Sometimes it involves physician practices paying out of their own billings, which can be a huge barrier, of course, to expanding interdisciplinary teams.

So more about what the team is there and how the model works, as far as funding and payment and so on.

M. Stilwell: My questions are in the bucket around recruitment and retention of physicians.

As you know, there are hundreds of Canadians studying medicine abroad who would love to come home and are prepared to give a return of service. If you had a rotating group of residency graduates obligated to stay for three years, as you say, the stickiness would increase as they’re liking to marry and establish themselves, and so on.

It’s been some time since I had any conversation with UBC about that, but one of the obstacles offered as a reason not to provide positions for British Columbia residents studying medicine abroad was lack of teaching. You have 28 very qualified and experienced practitioners who, when they leave, are going to take a lot of knowledge with them. My question is: what is the capacity and interest for having residents there? How many do you have now, and how many would you be willing to take? You probably don’t know the details of that.

Secondly, I’d like you to speak to the return-of-service concept. As a taxpayer loading a million bucks into a promising young person, to watch them go to Alberta to practise anything…. You know, it becomes problematic in our stretch times. I mean, we all respect freedom to move and work where we want to. At the same time, this is at a huge public cost. I would like to know if your organizations have started to think about it, talk about it and so on.

J. Rice: I actually want to go back to the lack of physicians in rural areas. I took down some notes, but I just wanted to know if you could repeat what the two challenges were. I think you said something to the extent that physicians want to feel supported or that they have a system around them. Then the previous item. I wasn’t too sure, but I understood…. Was it that they were trained in urban areas and that they don’t know the rural environment? I just wanted to clarify those two things.

One of the things you mentioned was the issue of telemedicine, teledoctoring, telehealth — whatever we want to call it. I sensed some excitement in your voice when you talked about that. I just wondered how far along you are in terms of your group looking at that as one of the things we could be doing. There are all kinds of indications of where that’s been done with spectacular success — serving more people with less doctors.

R. Lee: A lot of medical students actually don’t go into general practice. They go into specialist, and I think you, sort of…. The lack of specialists and the difficulty of getting a specialist….

The patient right now goes through the physician to get the referral. You’re talking about a shopping list on the computer you can choose. If the physician, when they refer…. The patient actually can go to the list for a surgeon. They can see which one has a shorter waiting list to choose from. Sometimes it’s an education for them to choose the one, getting the faster service.

I think my question is: can you bypass the physician and go to the specialist? I think the argument is that you have to have a gatekeeper so that not too many cases are referred to the specialists, which is necessary. What’s your thought on that?

I was quite interested in your point that a new model is needed. Certainly, if we look at the demographics, as you mentioned, there’s this bulge of retirees about to happen. I think one of the major changes, of course, is the, as you were saying, number of females now in medicine. A lot of them don’t want to go to the rural areas. They like to be close to the hospitals where the specialists are.

It’s always been the goal of the government to have a family physician for every patient. I’m wondering if that model is gone, if that’s not realistic anymore. I wondered what you thought about that. It seems to me that your multidisciplinary idea might work. Certainly, this idea that you can have a family doctor for every patient in the province, I just don’t think that’s realistic anymore. What do you think of that?

I really don’t have a question. This is very near and dear to my heart. I’ve been working on rural health issues for some time.

I have the same question as Moira. Why can’t these students come here and either become residents with doctors or…? There’s got to be a way that we can utilize their
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value. I always feel that if I’m trained in Germany, I can go to Germany, and they can look after me. But why can’t they come here and look after me? I don’t think medicine is that different anywhere. I think we have to change the way that the College of Physicians and Surgeons looks at this. I think this is a big stumbling block. I think it’s something that we have to address.

In rural British Columbia I think we also have to, at our universities in the urban centres…. There’s no reason why people can’t come to rural British Columbia to be doctors. I think that it’s not pushed there. I don’t think they’re ever taken out to rural British Columbia for a six-month sabbatical. Rural British Columbia has more to offer than an urban centre does, for families. So I think we have to somehow change the way of thinking in our education facilities.

Very interested in the fact that you did mention telemedicine, and one of our committee did also. I’m wondering. Because we are not going to have enough doctors — I mean, that’s fairly obvious, with the numbers that are dropping off — would a combination, through a clinic or the type of centre that you have, where those who have to stay at home plus those who need to see a specialist and so on can be done through a telehealth type of system and therefore…?

We’re not going to have a GP for everybody. You know, we’re just at that point in time. Is it possible, then, that one GP, through using some better technology, could actually serve more people? I know that there becomes a billing issue about that at some point as well. But I think that that could be quite effective.

Donna mentioned rural. My riding has 17 communities, and not one of them has more than 5,000 people. Only two of them even have close to 5,000 people. The type of centre that you’re talking about…. There’s no one of those communities that that centre would end up in. Instead, it would end up in a larger centre, in a big community like Penticton or Kelowna or whatever.

If my person out in wherever wants to see a doctor, if they can walk in somewhere and there’s a machine there, they can do that. I think that we’re going to have to do that, without a doubt. I think that your model could be expanded on to cover more than just….

And I love your idea of the specialist, where you press the button and “these are the ones that are available” versus that long process of trying to find a specific one. I think you’ve got some wonderful ideas.

Thank you very much for coming to talk to us. I’ll let you try and respond to the questions that have been raised, if you can do that.

J. Dimmick: Yeah. This is a memory test — right? — to see if I have pre-dementia or something. I undoubtedly will not remember them all.

Let me just say that what you’re talking about, the telemedicine model, has actually been in use for quite a number of years. When I worked at Children’s Hospital, the pediatric orthopedic people would do some follow-up in the early days of telemedicine. If someone in Fort St. John had had a procedure, that child stayed in Fort St. John, and they watched the child walk on the TV screen and so on, on the monitor. So it’s been going on a while.

I think the obstacle is not in the medicine or the technology. It’s in the billing and all that sort of stuff, which I have no idea how to solve. You folks can solve that.

The new technology can transform how we deliver medicine and can keep people in their communities and in their homes — no doubt about it. And it’s not just telemedicine. The monitoring of things like blood pressure, electrolytes, pulse, glucose — you name it — to keep a heart-failure patient at home….

There was a trial — I think it was out of St. Paul’s Hospital — where patients would go on their laptops every week and have a relationship with a nurse practitioner who would monitor their functions and say: “Well, you better jack up your digitalis a little bit or modify it.” That can be done. Or the patient would say: “Look, I’m really worried. I need to see someone.” Then it could be arranged, rather than have that person have to go to emergency or to an urgent care centre.

Modern technology. SFU and UBC technology areas are working at high speed on this. So I think there’s a lot to be said about that. It’s a matter, as you said, of figuring out the billing system so that it will work.

The multidisciplinary team business at the Oceanside Health Centre, to my understanding, is all on salary or contract. I don’t think it’s on fee-for-service, which makes it much more sensible. Well, for one thing, a patient may not see a doctor other than in the beginning. And everything is on one electronic health record. That’s key. So the nurse practitioner, the pharmacist, the nutritionist get to know that patient, and then they can all intervene. The pharmacist can look at all of the drugs that the patient’s on and say, “Well, this doesn’t make sense” or: “This does.” It’s a very valuable way of doing it.

In order for that to work, it really has to be on some contractual or salaried basis, as far as I understand. Maybe other areas work on fee-for-service. I’m not sure. I’ve seen some literature on multidisciplinary teams in the east that are on fee-for-service that haven’t worked cost-wise and that actually have been more costly.

J. Darcy (Deputy Chair): That’s right. Family care teams as opposed to community health centres.

J. Dimmick: Yeah. Certainly, in the States, where the system is profit-driven, the multidisciplinary team has
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been shown to be much more profitable. Even physician assistants, they have. I guess if that says something, it says that it can be cost wise to go that way. Certainly, from the patient outcomes point of view, it’s very effective.

Specialists. I kind of think that there would be all sorts of trouble if the patients had a list of specialists and started shopping. I think the referring physician probably knows best who on the list would be…. Everyone is licensed, so they all should be good, right? But some people have more experience with some of them. But I think if there was a list, then it would work better for the…. Maybe the physician’s office assistant could be the one who did this — looked at the list of gastroenterologists and then said: “Oh, this one here has an availability two weeks from now.” That sort of thing I think would be best done in the hands of the referring physician.

Also, I think to make this thing work, there has to be a set of criteria for the consultation so that it wouldn’t be a frivolous consultation. There would have to be…. This patient would have to have this, this and this to justify a consultation — a proper workup, etc. Otherwise, I think it becomes a real scramble. That’s my opinion on that. I think it would work.

I understand Fraser Health has tried that with surgeons. I understand that orthopedic surgery in Victoria here operates in a similar way, although I don’t know an awful lot about it.

Residents, medical students, foreign trained. Gee whiz, I’m not in the College of Physicians and Surgeons, and I’m glad I’m not, because I think it is a real problem.

When I was working at Children’s Hospital, we had a fully qualified Polish doctor who couldn’t work. He was actually a morgue attendant for us for a while until he finally got into the system. After about ten years he became and anaesthetist somewhere in the Prairies.

So we are losing a lot of talent. I don’t know how to fix that, but it needs to be fixed. We aren’t training enough people, in spite of 220 graduates, when you look at how many are going to drop off through retirement. We have to make use of everybody.

I think we also have to look seriously at the Oceanside Heath Centre model of multidisciplinary health care delivery, because that does take the heat off of a lot of physicians. It quite appropriately should. You know, they shouldn’t be doing a lot of stuff that they’re doing, I think. They should be doing the high-end stuff that they’re appropriately trained for, and other people should do the other stuff that they’re trained for.

I’m sure the BCMA or B.C. doctors would probably…. Well, they may or may not disagree with me.

L. Larson (Chair): Thank you. We are just about out of time, but already there are other questions that have hit the table. So very quickly I will allow those two that raised their hands….

M. Stilwell: I just wanted to give some information to the committee about the need for referral to a specialist. The need for referral to a specialist is for billing. It is covered by MSP if you are referred, which, by the way, I think is the appropriate way to go. If you want to go to a specialist without a referral, it’s not covered by MSP, hence specialist clinics operating legally.

You have to follow the money. They system works the way it works because billing and so on is aligned. I agree with you, though. I don’t think the answer is for people to self-select specialists. I’ll just quickly add that when they did this with heart surgeons and published the waiting lists, the people with short waiting lists got fewer patients than the doctors with long waiting lists because patients made a rather intuitive good judgment, or misjudgment, that the guy with the waiting list must be the best.

We do need a better triage and booking system, but I think that unintended consequences can be interesting.

D. Plecas: I notice in your written materials you don’t make reference to physician assistants, and you made reference to that. Some people would say that if we had more physician assistants, with a combination of that and telemedicine, we don’t need more doctors. I’ve talked to some doctors who are pretty convinced about that — without more doctors, more people at less cost and better quality of service than we’re providing now. I just wondered why that isn’t sort of highlighted in your presentation.

J. Dimmick: I don’t think physician assistants are really in the mix in western Canada. That’s why I didn’t think much about it. I think the nurse clinicians, nurse practitioners, are more or less in that role in our areas.

D. Plecas: Although I think there are some issues there with the whole cost and billing structure there.

L. Larson (Chair): I think Jim is right. It’s just that they’re not being trained as part of our system at the current time. We’ve moved on the nurse practitioner, and that’s moving ahead quite nicely, but we have not pulled in that next level, which I’m sure is coming.

T. Davies: Just to answer that question, there are three nurse practitioners at the Oceanside Health Centre.

I do want to comment, too, that often what is causing some consternation is that the doctors at the urgent care, who are on a contract basis, sign up on a sheet, and sometimes there are some shifts missed. It’s really become disconcerting to the community that if you go there between 7:30 and 10:30, you’re almost promised you’ll have a doctor on there, but sometimes there isn’t.

On the doctor recruitment thing, we note things that have happened up in the Revelstoke area, where they
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have no problem recruiting doctors because the community jammed together and said: “Listen, we think we can make this work. We need to provide the incentives.”

That’s where an organization like FORA comes in. We have the organization in place. We are meeting with all the key players, and we’d love to be able to assist in the doctor recruitment thing, no matter what it takes.

You’re absolutely right, sir, that you kind of wonder why people aren’t coming to a beautiful area like Oceanside. Well, I think Jim has explained that.

I’ll tell you one thing that bothers me a little bit. This thing was designed — I’m speaking as a community member — to be a model or a template for other communities within the province or Canada to emulate in some fashion, whether it’s a community that has 5,000 people in it or not. Maybe things can be done here, to try out, that might work in a community with 5,000 or 7,000 people. I don’t know. But I hope that we have this sort of an organization set up, the Oceanside Health Centre, and the potential for that, that we don’t lose sight of providing the resources to do that.

What worries folks around our area is $600 million being spent up in Courtenay and Campbell River, with two new hospitals there, which is great, and $16 million spent in Oceanside. We just don’t want to get lost in the mix there someplace, because we think there are some really wonderful opportunities to do something spectacular here and to serve other areas where they don’t have to reinvent the wheel every time some issue comes up.

J. Darcy (Deputy Chair): Maybe you can send this to us, but I’m just interested to know what the full range is of the multidisciplinary team — what those positions are.

J. Darcy (Deputy Chair): Just on the physician assistant, there’s an issue there of independent practice, right? In the case of physician assistants, they are directly under and accountable to the physician. Nurse practitioners can have more independent practice. I think that’s part of the debate, going forward, in this jurisdiction and in other jurisdictions.

L. Larson (Chair): Thank you, gentlemen. We really appreciate you coming in this morning and telling us what you’re doing. There are some wonderful things there. Hopefully, we can expand on those. We will certainly ask you more questions, as we move forward. Thank you for being here.
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L. Larson (Chair): We’re really privileged this morning to have Isobel Mackenzie here, the seniors advocate. She’s just put out a third report. I know we’ve seen them all. A fourth one is coming.

We’re very pleased that you could be here this morning to talk to us. We’re just sort of venturing into the end-of-life care aspect of health care in British Columbia, and I’m very glad you could be here and share what you have found as you have done your travelling around the province.

We’ll do a quick introduction around the table first, though I’m sure a lot of the people here you have met. Then we’ll have your presentation, and then we’ll go for questions after that.

I. Mackenzie: Isobel Mackenzie. I’m seniors advocate, and with me today from my office is Sara Darling, who is the director of communications in the office.

Okay. For the record, I’m Darryl Plecas. I’m the MLA for Abbotsford South and the Parliamentary Secretary to the Minister of Health Responsible for Seniors.

L. Larson (Chair): We’ll turn the floor over to you, Isobel, and thank you for being here.

I. Mackenzie: Thank you very much — a very kind invitation. I’m particularly heartened to know that you are interested in hearing specifically about seniors, and I think we can all agree that we all hope that end-of-life care is in our senior years. So there is, hopefully, an overlap there.

The first thing I’d like — I’m just going to make sure I’ve got the PowerPoint there, and you have copies of the PowerPoint in front of you — is to talk a little bit about the face of B.C. seniors, because I think context and perspective are important as we look at these issues.

There are 820,000 seniors in B.C., defined as people age 65 and over, which is about 17 percent of our population today. That’s going to grow to be about 25 percent of our population by 2031 — 16 years, so an average annual rate of growth of about 1 percent a year.

I think it’s important to recognize that, while some people may think that’s a tsunami, I view it not as a tsunami but as a continual, gradual increase in our population that will allow us to have thoughtful policies developed, have the time to be able to ensure that the supports and services are there as our population incrementally grows to embrace 25 percent of our population.

I think it’s also important to recognize that there are a number of jurisdictions around the world where they’ve already reached this threshold — and beyond — of 25 percent of their population being over the age of 65. So I think we want to keep some context and perspective there.

You can see the breakdown of the current age cohorts of our seniors. The majority of them are in the 65- to 74-year group where, arguably, we all know there is less intensive utilization of things like residential care, home support, etc. — but starting to creep into the other age cohorts. And 14 percent of the current population is what we would call — what I call from my previous life — the real elderly, which is 85 and over.

Complementing the actual numbers of seniors we have in B.C., I think it’s also important to recognize that the majority of seniors in B.C. are actually living independently and, for the most part, healthy and on their own. They have a number of challenges, not all of which are health care.

Less than 4 percent of our seniors live in residential care. It’s about 3.7 percent. That’s 1.7 percent of them that are age 84 and younger, and 15 percent of the people age 85 and plus live in residential care. So this idea that we’re all headed towards the nursing home is simply not supported by the data, where we see, in fact, that only 15 percent of seniors 85 and older are living in residential care. Complementing that is home care, where you can see that even over the age of 85, only 12½ percent of our seniors are receiving publicly subsidized home care on an ongoing basis.

Twenty percent of our seniors rent, and 80 percent own their own home. That’s important to remember, because 20 percent is a lot of people, and they are subjected to the vagaries of the rental markets and the rising costs. Homeowners are also subjected to some of the costs related to their housing that are rising beyond the ability of their incomes — which, in real terms, are fixed — to be able to keep pace.

Less than 4 percent of seniors in this province receive a housing subsidy. So less than 4 percent of people over the age of 65 are either on SAFER or living in a subsidized rent-geared-to-income house.

Here’s why all of that’s important. The median income of seniors in this province is $24,600 — in fact, I’ve got some more recent data that’s going to notch that down by a few hundred dollars — and 26 percent of seniors live alone. That’s really important context to have because I know that there can often be an image of seniors as having a lot of money and going out and bankrupting the younger generations by their profligate ways in their senior years, subsidized by the rest of us. But that’s simply…. That may be the case for some seniors, but it is certainly not the case for all seniors. I would argue it’s not even the case for the majority of seniors.

The simple math there is that if you take the 26 percent living alone and you spread it evenly over all income distributions, 13 percent of seniors are living alone on $24,000 a year or less. That’s about 106,000 seniors in this province living alone on $24,000 a year or less, and 52,000 of them earn $16,200 or less. That’s what you get with maximum OAS and GIS.

Eleven percent of our seniors are employed. I think that’s actually a good thing. I think that we will continue to see engagement in the workforce as the newer seniors, in the 65-to-70 age group plus, come into their senior years healthier and more engaged and want to continue that engagement. Some choose to sever their ties with paid work and focus on volunteer activity or travelling. Others choose to remain engaged in paid employment. I think that’s important.

This is the Select Standing Committee on Health. Improving health for seniors — how can we do that?

Well, the first thing I would like to talk about is that for seniors, the broader determinants of health are arguably even more important than for the population at large because seniors at certain points along their journey are not wanting to be fixed anymore; they are simply wanting to live. Whereas when we’re 35 or 40 or 45 and we have health ailments, we actually want to be fixed. That’s a different lens through which to view these things.

What is important? You have mentioned how I’ve been travelling about the province. What I heard — I have to say it surprised me. I come from a health care background. We know that when you’re a hammer, every problem is a nail, so I expected to hear about health care, health care, health care. In fact, what I heard was: housing, housing, housing.

Seniors are concerned about housing in urban areas, and particularly for renters. They are concerned about
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the cost of their housing exceeding their ability to continue to pay for those costs. If they are homeowners, costs are an issue, as well as: “Will services be able to come to my home?” In more rural and remote parts of the province, where I know that some of the MLAs around this table are from, in the coastal communities and in the Cariboo, it’s the availability of the appropriate kind of housing for seniors.

So housing is, arguably, the basic foundation upon which we are building all of our home care and health programs. We are assuming people are housed appropriately and affordably, and if they aren’t, then all of the services we’re bringing to them are irrelevant because the foundation is not there. We have to look at that.

Social connectedness. We know that’s an important social determinant of health, but I’ll also talk a little bit about how social connectedness is different for different people. Some people, it’s daily connectedness. For some people it’s weekly connectedness or monthly connectedness. People go through their lives with different degrees of need around their social connectedness. So we shouldn’t presume to know exactly what it is other than for whatever it is for that individual senior, there should be some ability to facilitate that social connectedness. We know it makes a difference — and sufficient income.

Weaving through a number of issues for seniors is the answer: “But for more money, I could,” and the list goes on. For some issues, money is not the issue. Whether it’s the issues of ageism, some of the infirmities of life that are visited upon us in seniors’ years, money can’t fix. Some of the frustrations we have in fragmentation of the system cross all income spectrums.

When we look at, “I’m worried about my housing; I’m worried about transportation….” Certainly, seniors who have significant resources — and there are some out there — it’s not an issue for them. My focus is tending to become more on those 24 percent of seniors who are living alone on low incomes — $24,000 and less. It’s those seniors who are certainly finding some challenges.

Another way we can improve health for seniors is to listen to how they want to live. Again, what health care looks like when you’re 90 is different than when you’re 45. If we actually listen to seniors tell us how it is they want to live, we may find that some of the frustrations in our system are ameliorated.

I know that probably everyone around this table has at least heard of, if not read, this book by surgeon Atul Gawande, Being Mortal. As we all know, there are dozens, if not hundreds, of books out there. I read from this for perspective on this issue that health care can be different for seniors than it is for the general population at large.

There are a couple of stories in here that resonate. One is the gentleman who lived at the foot of Mount St. Helens who was advised that Mount St. Helens was going to erupt. He would be buried in his home, and he would die. He was a veteran and a Prohibition bootlegger, all of these, and had led a very individualistic life in his cabin at the foot of Mount St. Helens.

He had attracted a lot of press attention with his curmudgeonly ways, holding forth in a John Deere cap and a glass of bourbon and Coke in his hand. The police had thought about — and this is important — arresting him for his own good. Okay, that’s important. However, they decided not to, given his age and the bad publicity they’d have to endure.

He got all these warnings, and what he said was: “If I die tomorrow, I’ve had a damn good life. I’ve done everything I could do, and I’ve done everything I wanted to do.” And die he did. Mount St. Helens did erupt, and he was buried. But he died the way he wanted to die, where he wanted to die. We didn’t, for his own good, pull him out of there.

The other story in here that I think illustrates the point is the story of Aunt Alice. It weaves throughout the book around a woman who had lived independently all of her life. She’d been having a few falls. What actually precipitated, ironically, her move into assisted living was being subjected to a fraud scam on the part of people who had done some excessive renovations to, I think it was, her garden or her house. So she goes into this assisted-living facility.

I think that this story resonates with me significantly because it’s the world I came from. I, unfortunately, recognize myself in some of these stories, along with many of my colleagues in these stories. It’s a reminder that we all have some thinking to do to honour what seniors want.

“Alice wasn’t facing a volcano, but she might as well have been. Giving up her home on Greencastle Street meant giving up the life she had built for herself over decades. The things that made Longwood House so much safer and more manageable…were precisely what made it hard for her to endure.

“Her apartment might have been called ‘independent living,’ but it involved the imposition of more structure and supervision than she’d ever had to deal with before. Aides watched over her diet. Nurses monitored her health. They observed her growing unsteadiness and made her use a walker. This was reassuring for Alice’s children, but she didn’t like being nannied or controlled. The regulation of her life only increased with time.

“When the staff become concerned that she was missing doses of her medications, they informed her that unless she kept her medications with the nurses and came down to the station twice a day to take them under direct supervision, she would have to move out of independent living to the nursing home wing.

“For Alice, it must have felt as if she had crossed into an alien land that she would never be allowed to leave. The border guards were friendly and cheerful enough.” That’s me and my people. “They promised her a nice place to live where she’d be well taken care of. But she didn’t really want anyone to take care of her. She just wanted to live a life of her own. And those cheerful border guards had taken her keys and her passport. With her home went her control.”

We don’t do a very good job of health care for the Alices of this world. We do a good job for the people who
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are not like Alice, who actually do crave security and conformity and routine. There are seniors out there who do crave that. There’s DNR, and there’s full code. Both are represented in the population at large, and both are represented in seniors.

There’ll be 95-year-olds who will say, “Shock me; tube me; feed me. I want it all,” and they’re entitled to that. Their health care looks one way. Then there are seniors who don’t want any part of that. Those seniors? We’re not necessarily where we need to be in meeting their needs.

Listening to seniors about how they want to live, I think, is very important in delivering good health care and end-of-life care to seniors — and utilizing the full potential of home care. A lot of seniors…. Again, it’s never a statement of “all seniors.” Many seniors have expressed very clearly: “I want to live at home.” I think — I’m going to show you some data here in a moment — that maybe we’re not doing all that we can, everywhere that we can, in terms of allowing home care to realize its full potential.

The next slide. You can either look at on the screen or there’s a printout of it in your package. There are three columns here. This is seniors who live in residential care. This is their data. These are seniors receiving care in the community under provincial home care program. These are seniors living in assisted living.

This is a sample, not a census data. It’s slightly less reliable. There’s a whole explanation, because it’s how we collect our data on assisted living.

What I want to point out here are the similarities between the populations we are caring for in the community and assisted living, and the populations in residential care.

As you can see, things intuitively make sense. There are more people over the age of 85 in residential care than in home and community care, but there are more people over 85 in assisted living. So age, in and of itself, is not a…. We care for people over the age of 85 — 40 percent of them are over the age of 85 in our home care program.

Diagnosis of Alzheimer’s or other dementia. This is interesting, because there’s this notion out there that everybody in residential care has dementia. They don’t — 61 percent do, but that means 39 percent don’t. That’s another discussion for another day, about how we can care for those 39 percent in the same environment as the 61 percent. But 34 percent of our home care clients have the same diagnosis, and we’re caring for them at home.

Needing to reside in a special, secure dementia unit. This is about wandering and a secure unit within secure, so it’s not applicable in…. It shows you the population in our residential care facilities is 20 percent that fit that profile.

This is as you would expect. This is minor assistance with personal care and the activities of daily living. You would expect to see a lower percent in residential care and a higher percent in home care. These are higher-functioning people. But 33 percent of our people in residential care only have minor assistance required, so there are some questions there.

Moderate to significant. You would expect to see an increase in res care, and that’s what you do see. But 15 percent of our people we’re caring for in the community also have significant needs around their ADL activities and their personal care.

Mild cognitive or memory impairment — 38 percent. This makes sense; 61 percent have Alzheimer’s, and the rest have mild cognitive memory impairment. The threshold is very low for mild cognitive impairment. That’s what we call a CPS score, or a mini-mental exam, of about 25 or less. To put it in perspective, when I took the mini-mental back in June, I scored 27 out of 30, not 30 out of 30.

Eighty-one percent of seniors are living in the community with mild to moderate cognitive impairment.

Moderate to severe. This is now what we would call a CPS score of 3 or greater. This is a mini-mental of probably 18 or less. Twenty percent of our people living in the community have that.

This is the one that’s very interesting: combination of complex conditions indicating high or very high need for facility-level care. Only 82 percent of our residential care population actually fit that criterion, and it could be argued that that should be close to 100 percent, but that’s a different issue. Fifty-three percent of the people we’re caring for in the community fit that definition.

Some of these other ones. Requires wheelchair for indoor mobility — 50 percent of people in residential care primarily use a wheelchair for getting out and about. Eleven percent of our home care population regularly uses a wheelchair — only 5 percent of our assisted living population, however. And we’re certainly looking at that in our report that’s coming out the week of May 20 around what we’re doing and not doing in assisted living.

We know the medication story — too many drugs. And it’s not just in residential care. Half of the people in residential care are on nine or more different meds. Now, I don’t know if anyone around this table ever had past experience with the RAI. This used to be six or more. We used to measure six or more. Now we measure nine or more, so we might want to think about that. But, look, it doesn’t drop much in the community. Forty-four percent of people in the community are on nine or more medications as well.

Then I have been talking about this number on antipsychotics, antidepressants and hypnotic or pain medications, and I particularly want to focus on the antipsychotics and the antidepressants because of the side
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effects that they have. You can see the usage is greater in our facilities than in home care, but we still have a significant population in home care under antidepressants and antipsychotics.

The next slide. What this shows is home support by informal caregiver. This is important because what it shows is that when…. This is the acuity rising — of home care clients. This is only home care clients. Here are all of them, right? Here’s the average right there, the red one. When you push up, they co-reside with a caregiver, and when you push down, there’s no co-residing caregiver.

I think it’s also important to recognize, as we push the boundaries on home care and as we look at the slides I was showing about the acuity that we’re caring for at home, that a co-residing caregiver does influence the degree to which we can care for people at home.

I know that from my own experience as well. When you are providing four home care visits a day to somebody because of their…. They are often…. They need a co-residing caregiver — certainly for issues around wandering and dementia. But not all of them have a co-residing caregiver.

What I think is also important to recognize — this was a surprise to me, because it did not match what I thought I observed in my previous life — is that only 25 percent of the time is the co-residing caregiver a spouse. Twenty percent of the time it’s somebody else. What this says it that there’s a co-residing caregiver 45 percent of the time. Of that, 25 percent of the time it’s the spouse, and 20 percent of the time it’s not. That will be, for the most part, sons and daughters.

That’s important to remember when we look at the kinds of support that we give to caregivers to continue to care for these people at home. You hear a lot about caregiver burnout, and it’s a genuine concern. Also, it needs to be a genuine concern to policy-makers because if these people tool down because they’re exhausted, there’s no place else for these folks to go but into residential care. So we really have to think about that.

This is it with dementia. When there’s a diagnosis of dementia, it just goes up exponentially from what we saw on the other slide, and that’s as you would expect.

A high degree of physical frailty. We would have clients for whom we would be doing four visits a day, and the client would not move in the home until we came to reposition them, but they had full cognitive function, so they knew when to call for help.

You can accommodate that degree of frailty in the home without a co-residing caregiver, but once you have lack of cognitive function, you need a co-residing caregiver, and that’s what that….

Can we do better? Yes, we can. I’m just going to highlight a little pilot project that I was part of here in the south Island with the Vancouver Island Health Authority, which was a provincewide initiative that many of you…. It had different names — Home is Best, home-first. We called it home-first here in the south Island. The theory behind home-first was that the alternative level of care population sitting in hospitals awaiting placement could be returned to home while they waited, with intensified supports.

I like to talk about this, because it shows what we can do when we focus on it and when we make it a priority. This was a pilot project. It had significant resources put toward it. What we were able to do was, for want of a better term, throw the kitchen sink at the client in terms of the supports that would be offered at home.

The results. Here’s what happened. This was over a two-year period from 2012 to 2014. There were 707 admits from acute care, so this is people who have been assessed and are awaiting placement for residential care. This number could have been much higher, but anybody who participated in this program did so voluntarily.

I think we are going to have to acknowledge, sometimes, the impact that family members have in wanting to have Mom or Dad go into residential care — again, because it’s safe. Don’t forget. It was comforting to Alice’s children to know that she was being medicated appropriately and all of those other things. We certainly saw that a bit in this.

So it’s 707 people. It’s still a fairly good sample. Only 28 percent of these 707 people proceeded to residential care as planned. That’s important. So 31 percent remained at home with home care after three months, and that was the plan — that they would remain at home. Ultimately, if we had followed it out further, they may have had at some point needed to go to residential care. But we had, at a minimum, delayed it.

The reason that we were able to do that was because we increased the number of home support hours. We didn’t look at an artificial cap. Arguably, it would not be sustainable in the long term. But sometimes what we who have worked in home care know is that you can need a lot of supports for a short period of time and then you can stabilize and those supports can be pulled back. Sometimes there’s a fear that we can’t sustain 24-hour home support ongoing, but we may only need it for three weeks, and then we can start to get it manageable. Over the long run, it is more cost-effective.

The first thing was, the home support hours were, for want of a better term, liberated to focus on this population. It was an interdisciplinary team that included a physician, nurse practitioner, OT/PT, as well as nurses. If the client needed a raised toilet seat, if they need a Sask-a-Pole, if they need grab bars, there was a team to make sure that that was done fast and that the home was ready to receive them.

I think there’s a lot of merit in continuing to look at this program and somehow getting the culture and the philosophy of this program to better bridge over all of acute care seniors’ admissions.
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In summary, what do we need to do to improve the health status and the end-of-life care for our seniors? More supports for low-income seniors. I want to clarify that that’s a distinct population. Not all seniors are low income, but those who are have got some genuine problems out there.

Focus on home care through the seniors’ lens of risk tolerance. Oftentimes we default to safety. If a senior is competent to make decisions, they are competent to know what kind of risk they want to assume, and we should support that.

All too often what we do is we tell them that it’s not safe for them to be at home because they have stairs or they’re at the foot of a mountain. What we do is we don’t commit them to residential care, but we pull back our home care. That’s how we do it. I think we need to accept that they have a right to live in a way that they want to, even if it’s not what we as health care providers think is the optimal, safe way to live.

Residential care that focuses on living not curing. We do have a lot of work to do there. People don’t go to residential care to get fixed; they go to live. You go to the hospital to get fixed, and then you get sent home. What has happened is that most of our training is focused on fixing people, so we don’t quite know what to do when they don’t want to be fixed and they just want to live.

When you’re 45, you want to be fixed. But when you’re 95, perhaps you want to live. Perhaps you do want to be fixed. I think that that is something that is behind a lot of our drug usage. I think, if we were really honest, the physician and the clinical community would admit that we’re giving a lot of drugs to fix problems rather than acknowledge that there are infirmities of aging, that people have a decision and a choice to make.

One of the things in the survey that I’m doing of all residential care facilities is that we’re going to be asking residents about the involvement they have in their decisions around their medications. When you’re in acute care, we have a system in place where we will advise you what the medication is that we’re providing for you before you take it. We don’t do that in residential care. We make a lot of decisions for people.

We need to focus residential care on living not curing. Health care for seniors needs to recognize seniors’ right to choose. One choice is: “I don’t want health care.” We need to do a better job of recognizing that. I think the care community is part of that problem, and the family community is another part. We all want our mom or dad to live, and some of us will tenaciously cling to whatever part of Mom or Dad we can, even if that’s not what they want.

What we’ve been doing this morning, Isobel, is we’ve been…. Hopefully you have a pencil or pen — you did fairly well on the score — so if you can’t remember the questions that are being asked around the table…. What we did is have each of the members here at the table pose their question that was the most important one to them, rather than ten different questions, and then let you respond to them.

There are probably some similarities in some of the questions that’ll be asked. That way it’s a little bit easier rather than you repeating yourself over and over again. If that’s okay with you, we’ll just start and go around the table and let people put their first thought or first question on the table and rely on you and your help there to keep track. All right?

B. Routley: One of the first issues that you raised is that there are other jurisdictions where they’re already there in terms of facing the growing number of seniors. I wondered if you could talk about some of those jurisdictions and their experiences — like, how advanced they may or may not be in terms of dealing with seniors and aging.

I. Mackenzie: Certainly. Japan already has more than 25 percent of its population over the age of 65, as do some of the European countries. I think, in looking to the European countries, what we find is that they don’t default to residential care to the degree that we do, I would argue, in North America in general and in Canada. There is a much better job done of supporting people to live at home.

Now, there are some circumstances in Europe. Things like concentrations of population make things much easier, and you see more of that in Europe. Expectations are different in Europe than they are in North America, to some extent. But certainly, what we see is that the solution is supporting the aging at home versus some magical redesign of residential care.

L. Larson (Chair): Yes, thank you. I’ll ask you: don’t answer them. Just remember what they’ve asked you, and don’t answer them.

L. Larson (Chair): Not that I’m being rude to them, but don’t answer them. Just take note of what they’re asking, and then we’ll get you to answer everything at once.

J. Rice: Actually, I don’t want to argue with the method, but it would be great if she could answer some, because that’s a lot to remember.

J. Rice: Okay. If there’s time, I actually have three. The chart on page 3 — when we were talking about the residents in care that have dementia cohabitating with those that don’t and how that works. I would love to learn more about that. I used to work in long-term care, and that was a challenge that we experienced all the time. I would love to know your ideas on going forward and how that happens.

Two, I was curious about the percentage of people receiving antipsychotic medications and antidepressant medications, 33 percent and 45 percent. Are there studies that show, for these residents in long-term care or residential care, what percentage of them were on those types of medications before they ever became a resident or before they were even a senior? I’d be really curious to know that.

Then, lastly, the chart “B.C. home support.” I did not understand the explanation. I don’t understand what this is telling me. If you could just summarize that for me. It’s not that you didn’t do a good job of it. I noticed everyone else understood. I just didn’t get it.

S. Hammell: I think my question lies around…. Similar to Jen’s, so she doesn’t need to feel she’s the only one. It seems to me this chart signals to us that things are not quite right in terms of the assignment of people to either residential assisted living or community care and that there should be some other way of assessing whether this person needs to be in one place versus the other. I’m just asking if that sense is correct.

J. Darcy (Deputy Chair): A couple of things. In your report that you released a few weeks ago, you talked about — 1,500, I think, was the low end; 4,400 was the high end — people in residential care who don’t necessarily need to be there — at the low level of dementia or functionality and so on. This is probably too big for today, but what do we need to do in order to have people not in residential care who don’t need to be?

One piece you didn’t touch on today but that I was very interested in, from your report, and that hasn’t gotten a lot of attention, as much attention as the overmedicating and so on, is the issue of rehab. A lot of what’s been written, including by the author you referred to and one we talked about last week….

Dr. Sloan is very much about us medicalizing end of life, medicalizing seniors care — overmedicalizing it, if that’s a proper term — when what matters most to people, to a lot of seniors, are function and comfort. That piece about rehab, including physio, occupational therapy and so on, is obviously really critical to function and comfort. We have a long way to go in that department.

D. Barnett: Thank you for your presentation. I am a senior, so I can sit back and listen and have a few comments. I think one thing that really and truly you’ve hit the nail on is that we do not listen to seniors. We tell them what they want, and we don’t listen. I’ve been engaged with the seniors in my community, in some of their meetings and things. It’s very heartwarming to me to see that you, as the advocate, have got it. We don’t listen.

One of the other issues that seniors do face in rural communities is transportation. I don’t know how we solve that issue. We have a huge amount of widows and widowers in rural British Columbia. They have money, but they have no transportation. They live in huge houses, and they can’t make a decision about where they should go or what they should do.

If you talk to them, they don’t want an answer. They want someone to help them figure out: “How do I get from point A to point B?” That’s a big issue in rural British Columbia. If you could solve that, you’d be great.

D. Bing: You probably don’t know, but I’ve been a dentist for 36 years. One part of health care that isn’t really addressed with our medical system is dental care. I wondered if you’re hearing complaints about the lack of dental care for seniors or the ability for them to access care.

R. Lee: I think in the beginning you mentioned that the senior population would be increased 1 percent a year, yet I think now it is 17 percent. So 2031 would be 24 percent. Can you clarify the percentage of increase of seniors in our population?

That question is related…. On seniors in residential care, you mentioned 82 percent are there. The other 18 percent shouldn’t be there, probably should not be in that category. What happened, actually? Is it the family’s decision, the patient’s decision, or does the system somehow allocate them to residential care? I think I want to hear more about it.

My question would be around the whole matter of your statement about median income being $24,000. I think it would be helpful to have a further breakdown on that. Are we talking median income for individuals or couples? You could say: “Well, if you take into account these couples, we’re really talking about $48,000.”

Then, how many of those people…? What is the income situation for people living alone? I could also envision my older in-laws living with me. If it was the case it was $24,000 or less, they have no expenses, because they’re living with me. So it just seems it would be helpful, because I know how concerned you are about affordability, to really have it drilled down so that we could say: “Well, just how many people are we really talking who
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are in a situation where they can’t afford the housing and other costs that they need to live as they should be?”

M. Stilwell: Thank you very much for your presentation. Certainly, the concern about housing is what I hear almost overwhelmingly in my constituency, which is being rapidly densified. I also have very elderly, so I’m hearing from people who are over 85, renting and can see that they’re not going to be able to stay.

There are always these kind of key events. For example, if you’re over 80 — you would know this — and you break your hip, your fatality rate in the next year is 20 percent, and your chance of having to go into assisted living is 80 percent in the next year. So there are these definable events.

I am wondering if there is data. It seems to me that to become…. For an over-85-year-old to navigate finding housing…. And in all likelihood for the people who come to see me, they are going to be vastly displaced from where they’ve lived for up to 85 years. To re-find community and supports and so on is so unlikely. It seems to me that that is likely a key event.

I’m wondering if you have data that shows that that kind of event…. I would think it would be linked with higher fatality and high probability that you would have to go into assisted living, that you just simply could not navigate those changes on your own.

I’m wondering if you have specific data about that. We know about rising homelessness and the concerns, but I’m wondering if we actually are seeing that this is a small population that, if we could bridge them, would be well worth it.

L. Larson (Chair): Thanks. I just wanted to ask a couple of very quick ones here too.

The pilot project that was done — I don’t see any figures here about the actual costs associated with having that team keep somebody at home versus the cost of them being in a facility. As you said, it was quite a lot of people involved in keeping that person out of the facility, so I’m wondering whether there was a significant difference or not at that level of home care.

The other is the fact that there are…. We do need more home care. How short are we in that area? Are we even beginning to train the people we need? Are we short 1,000 or 10,000? I mean, how many people are we short to actually do that home care at home so that that senior can make that choice and say, “I want to stay here, but I do need somebody to come in and help me with my bath” or whatever it might be? I’d like to know how many we’re short in order to actually be effective at doing home care, right?

We haven’t given you very much time to answer, but we’ll go for ten minutes or so and let you answer what you can. Then we’ll just ask that you…. Perhaps you could send us the information through staff here if we don’t get through what’s been asked so far.

I. Mackenzie: I’ll just try to go through, and I’ll give a cursory answer. Then people can talk to me after.

Cohabiting with dementia and non-dementia. Certainly, I’ve got a housing report coming out that’ll touch on this a little bit, but there will be other reports in the future. It is a challenge. It’s the consequence of going to one level of care, complex care. Those of us can remember before that. There are pockets of excellence where we are caring for dementia populations specifically, but it is a challenge, and we need to do better. We’re going to be looking at that.

The percentage on medications before coming into residential care. The best we can do is if you look at the RAI data, you can see the percentages on antipsychotics and antidepressants who are on the home care program and in assisted living versus in residential care. That’s the best proxy we can give. It’s not very good, because there’ll be a population in home care that are at a very high level of function. But you can see that there is a higher use.

On the home support only chart. Maybe after the meeting I can go over it with you and explain it to you. I think that’ll be easier.

The assessments of home care and residential care. We have identified that in a report, our third report, that we put out, and we’re going to be further talking about that in our housing report that is coming out in late May. We did take a population from home care. We overlaid it on our residential care population. We compared it to two other provinces. What came forward was, as Deputy Chair Darcy has said, that anywhere from 5 percent to 15 percent of people in residential care arguably shouldn’t be there.

The assessment that’s used is the RAI assessment. It’s an internationally used assessment tool with inter-rater reliability. It’s the score that you allow people in with, rather than the tool you’re using to assess them.

We think, and we’re going to be talking about it in the housing report, that part of it is that the assisted-living system we have in the province, under its current regulatory regime and the two prescribed services, is frustrating the ability for some people who could live in the more independent kind of environment of assisted living. We think that in certain parts of the province, particularly in more rural and remote parts, the home support program, the home care program, is not as robust as it should be, and that’s causing people to go in.

Then if we look, for example, at Vancouver Coastal, we find an even higher percentage of folks in residential care who arguably don’t meet the RAI score for admission. We think what is happening is it’s a substitute housing place for people who have mental health and addictions issues who could be housed differently, but residential care is
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where they go. We think that that’s what’s happening in our residential care around the people who could live elsewhere and not be there. That’s the assessment.

The rehab. Certainly, we’ve identified that we’re not doing as good a job not only as we should be doing but compared to other provinces, which I think was a surprise to some people, including myself. I actually knew we weren’t doing as well as we should, but I thought there was greater parity, actually — we were doing equally bad across jurisdictions.

You can’t argue that it’s because our population in residential care is more acute than in the other jurisdictions, because the opposite is actually the case. We just need to, I think, have a greater commitment to it.

The skill mix and the training is part of the issue. Physiotherapists are now master’s-prepared out of the school of rehab medicine. It takes a long time. I think we’ve got about 35 seats in this province for physiotherapists.

We may need to re-examine the role of the physiotherapist versus the recreational therapist along the lines of the RN, LPN and care aide model. We haven’t really done that yet in physiotherapy, and we need to. And recreational therapy — we need to value it more. Every resident should be getting rec therapy every day. That’s your engagement, that’s your connectedness, and that addresses this issue of feeling alone even though you might have three roommates in residential care.

Transportation: it’s certainly an issue. I have to say it was eye-opening for me to travel to rural parts of British Columbia. I joke about how I thought TAP was a form of dance, and then I got out and found out about this travel assistance program.

It is a challenge for people on low incomes around some of the costs that aren’t covered — some of the unintended consequences of decisions made over here to save money on ferry routes, resulting in three-night stays instead of two-night stays for people from some coastal communities. An unintended consequence, right? Maybe there’s a way to fix that that’s not about going back on the whole ferry thing.

The transportation within, the kind that you are talking about, is very, very challenging, because it is not clear that there is a fix — that people aren’t looking for the proverbial item that’s not on the menu. I think seniors also have to acknowledge that there are choices to make. I think that, from my perspective, we want to make sure that there is a place that they can move to within their community if they are required to move in order to deal with the transportation issues.

I actually use the Cariboo as an example of the person who’s on the ranch 100 kilometres from everybody and may have some choices to make if and when they lose the ability to drive, but that choice should include being able to find accommodation in the town that is their community, where they would go for their groceries, where their children went to school. They shouldn’t have to go beyond that to where they have no friends. That’s more the focus around transportation.

Dental care is very important. My office is, in fact, beginning to examine this whole issue. It’s a suite of services, auxiliary health care, if you want to call it. It’s dental care, it’s vision, it’s hearing aids, and it’s mobility aids. For our low-income seniors in this province, there is no program to cover them.

We did a survey. Our second report highlighted a lot of things, including that 65 percent of seniors with household incomes of $30,000 or less have no benefit program to cover eyeglasses, dental care, medical-only benefits. If you are a senior who has…. Ironically, if you have been a person with disability on income assistance or been a persistent-barrier-to-employment income assistance recipient and you turn 65, you actually have that coverage. But if you have been working all your life and you turn 65, you get the average CPP payment of $500-some-odd and you get your OAS, so your income’s about $18,000 a year. You get nothing.

We’re looking at a way to…. You don’t get any help with your eyeglasses. You don’t get any help with your dental care, etc. It is a problem. You know that, right? The cheap solution is to pull the tooth. That presents some other challenges in our aging population. Dental care is important.

The data linking fatalities with changes…. The short answer is: I don’t have the kind of data specifically that you’re speaking of. There are data out there that talk about moves and the fatality that moves…. There’s a study going on right now, I think, with the new seniors Carey Road site here in Victoria. Somebody’s studying how shortly after the move people are dying versus….

I think it is not unreasonable. It’s a question around these renovictions in Vancouver. We know all the money in the world isn’t going to solve the problem for the 90-year-old. They’re not going to move into another apartment, and we know where that’s going.

The question around incomes. It’s difficult to get the exact number that we want to get. We have to pull from a variety of different sources.

So what do we know? We know the median, and that’s income. That’s personal income. We know that 50 percent of seniors are living on $24,000 or less as their own individual income. We know that 24 percent of seniors living in private households…. This takes out the 7 percent that are living in residential care or assisted living. We know that 24 percent of those people are living on their own. We don’t know what the income is of the 24 percent of people living on their own.

If you take a rational approach of distributing that over the income spectrum, you would then say that 13 percent of the people on $24,000 a year or less are living
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alone — one way to slice that. That would give you approximately…. I think it’s about 103,000 people over the age of 65 are living, one, alone and secondly, on $24,000 a year or less.

We know there are approximately 52,000 seniors who are living on maximum OAS and GIS, and we know that because those seniors are in receipt of the seniors supplement, which is a provincial entitlement of about $50 a month. You only get that if you’re very low income.

The last time I checked there were about 52,000 seniors getting the seniors supplement. That gave us the number living…. What we don’t know, and I will go back and try to…. Of those 52,000 seniors in receipt of the seniors supplement: how many of them were living alone? I believe household income does factor into it, but I will determine whether that’s true or not.

I think it is true that there are a number of seniors for whom income is not the significant challenge, but for those seniors for whom it is a challenge, it is very significant. We have to remember that seniors are not active participants in the labour force. Their incomes will not rise in real terms. So a lot of the costs…. You’ll see this in our housing report. When we’re putting forward a lot of the costs related to housing, they actually exceed the rate of inflation, so they’re increasing beyond the ability and the income of seniors to keep pace.

Certainly, with regard to rental incomes, they’re increasing, we know, at rate of inflation plus 2 percent — which is the rate increase allowed. So it’s at least…. I think what is happening, although this is intuitive not evidence based, is that it’s starting to catch up. When your rent increases start out, it’s compounding and compounding. For the first four or five years you don’t feel it, because your OAS and your CPP are keeping up in real terms, but now your rent is actually increasing beyond the increases you’re getting from your fixed income. And it’s cumulative, so it doesn’t happen in year 1. I think that’s what you’re seeing.

Certainly, that is a big concern in the Lower Mainland. And in the housing report there will be some very clear, I think, evidence of real need amongst some seniors.

L. Larson (Chair): Thank you, Isobel. We didn’t get to my question, but that’s okay. I can get that information from you about how the pilot did dollar-wise. We do need to wrap up. We have members here that have to be at other functions at 12 o’clock.

Thank you so much for being here this morning. We certainly can contact you through your office if we have follow-up questions, and we really appreciate your time.

L. Larson (Chair): Adjournment has been moved by Donna. Seconded — thank you, Darryl.

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Chair:	Linda Larson (Boundary-Similkameen BC Liberal)
Deputy Chair:	Judy Darcy (New Westminster NDP)
Members:	Donna Barnett (Cariboo-Chilcotin BC Liberal)
	Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	Sue Hammell (Surrey–Green Timbers NDP)
	Richard T. Lee (Burnaby North BC Liberal)
	Dr. Darryl Plecas (Abbotsford South BC Liberal)
	Jennifer Rice (North Coast NDP)
	Bill Routley (Cowichan Valley NDP)
	Dr. Moira Stilwell (Vancouver-Langara BC Liberal)
Clerk:	Susan Sourial

2) Federation of Oceanside Residents’ Associations (FORA)	Dr. Jim Dimmick
	Tom Davies

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH