Canada needs equitable, earlier access to palliative care

We commend Downar and colleagues for their research on early experiences of medical assistance in dying (MAiD) in Ontario.¹ However, we have to question their interpretation that people are not requesting MAiD owing to lack of access to palliative care, because of the inadequacies of their data.

As clinicians, we find that palliative care is often consulted at the time of a MAiD request. The study does not show how the authors determined that a patient received palliative care, nor how long before the MAiD request that palliative care was initiated. The authors use an Ontario study² to compare data on palliative care access in MAiD recipients and interpreted its data, which showed access by 74.4% of MAiD recipients versus the other study’s 47%, as evidence that MAiD requests did not result from lack of access to palliative care. A 2017 Ontario study³ found that 38.8% of patients had their first palliative care access in the last month before death, and 12.0% in the second month before death. This study concluded there is a large variation in the intensity and timing of care, with many receiving little care, and a substantial proportion of care initiated and delivered close to death. This conclusion is supported by a 2018 Canadian Institute for Health Information study⁴ that showed most palliative care services were received only in the last month of life, and that more than 80% receiving palliative care in hospital were admitted through emergency, demonstrating that palliative care is not accessed early or systematically in Canada. The same study examined 349 records of MAiD in hospital between June 2016 and March 2016 and found 70% were identified as palliative on their last hospital admission, where they received MAiD.

Previous research^5,6 has illustrated that individuals with months of high levels of disease burden (physical, emotional and spiritual or existential distress) and the convergence of certain psychosocial factors leads to depression and hopelessness, and ultimately to a desire for hastened death. Providing palliative care to those who have already been suffering for months and thus end up distressed and suffering enough to request hastened death is most often providing palliative care too late. This is not even to mention the substantial minority of 22.8% of MAiD recipients in the study by Downar and colleagues¹ who apparently had no palliative care involvement whatsoever at any time before medically assisted death.

We find that the suggested conclusion, from less-than-transparent data, is unsupported and more of a political statement than research.

There remains a well-known^4,7–9 need for earlier, equitable access to palliative care for all Canadians with a serious illness.