The system is broken – here’s how to fix it

"Most doctors don’t feel comfortable talking about death. They don’t like giving out bad news and they may or may not have the communication skills. We go to school to learn to become a doctor or a surgeon. We don’t go to school to learn how to communicate.”   – Peter Zalan, President,  Medical Staff, Health Sciences North

“Most doctors don’t feel comfortable talking about death. They don’t like giving out bad news and they may or may not have the communication skills. We go to school to learn to become a doctor or a surgeon. We don’t go to school to learn how to communicate.”
– Peter Zalan, President, Medical Staff, Health Sciences North

Dr. Peter Zalan, president of the medical staff at Health Sciences North in Sudbury, has a reputation for speaking and writing bluntly about the perilous state of the health-care system.

Through January and February, he notes, there were more than 100 alternate level of care patients occupying beds at Health Sciences North and the occupancy level hovered around 116 per cent with as many as 35 patients in hallways, lounges and on stretchers in the emergency room.

The provincial government is already spending $52 billion a year on health care and has been warned by the Financial Accountability Office that it will have to cut $2.8 billion of health-care spending in order to honour its pledge to eliminate the deficit by 2018.

Of the $52 billion, 25 per cent is spent in the last year of life.

“We have the wrong model of medicine,” Zalan maintains. “It was designed in the 60s when socialized medicine came along and we were a young society. Now, we’re an aging society.”

The solution, according to Zalan, lies in advanced care planning.

Participating in an advance care planning exercise is especially valuable “when you’re on the edge and your life has become difficult,” he said. “You may be short of breath walking to the bathroom because your lungs are giving out or because you have congestive heart failure. You’re still managing, but it’s getting more difficult, or you’re getting frail, your strength is failing and you have a tendency to fall down and break things. On top of that, all of a sudden, you get an acute illness, whether it’s pneumonia, another bout of heart failure or cancer. There’s a lesion and the surgeon says, ‘I can cut that out.’”

It’s at that point that an advance care plan is important because the decision about surgery should be made in the context of the patient’s overall health – not just in reference to the lesion, according to Zalan. The surgery may be successful, but at what cost to the patient’s overall health?

An advanced care plan takes into consideration the mental and physical state of patients, their support network, home environment and preferences relating to medical interventions. It’s a long and intimate discussion best conducted by someone with advanced communication skills, he says.

“Doctors are not equipped to have that conversation. Most doctors don’t feel comfortable talking about death. They don’t like giving out bad news and they may or may not have the communication skills. We go to school to learn to become a doctor or a surgeon. We don’t go to school to learn how to communicate.

“These kinds of conversations also take time and the fee schedule is set up to do rapid piecework. If you see 10 patients instead of one patient, you make 10 times the money.”

Zalan is confident that doctors would welcome the opportunity to review a patient’s advance care plan if someone else did it.

“They would know how frail a patient is, what their home situation is and what their mental state is because, otherwise, all the doctor knows is that the patient has cancer. He doesn’t know about the patient’s five co-morbidities. If he saw an advance care plan that advised against surgery, that would be fine because surgeons are not short of work.

“Most doctors don’t have the time to go through all this, so if someone did all this work for them, all they would have to do is read the report, sit down with the patient and come to a decision.”

Zalan persuaded Health Sciences North to launch an advance care planning pilot program for patients over the age of 85 on 8 North, a cardiology floor, but the financially strapped hospital provided no dedicated funding or resources.

Nurses working in the unit were tasked with having the conversations with patients, but “some of them feel this is an extra duty we’re giving them and they’re already busy,” said Zalan. “I can totally see their point. Ultimately, what we really want to do is move this to the community where it should be happening.”

Zalan has also lobbied the North East LHIN to support advance care planning, but without success so far.

“I think it’s the right thing to do for patients because if you don’t tell them how sick they are, it’s not really an informed choice they’re making,” he said. “Secondly, we’re spending all these resources on (interventions) that have no value and we’re short of money. Plus, we’re torturing people. Having been an intensive care doctor, I know you only want to torture people if there’s going to be a lasting benefit, as opposed to torturing them and then have them die or end up in a nursing home.”

As bad as it is now, it’s just going to get worse because of continuing advances in technology, warns Zalan.

“When I graduated from medical school, we prescribed oxygen, morphine and bed rest for patients who had heart attacks. That’s cheap, plus a lot of people died, and when they died, they didn’t cost the health care system any more money. Now, we have stents and cardiac surgery and replacement of aortic valves. The cost of all these things is amazing, plus you don’t die, which means you get to come back. This is in the space of 40 years, so what will we see in the next 40 years? It’s going to be an increasing problem and I don’t think anyone has dealt with it well.”

There’s another more drastic solution – a government-funded basket of services with unfunded interventions covered by patients, “but I don’t think we’re ready for that – not until things really fall apart,” said Zalan.

If advanced care planning is properly funded and enters the mainstream of health care, we will also have to get serious about increasing access to palliative care, urged Zalan.

“Once a patient makes a decision to forgo aggressive therapy, we have to relieve the symptoms and make the dying process as comfortable as possible. It’s shocking that 70 per cent of people don’t have access to palliative care.

“A lot of the demand for medical assistance in dying is because of inadequate palliative care services. If people knew that their distress was going to be relieved at the end of life, a lot of them wouldn’t care too much about it.

“I think it’s quite cynical of government to provide medically assisted dying, but not provide palliative care.”

As Zalan noted in one of his most recent columns in Northern Life, Sudbury’s community newspaper, implementation of the necessary solutions “will require political courage and leadership.”

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