Canadians spend more on end-of-life care than other high-income countries, including the United States, yet we achieve poor results compared to most. There are structural factors and inefficiencies within our healthcare system that facilitate unhelpful and unwanted medical interventions at the end of life. In this Commentary, we review these factors and suggest several structural changes to address the high costs for healthcare and low satisfaction for patients.A major avenue to cost saving is greater use of palliative care, rather than more costly acute care, in end-of life treatment. Palliative care primarily focuses on improving comfort and quality of life, often avoiding hospital-based, invasive, costly and potentially inappropriate care. Palliative care is preferably (but not always) delivered outside of acutecare settings, including in patients’ homes. People approaching the end of life (EOL) often require an intensification of healthcare services, and at least three in four would potentially benefit from palliative care prior to death.Yet, only one in five Ontarians, for example, receives a physician home visit or palliative homecare in their last year of life, and only half receive palliative care in any setting. Instead, most Canadians facing their end of life receive acute care without a palliative focus. As a result, the cost of healthcare delivery increases significantly in the final months of life and does so in particular for hospital admissions and emergency room visits.Several structural problems exacerbate the situation and need to be addressed. They include:(i) Inadequate EOL beds and options. There are limited options for patients who require support as they near the end of life. In-patient palliative-care units and residential hospice beds may be appropriate for people with significant symptom control and supportive needs, but there are so few such beds available that admission is usually restricted to people in the final weeks of life.(ii) Siloing of budgets. Canadian healthcare budgets are siloed by sector. Acute-care beds are substantially more expensive than hospice or in-patient palliative-care beds, long-term care (LTC) beds or homecare. If budgets were global, then we would find efficiencies by increasing capacity in lower-cost settings to reduce backlogs in higher-cost settings. But since each sector or organization manages its own budget, it is more difficult to enact decisions that increase costs in one sector that will ultimately reduce costs by a larger amount in another sector.(iii) Lack of timely prompts to transition to a palliative approach. Since our healthcare system all too often uses acute-care options by default, patients must transition to a palliative approach early enough to experience the benefits of this approach and avoid EOL visits to the emergency room, hospital and the intensive care unit.(iv) Barriers to home and community-care resources. There are some notable barriers to increasing the use of homecare for patients nearing the end of life. These barriers cannot be overcome by increasing the number of available caregiver hours.If implemented, the structural changes we recommend could result in substantial improvement in end-of-life care and potentially save hundreds of millions of dollars annually for the Canadian healthcare system
