Palliative Care in Canada — Dr. Naheed Dosani

Avis Favaro

It's a subject we don't like to talk about, but death is a fact of life. Over 320,000 Canadians die each year. And as our population ages, there's a growing need for palliative care, designed to ease suffering at the end of life.

The Canadian Institute for Health Information has now published its second report on palliative care.

The good news, more Canadians are getting some form of end-of-life care than they were five years ago, and more are dying at home, their preferred choice. But there are also signs that many who need palliative care aren't or can't get it because of who they are or where they live. And that troubles our guest today, Dr. Naheed Dosani.

Dr. Naheed Dosani

I'm here to tell you and tell listeners that absolutely every Canadian should have access to palliative care, because palliative care is the right thing to do.

Avis Favaro

Dr. Dosani is a palliative care specialist who works at St. Michael's Hospital at Unity Health Toronto, and who also set up the first Canadian palliative care service for the homeless, called PEACH. He's also medical director at Kensington Hospice in Toronto, where we were allowed to meet some of the patients and their families, and they talk about what good palliative care means to them.

Mark

Without palliative care, the answer is simple. Mom would have been hospitalized and would have died in hospital a long time ago.

Avis Favaro

Hello and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I'm Avis Favaro, the host of this conversation. A note: The opinions expressed here don't necessarily reflect those of CIHI, but this is a free and open discussion, and this episode is about CIHI's report on access to palliative care in Canada.

Welcome to the podcast, Dr. Dosani.

Dr. Naheed Dosani

Thank you so much for having me on, Avis.

Avis Favaro

So, let's start with the fact that you are one of a few doctors in Canada who have basically dedicated your life to palliative care. What was the interest in this area? Was there an event or a case that triggered your interest?

Dr. Naheed Dosani

Exactly. There was a case that I was dealing with when I was a resident at the University of Toronto working at a local men's shelter. He was a man in his early thirties. He widespread had a neck cancer, and he was shaking, he was writhing, he was curled into a ball. And as I examined his mouth, I could see what was causing him distress. It was this cancer that started at the base of his tongue and spread throughout his head and his neck. And he was experiencing significant pain.

I learned that he was actually diagnosed with cancer one year before and due to an unfortunate sequence of events with his mental illness, he wasn't able to follow up for care. So the tumour grew. He started to experience pain. He went hospital to hospital seeking the kind of pain control that any person should have access to. He wasn't given pain medicines. And so he found himself in our care in crisis.

I got to work the next day and I couldn't find him anywhere. Terry had died overnight, and his body was found in the early hours of the morning. He had overdosed on a combination of alcohol and street drugs.

To me, this was a very traumatic event in my training to see that, in a world-class city like Toronto, where we have world-class health care, that someone like this could fall through the cracks. And I guess that really launched me into this passion for health equity and access to palliative care as a human right.

Avis Favaro

Do Canadians, all Canadians, have a right to palliative care?

Dr. Naheed Dosani

I'm here to tell you and tell listeners that absolutely every Canadian should have access to palliative care because palliative care is the right thing to do. It provides appropriate medical care, pain and symptom management, emotional and psychological support, for people at a time when they're most vulnerable, dealing with serious life-limiting illnesses.

But it also provides support for caregivers and families during a difficult time. And it actually makes sense from a cost-effectiveness perspective, from providing care to the right person at the right place at the right time, it's actually an efficient model of care.

And so yeah, it is something that every Canadian should have access to. But unfortunately, we're not quite there yet.

Avis Favaro

And that's why we're here today, to talk about this CIHI report. So it's the second report that CIHI has done. And we've learned that data is critical to understanding what's being delivered: are you improving; are you losing ground. So let's talk a little bit about the report and where are we, based on what you saw.

Dr. Naheed Dosani

Yeah. So it's not every day that we get access to the kind of picture that is being provided in this report and the kind of picture that is actually a national coast-to-coast perspective of how we're doing as it pertains to palliative care.

In 2018, the government of Canada released a framework on palliative care in Canada, establishing what is supposed to be the blueprint, our goals and our hopes for what palliative care will deliver.

Avis Favaro

So let's break it down. The good news is that compared to the last report, there are more Canadians getting palliative care. It went from up 6% from 5 years earlier to sort of national average of 58%. What's your reaction to that increase?

Dr. Naheed Dosani

You know, some people might say that 6% is not a lot. And I'm here to say that, actually, in the world of palliative care, it is a lot. And so actually, this is a fantastic achievement that needs to be celebrated. We certainly have a long way to go, but it's something that needs to be celebrated at this point in time for sure.

Avis Favaro

But it does suggest that when you look at the data, it goes from as high as 59% in Ontario to a low 50% in the Yukon. So only half of those who might qualify are getting palliative care. So it's not a consistent picture across the country.

Dr. Naheed Dosani

Absolutely. When it comes to location and geography across the country, we see quite a bit of variation, which is likely a product of the kinds of systems that have been developed and are in the process of being developed in their stages of evolution, so to speak.

But it also speaks to other issues that need to be discussed, such as urban and rural divide. While access to palliative care was relatively equal between rural and urban areas, what the report says is that patients who were living in rural areas were actually more likely to be hospitalized primarily for palliative care compared to those living in urban areas, and they were actually more likely to die in hospital compared to those in urban areas.

So even when we had that equal access, technically, we saw different outcomes throughout the trajectory when it comes to palliative care as it compares to urban and rural. So that was an interesting finding also.

Avis Favaro

Was that a surprise to you?

Dr. Naheed Dosani

To me, not necessarily, simply because of the concentration of services that we tend to see that exist in urban areas as compared to rural areas. And it really speaks to the ways that we have a long way to go to develop probably more novel and innovative ways to support rural care.

Avis Favaro

So one of the other questions or one of the other windows that the report gives is where Canadians are getting palliative care. So the vast majority of people when they're surveyed, they want to die at home. That would mean home care. The rate of that went from 7% to 13% were getting home palliative care. Is that good news? You're smiling.

Dr. Naheed Dosani

Yeah. I'm so happy. This is incredible, nearly double basically since last measurement.

I think we have to also remember that, for some people, home is not a stable environment to receive care. And as someone who provides palliative care for people who experience homelessness and other structural vulnerabilities like poverty and homelessness, sometimes metrics like this are unfair because, when we say home, what do we mean? Are we talking about a three-storey house in a suburban region? Or are we talking about a shelter? Or are we talking about long-term care, for example, which was also discussed in the report?

So happy to see the outcomes, but we have to remember that home means different things for different people across this country every single day and not everyone is set up in the right environment to receive that kind of care at home. And that's why our systems need to be agile and flexible.

Avis Favaro

We were allowed to film at the hospice where you're medical director, that's Kensington Hospice in Toronto, 19 beds. And one of the people that we met there was Julian, a 70-year-old man with end-stage cancer. He told us he did want to stay home, but the home care was spotty and he had to turn to 911 for help, if you can believe it.

His clip is followed by a comment from the hospice executive director, Dr. Nadine Persaud.

Julian

After I had my blood transfusion, I was in extreme pain and I couldn't function myself. I used to sleep on my easy chair, my gaming chair, with my feet up on the hospital bed, and the bed and the chair separated, so I had to wait 30 minutes while the fire department came.

Avis Favaro

How many times did you have to call 911?

Julian

I think three times. The home care I had didn't speak English. So this one time I phoned them, I couldn't get out of the bathtub.

Avis Favaro

So if you could have, you would have preferred to be at home?

Julian

Yes. So I'd prefer to stay at home.

Avis Favaro

And now you're here?

Julian

Yeah.

Avis Favaro

So I think I was asking you earlier about people calling 911 when they don't have home support. You've seen that?

Julian

Yeah.

Dr. Nadine Persaud

Yeah. I've seen that often where people have no other resort but to call EMS or call 911 and the fire truck company will come to support. And I think often of people who don't have the capabilities to call and who will just end up on the bathroom floor until their next PSW comes to visit or a caregiver comes because there is a lack of resources.

Avis Favaro

Does Julian's story highlight some of the problem with home palliative services? If people want to die at home, but it's not there, they end up like Julian needing more help.

Dr. Naheed Dosani

Yeah. You know, Julian's story is a story I hear quite often from people and is the story of many people across Canada who would have loved to have stayed at home, if they had had more access to resources by way of home care.

And actually, our systems make really significant assumptions. One of the biggest assumptions is that you have other people in your life, you have other caregivers, family members, support systems that will fill in when publicly funded home care is not around. And the raw reality is that there are many people who don't have those kinds of supports and aren't able to privately pay for those supports.

And so, when you talk to folks in hospice, the vast majority, if not all of them, say, yeah, I would have loved to have been home; I'm only here because there wasn't enough home care to support me when I needed that support so now, I'm here.

And so institutions like hospices are obviously very important and they're needed. But if we expanded our home care systems and provided more resources for people, more people would be able to stay at home. And when it comes to palliative care, more people would be able to stay at home for their end-of-life care.

Avis Favaro

That would be the goal. That would be the goal.

So where are most people in palliative care dying, based on the report?

Dr. Naheed Dosani

Yeah. Unfortunately, what we're seeing is that still a significant proportion of people are dying in hospital. And from a cost allocation and resource perspective, it's actually a very expensive way to do things.

Hospitals do play a role. The idea is that, though, when folks are using the hospital, they're using it at the right time and they're using it for a short period of time, such that it's not actually the place that they stay for long periods of time.

Avis Favaro

So, one of the things about the CIHI report is that the hospital seemed to become a default when there was a crisis. And I've heard that palliative care should never be a crisis, but they were ending up in hospital because there was a seizure or there was some sort of problem. And the CIHI report says that some 44,000 end-of-life patients who went to the emergency department for some sort of palliative care, the majority, 66%, were admitted, they were unplanned, and one in four died within 24 hours.

What happens when someone who's near death and is palliative is sent to hospital that way? What does it trigger?

Dr. Naheed Dosani

Yeah. So a lot of people might think, oh, like, go to the hospital, it's the right thing to do, it's the best place for a person to be. Well, in reality, what it often means is that people are going into a system where they're kind of put on this conveyor belt, where they're now going to be admitted to the hospital. They're going to be poked for blood work, they're going to have investigations, and they're going to have a multitude of tests that they would have never really wanted to have in the first place. That's not a great thing because it's not a place that always has that emphasis on quality of life.

Now, many hospitals, like the one I work at, have done a really great job in implementing and growing palliative care consultation teams and having palliative care beds in hospital, but we still see this all the time. And that's why there's so much effort being made up front to prevent hospitalizations to begin with.

Avis Favaro

Yeah. I believe the report talked about how, in Prince Edward Island, they're training paramedics, first responders, to be able to identify when someone's in a palliative situation, see if they could stabilize them at home rather than put them on that conveyor belt.

Dr. Naheed Dosani

Absolutely. I think the paramedics project, which is being piloted in many provinces across Canada now, is a really great innovative use of existing health human resources that really can make such a difference upfront and upstream and prevent visits to the emergency department and, ultimately, hospitalizations.

I also think that another innovative intervention has been training up our health human resources across this country around primary palliative care skills. And there's a training program run by Pallium Canada called the LEAP program. And LEAP has done incredible work coast to coast training professionals from all disciplines about a palliative approach to care. And the more that people know about these issues and have these skill sets, the more they're going to be able to intervene up front.

I also think about the role of virtual care. I think about the work that our palliative care outreach team does for people experiencing homelessness and thinking about the special and vulnerable populations that need that customized and tailored trauma-informed support to be able to support care, to keep people in a community where they want to be if they want to be there.

And so, it's likely a multi-pronged approach and these kinds of innovative solutions are important.

Avis Favaro

The idea of delivering more palliative care out there, not at the hospital, I would imagine it's pretty expensive at the hospital too. It must be agonizing to be at end of life and they have to do routine blood tests, routine CAT scans.

Dr. Naheed Dosani

Absolutely. One of the things that happens quite often when I'm providing palliative care in a hospital, and a lot of my advice actually stems around stopping investigations and tests. And someone might think that's a little strange and it's actually quite a relief. It's a breath of fresh air for patients and their loved ones because now they're not going for those CT scans, they're not getting that blood work anymore, and they're being listened to. Because what people actually want at that stage and phase of life is they want their quality of life addressed. So we call that de-medicalizing, and de-medicalizing is a big part of what we do, particularly in the inpatient hospital setting and palliative care.

Avis Favaro

Now we've talked a little bit about hospice, but for people who don't know what hospice care is, this report did highlight hospice care. I counted there are 36 residential hospices; I thought there were more than that. What are they and what is the role of the hospice?

Dr. Naheed Dosani

For sure. They are typically accessible to people who, for whatever reason, can no longer continue to receive their palliative care at home or sometimes are sites that receive patients who have received palliative care in a hospital, for example. And really, the raw reality is, we don't have enough hospices across Canada. The raw reality is that hospices are not fully funded across Canada. And in many provinces, the provincial government offers a proportion of coverage for operational costs. And in many places, capital investments are not covered at all or are covered for a very small portion.

And so, it's actually very expensive to create these institutions. And even when they're created, hospices are often having to fundraise to make up the difference.

With that said, hospices are incredible places to receive care. They are community oriented. They offer different kinds of supports that you wouldn't see in a hospital that someone might not have access to at home, like music therapy, art therapy. And it just provides a sense of community around a time that is very sad and very difficult for many people.

Avis Favaro

I think a lot of Canadians would like a hospice as an option, but there's few spots. And one of the things that the CIHI report identified is that at least half said they were always or usually operating at full capacity. And the one we were at obviously was full.

And I spoke to your colleague there, Dr. Nadine Persaud, who's the executive director. And not only was it full, but she said, there were 3 or 4 at least on the wait-list. And they seemed to arrive late in their illness. The average stay, she mentioned, was three weeks before they pass.

This is Dr. Persaud talking about what she saw.

Dr. Nadine Persaud

We hear of people in the community dying before they can get to hospice. And when you look at the amount of hospice beds in Toronto, it seems as if sometimes it's like the lottery to get a hospice bed because there's so few hospice beds that it's so hard for people to get access.

So it's not unheard of for us to get referrals and say, Mr. So-and-so died or Mrs. So-and-so died before admission. It's become so normal because we know referrals aren't made until the last minute.

Avis Favaro

How do you feel when you hear that?

Dr. Nadine Persaud

I think it's really disheartening. It's upsetting to know that, often, if people are not dying with palliative care, that means that they're likely dying with existential distress and they're dying suffering of other things that we don't even have the time to discuss – grief, anticipatory grief, loss, so many things.

Avis Favaro

Dr. Dosani, are too many referrals being made too late in the palliative process?

Dr. Naheed Dosani

Absolutely. We are identifying the need for a palliative approach too late in the trajectory of too many people across Canada.

Avis Favaro

Why?

Dr. Naheed Dosani

In many places across Canada – the CIHI report talks about this – there is the use of these checklists that really reference these tools. For example, the Palliative Performance Scale Score, which really scores function for a palliative care patient from zero to 100%. And often, people are only thinking about initiating a palliative care approach when someone has dropped to below 50%, for example, and has a steady decline.

That works for cancer and solid organ cancers actually fit that profile, and that actually allows us to provide early palliative care quite easily. But how does that work for someone with COPD or heart failure, or someone who's had strokes or multiple strokes, where someone can be a solid 50 for a long period of time, for example? So some of it is that we've applied some of these checklists uniformly across the population and what we need is a more tailored approach.

The other thing is that I think even in our primary care and specialty care systems, there still, even to this day, somewhat of a resistance to initiating a palliative care approach earlier in the trajectory, even when we have so much evidence to show that people feel better and even in some disease states, like some cancers, people actually live longer if they get early palliative care.

Avis Favaro

Well, that begs the question, when should palliative care begin? Your colleague, Dr. Persaud, said 3 months for hospice care, but we met a woman who was there at Kensington, Penelope, and her son, Mark. She was diagnosed with advanced multiple myeloma, which is a blood cancer, correct? And she started palliative care earlier than most, which was around the time of her diagnosis, and they deemed it palliative at that point.

Here's a clip of Mark about his mother.

Avis Favaro

How long has your mom been here?

Mark

Here since December 16, so 3-and-a-half months.

Avis Favaro

What kind of difference has it made to her quality of life and your quality of life?

Mark

Without palliative care, the answer is simple: Mom would have been hospitalized and would have died in hospital a long time ago. If mom had not had the pain management, which was facilitated through palliative care, she would have gone into hospital. So instead of costing the government a couple of hundred dollars a day, it would have cost $20,000 a day, and she would have been there for some period of time.

So, mom, how do you like this place?

Penelope

I think that makes a big difference in how you find those last days of your life and to have spent them with your own families and that kind of thing.

Avis Favaro

What does Penelope's story tell you?

Dr. Naheed Dosani

I think Penelope's story is a reminder that palliative care is a powerful tool that should be initiated at the earliest time possible. And many of our national bodies in palliative care, if you go and look up the definition of palliative care and when it should be started, talk about, really, palliative care should be starting at diagnosis.

Even in the CIHI report, we see that people who get access to home and community care for palliative care actually are less likely to end up in hospital because they have that embedded support in community to meet the person's goals.

I do want to comment on Dr. Persaud's comments about less than 3 months of life, and I do agree with her that, often, that has been the definition of hospice care or what many call end-of-life care. And so remembering that hospice and end-of-life care usually encompasses the last days to weeks of a person's life, and often, in many provinces, it's talked about as less than 3 months; but palliative care encompasses the larger trajectory all the way from diagnosis towards end-of-life, and even the bereavement phase.

And so, Penelope's story really brings home the power of a palliative approach to care. It's a real success story, if you ask me.

Avis Favaro

Who isn't getting palliative care in Canada? What worries you?

Dr. Naheed Dosani

I think, once again, the CIHI report emphasized that people with cancer are predominantly getting access to palliative care, and people who have diagnoses like dementia are not often getting access to palliative care. That's very concerning, actually, when you really think about it.

Avis Favaro

The majority of people over 85 are not getting palliative care.

Dr. Naheed Dosani

Yeah. And it's probably because we built a system that is very much focused on the trajectory of cancer.

Avis Favaro

And the report also shows that people in different ethnic groups, different cultures, are also less likely to get palliative care.

Dr. Naheed Dosani

Yeah. We continue to see through and through that racialized Canadians are not getting equitable access to palliative care. My sense is that racialized people do want access to an approach to care that alleviates suffering when they're dealing with a life-limiting illness, but they're often fearful of the term palliative care because of the ways that we talk about palliative care. The language we use, the lexicon, the approaches typically are more one-size-fits-all approach that has really actually been designed for a more Caucasian population in our communities.

And so we need more culturally safe approaches to talking about and delivering palliative approaches to care. That can mean many things, including offering palliative care delivery and information in different languages, to representation. We need a workforce that reflects the population that is actually delivering the care; more training around what culturally safe and anti-racist approaches to care and palliative care can look like.

And finally, we've literally gone out and created a system that delivers palliative care to people, and we called it Home Palliative Care. And it's not semantics. We literally designed a system that left out a significant proportion of Canadians that lack stable housing. And so people who experience homelessness and various forms of homelessness across Canada suffer every single day. They don't get access to palliative care because there's no system that's able to deliver that for them in community.

And that's why the PEACH program, Palliative Education and Care for the Homeless, our mobile street and shelter-based palliative care program, that has been developed and evolved and grown over the last nine years in Toronto. We now have programs in Victoria, Edmonton, Calgary. And I think it speaks to the fact that there are many people in this country who realize our systems are not designed to meet every person where they're at.

Avis Favaro

And that's rewarding for you. I can see you get very – that's close to your heart.

You help them die on the street. Right? Sadly.

Dr. Naheed Dosani

Yeah. Wherever a person calls home, we respect that. I think many people listening would say, well, I would never want that for myself. But we have to remember that we can't project our hopes of what a home looks like or what a good death looks like on people. And that for many of the people I care for in Toronto, home is actually a shelter or a respite or a drop-in or a friend's place.

Avis Favaro

And can you do good palliative care in a shelter? In a tent?

Dr. Naheed Dosani

I think, if you carry a big heart and you bring forth compassion and you are trauma-informed in your approach, we can do anything. When we go out and we meet people, often, they're kind of at first a little bit resistant in the sense that they find it strange that a doctor or a nurse or a social worker is spending so long with them in a setting that typically health care doesn't go to. Well, actually they say, well, what's the catch? This is kind of weird. And as we go back and we build that trust and rapport, they're like, this is really amazing.

As one man said to me the other day, I have avoided health care for a really long time because health care has been very mean to me. And now that you guys come to me and see me in my shelter while I'm dying, well, this is what health care should always look like. And I found that really powerful.

Avis Favaro

One of the things about the CIHI report, shifting focus a bit here, is caregivers. They took stories from caregivers, the people who have to deal with their loved one dying. What does the addition of that or what were the messages from that component of the report that hit you?

Dr. Naheed Dosani

A lot of what happens in a kind of care trajectory actually impacts caregivers. And ultimately, the sequelae of ineffective systems falls on caregivers and their caregivers too. And so I think it's a really important voice to have.

What we heard peppered throughout this report is that, when our systems fail, caregivers are the ones who are filling in, and they are providing that care that isn't always being documented, it's not always being counted, but it's a lot of care. The volume of care being provided by caregivers is important. And you have to think, if all the caregivers across this country one day said, we're not going to do this anymore, we'd be in a really bad spot. Caregivers are the reason our health system and especially our palliative care systems in community are able to move forward.

What also came forward in their narratives is that we must do more to support them. There needs to be more access to care and supports. There needs to be more clinical resources. There needs to be more financial supports for caregivers who are taking time off of work to support folks. And I think that that doesn't get talked enough about.

Avis Favaro

So where do we go from here? We've got a snapshot – there's some good things, there's some gaps. What comes next?

Dr. Naheed Dosani

Yeah. I think that we have to celebrate some of the incredible improvements that we have seen around access to palliative care, access to community and home-based palliative care, the development of systems coast to coast to really get people the kind of care they need when they're dealing with serious life-limiting illness.

Avis Favaro

Do you find that the provinces are responding? Because I understand that Ontario and Quebec are putting more money in and there was some money put in federally.

Dr. Naheed Dosani

Yeah. So there are pockets of excellence where we're seeing particular provinces like Ontario and Quebec that have earmarked specific money, particularly, for example, in the area of hospice, to be able to expand care. But it's just the beginnings. It's really something that needs to grow and it needs to grow quite quickly.

I'm also concerned about the variance across the country. Considering this is a country where everywhere people are dealing with palliative care issues, why is one province giving more to this issue than another? I think we need more of a uniform approach to these situations.

I do think there's a few issues we need to really zone in on. We recognize that most Canadian primary care physicians are having end-of-life care discussions with patients, somewhere around 94%, but only 40% actually feel prepared to have the conversation.

I'm actually spending a lot of time with practising family physicians around how to have serious illness conversations and how to have the goals of care discussion, how to bring up the topic of a palliative care approach for people. These are deep conversations that require time. And how can you have a conversation like this in a 15-minute appointment? Those are some real issues that need to be discussed.

Avis Favaro

Palliative care and MAID. I have heard that some patients have said, I don't need palliative care; I'm having medically assisted death. But I've also heard that some patients who request medically assisted death, once they get palliative care, they don't want medically assisted death.

Dr. Naheed Dosani

In some cases, when people are exposed to what palliative care can offer, they say, oh, I didn't know this was an option, I didn't know this existed; now that I know this exists, I don't think I want to pursue medical assistance in dying.

And then in other cases, people say, this is really great. Thank you so much for offering me this palliative care and I will continue to receive this. But for other reasons, I still want to pursue medical assistance in dying.

I think the way forward in palliative care, Canadians have spoken, they want access to medical assistance in dying. I think we need to respect the different trajectories that people experience and need to be humble and have humility in our approaches to supporting care for patients, no matter what their trajectory is.

Avis Favaro

So to sum up, we know that there are improvements, but we know that there is a ways to go. What would be your hope in the next report?

Dr. Naheed Dosani

Yeah. So in the next report, my hope is that we see less variance across Canada, province to province, region to region, by way of funding and supports that are being provided around palliative care in community. For example, hospice funding would be a really good thing to see more of and more equity in across provinces and territories.

I think that the second thing I would really like to see is a robust strategy that really empowers and supports primary care physicians and primary care health care teams to initiating a palliative care approach, such that it allows us to shift the conversations from downstream to much earlier upstream. That might mean new funding envelopes or billing codes that support conversations like that.

And the third is I'd like to see in a future CIHI report more robust data about the experiences of people who are going through different kinds of structural vulnerabilities across Canada. I'd love to see a breakdown on income, on housing status, on mental illness, looking at people who use substances as well. Because I think if we really are serious about a health equity approach to palliative care, we will drill down to those specifics, but without the data, we won't know where to go.

Avis Favaro

Well, I hope you get your wish. It is. It's very important, but it's also such a big subject. But at least your sense is, it's in the right direction.

Dr. Naheed Dosani

Absolutely. We are totally moving in the right direction. There is absolute reason for us all to be hopeful and that we should use that hope to drive more change in the future. And I hope we are having that kind of conversation in the years to come.

Avis Favaro

All right. Thank you so much, Dr. Dosani. Thank you for joining us.

Dr. Naheed Dosani

Thank you so much.

Avis Favaro

CIHI's palliative care report can be found on our website for a closer look at the data and the implications. Thank you for listening in.

Our executive producer is Jonathan Kuehlein. And a shout out to Alya Niang, the host of our French CIHI podcast.

And if you want to learn more about the latest Canadian Institute for Health Information Data, please go to CIHI.ca, that's C-I-H-I dot C-A, and subscribe to the CHIP wherever you get your podcasts.

I'm Avis Favaro. Talk to you next time.