Another Tale of Two Patients: Shrodinger’s Cat

Is the glass half empty, half full, or both?

“In quantum mechanics, Schrödinger's cat is a thought experiment that illustrates a paradox of quantum superposition. In the thought experiment, a hypothetical cat may be considered simultaneously both alive and dead, while it is unobserved in a closed box, as a result of its fate being linked to a random subatomic event that may or may not occur.”

In simple terms, Schrödinger stated that if you place a cat and something that could kill the cat (a radioactive atom) in a box and sealed it, you would not know if the cat was dead or alive until you opened the box, so that until the box was opened, the cat was (in a sense) both "dead and alive.”

Lovey, in a shoebox

So what does this have to do with palliative care in Canada?

A lot of my articles are fun, even light and fluffy. That’s a funny thing to say about a guy who writes mostly about palliative and end of life care.

Regardless, this is not one of those articles.

Back in April 2023, CIHI released its report on Access to Palliative Care in Canada.

Are we doing better? Sure.

Is it good enough? Not really.

A high level summary concludes:

• More people are receiving some form of palliative care compared with 5 years ago.

• More people are dying at home with palliative support compared with 5 years ago.

• Some people experience greater barriers to accessing palliative care because of their age, where they live or their disease diagnosis.

First, I want to appreciate CIHI for including patient stories in their reports. I’ve written previously about the power of patient stories. This report highlights Suzanne Szukits, wife of Paul Adams, and Amy Greening’s mother.

“Paul was a caregiver for his wife Suzanne, who was diagnosed with breast cancer. In the 4 years between her diagnosis and her death, the cancer spread to the bone and put pressure on her brain, causing seizures. Most of her care was provided by Paul at home with little home care support. They made multiple trips to hospital for her symptoms before she eventually died in hospice after a 2-day stay.

Amy was a caregiver for her mother, who had dementia and chronic obstructive pulmonary disease (COPD). Amy lived with her mother while she cared for her and had the support of home care and a palliative care team. Amy and her mother made many trips to the emergency department for hydration and pain management. Amy was with her mother when she died at home, 2 months after her mother started receiving palliative care.”

Combine patient stories with good metrics and you have a powerful tool to make effective policy and move the needle.

Hospital capacity remains a huge issue in Canada, both prior to and after the pandemic. As such, I was very interested in the report’s take on access to palliative care in hospitals:

“For many of those admitted to hospital, there is an indication they wanted to be discharged but were unable to leave, mainly because they were waiting for a bed outside of the hospital. Since 2016–2017, there has been some improvement in the amount of time palliative care patients spend waiting to be discharged — in 2021–2022, 8.6% of patients receiving palliative care spent 2 or more days waiting to be discharged, compared with 9.5% in 2016–2017.

 Fewer patients (46%) whose main reason for hospitalization was palliative care died waiting for admission elsewhere, down from 47% in 2016–2017.”

Both metrics here show improvement but neither is spectacular. Neither moves the needle.

Moving on. I work in community palliative care. As such, I was particularly interested in the section on home care:

“Canadians would prefer to die at home with support, and more are doing so. In 2021–2022, 13% of those who died did so at home supported by palliative home care. This finding is a substantial increase from the 7% we reported in 2016–2017.

There are many benefits to dying at home. CIHI illustrates one nicely:

“only 11% of people receiving palliative home care had [inappropriate] life-saving interventions, compared with 26% among people not getting palliative home care.”

While deaths at home improved, it remains shockingly low. Surveys indicate that as many as 75% of Canadians would prefer to die at home if they could. Improving home deaths from 7% to 13% is encouraging but not the paradigm shift we needed.

While dying at home may also have its challenges, access to palliative care should not be one of them.

What then, is holding us back?

I have written previously about the lack of palliative care training in our medical schools and lack of basic palliative care competencies for healthcare providers in general.

Many medical schools, like the Schulich School of Medicine and Dentistry at Western, do not even have a division or department of Palliative Medicine.

So it came as no surprise to me when I read this in the CIHI report:

“only 40% of primary care physicians reported feeling prepared to care for patients with palliative care needs — this is similar to the proportion reported in 2019 (39%). Feeling prepared could reflect having both the resources (such as enough time to spend with patients and support from other health providers) and the ability and/or training.”

A 1% increase from 2019 to 2023 for me is perhaps the single most important metric in this report.

One percent. In Four Years.

This is more than a failure of training.

I am repeatedly told that we cannot train enough specialists to meet the need for providing universal palliative care for those who need it, when and where they need it.

I am also repeatedly told that building primary level capacity is the answer.

Most people don’t understand the meaning of Schrödinger's cat.

Schrödinger's cat, or even simply Schrödinger, is used as a way to reference something as a paradox, unfeasible, or working against itself.

When I look at this report, I see a paradox in plain sight.

Do you see it too?