All I want is a good death. Is that too much to ask?

Like most Canadians, I’d like to die in my home surrounded by friends and family.

Or second best, a home-like setting like the lovely Kamloops Hospice House.  That peaceful setting is where my wife spent her last days as she was dying of cancer.

Kamloops Hospice House. image: CFJC Today

But contrary to Canadian’s wishes, only 15 per cent die at home.

More often we die in hospitals; more than comparable countries.  Most Canadians, 61 percent, die in hospital. Far more than the Netherlands at 30 per cent. And although we like to boast about our health care system, only 20 per cent of Americans die in hospitals according to a report from the C.D. Howe Institute (Globe and Mail, Oct. 26, 2021).

We die in hospitals in the most unpleasant way, hooked up to tubes and machinery that unnecessarily delays the inevitable. Our lives may be prolonged slightly but the declining quality of life is hardly worth the price of suffering.

Canadian cancer patients have the highest rates of hospitalization in their last six months of life (87 percent), compared to England (83 percent), the Netherlands (77 percent) and the US (75 percent).

It’s so unnecessary.

Cancer patients whose condition is stable or reacting positively to treatment don’t require hospitalization. Those dying of cancer, as was my wife, typically require assistance with activities of daily living only in the final weeks or months of life. Terminal cancer patients differ from those dying of almost every other illness -those dying of other illnesses typically require assistance for many months or years before they die.

Older Canadian cancer patients are more likely to die in hospitals and less likely to receive palliative-care.

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 delivered outside of acute care settings, including in patients’ homes.

It’s not the fault of doctors in hospitals or because healthcare workers are unfeeling or uncaring. It’s because of the way the system is structured.

There are too few palliative care beds.  Canada has one-half the number of hospice and palliative-care beds as the United Kingdom. 

Treating patients at end of life in hospitals, rather than palliative care beds, is expensive.

Our per capita hospital costs are US$21,840. Canada’s costs are 18 per cent greater than that of the U.S., 100 per cent greater than Netherlands, and 233 percent higher than England. Canada’s relatively poor performance in terms of costs and quality of end of life care is clearly related to the high use of hospitals.

The authors of the report suggest the following remedies:

1 Canada must stop treating end-of-life care as acute care.

2 Palliative and end-of-life care must be provided across multiple healthcare settings. It cannot be the sole responsibility of hospices and palliative care facilities.

3 Training for clinicians, caregivers, even for patients must be provided recognize the end of life period.

We must have a frank discussion about death. Unless we know the signs of death’s knock on our door, we will be poorly prepared.

Lies, damn lies, and category 1 carcinogens

The World Health Organization recently placed processed meat in category 1 of carcinogens, along with radioactive elements and asbestos. That’s the list of agents “carcinogenic to humans.” They also placed red meat in 2A which includes Glyphosate (Roundup) and lead compounds which are merely “probably carcinogenic to humans.”

bacon

Is eating bacon more likely to cause cancer than exposure to an herbicide? No. Agents aren’t listed according to risk. The criterion used is: do they or do they not cause cancer. The categories are grouped by experts according to certainty from the most evident all the way down to category 4, “Probably not carcinogenic to humans” of which there is one item, Caprolactam (used to make nylon).

Risk is determined by how much you are exposed to the carcinogen. André Picard, public health reporter for the Globe and Mail explains:

“The expert group does hazard identification, not risk assessment. Practically, that means they determine, yes or no, whether something may cause cancer, but not how potent it is at a causing cancer,” and adds, “It’s important to remember, however, that not every exposure to a potential carcinogen will cause cancer: Frequency, intensity and potency matter.”

All agents in a category don’t carry the same risk. If they did, people would be dropping like flies from eating meat. Compared to other items, they are not.

Eating processed meat and smoking tobacco, both in category 1, don’t have the same mortality rate. Processed meats result in 34,000 deaths worldwide annually whereas smoking causes about one million cancer deaths. Also in category 1, asbestos kills more than 100,000 and alcohol causes 600,000 cancer deaths a year.

Also misleading is the way percentages are used to translate statistics. For example, two slices of bacon are reported to increase your risk of colorectal cancer by 18 per cent. Eating a 4 ounce steak will result in a similar increase. But when risks of colorectal cancer are low to begin with, a small percentage increase of a small risk is still a small risk. The actual numbers expose this fallacy, explains Pickard:

“Based on these estimates, about 66 in every 1,000 people who eat a lot of red meat or processed meat will develop colorectal cancer in their lifetime; by comparison, 56 of every 1,000 who eat very little meat, processed or otherwise, will develop colorectal cancer.”

In other words, the increased risk is 10 out of 1,000. If you are one of those 10 persons who acquire cancer from eating meat, it’s tragic but as a risk assessment it’s not that bad.

Risk assessment is complicated by the toxicity of the agent, the amount of the agent you are exposed to, the length of time exposed to it, the way you are exposed (inhaled, ingested, topically applied), and your genetics.

The categories are useful in determining what to avoid, if possible. But some things are almost unavoidable. Like living: walking in the sun (ultraviolet rays), working (painter, hairdressers and shift-workers), eating (barbequing at high temperatures), camping (wood smoke), and travelling (cosmic rays from flying in a plane, breathing vehicle exhaust).

Unavoidable, like being alive: the naturally produced hormone estrogen has been linked with cancer, especially when combined with the artificial hormone progestin.