Tracking the Evolution of Hospice Palliative Care in Canada: A Comparative Case Study Analysis of Seven Provinces

Background: An aging population, rise in chronic illnesses, increase in life expectancy and shift towards care beingprovided at the community level are trends that are collectively creating an urgency to advance hospice palliative care(HPC) planning and provision in Canada. The purpose of this study was to analyze the evolution of HPC in sevenprovinces in Canada so as to inform such planning and provision elsewhere. We have endeavoured to undertake thisresearch out of awareness that good future planning for health and social care, such as HPC, typically requires us to firstlook backwards before moving forward.Methods: To identify key policy and practice events in HPC in Canada, as well as describe facilitators of and barriers toprogress, a qualitative comparative case study design was used. Specifically, the evolution and development of HCP in7 strategically selected provinces is compared. After choosing the case study provinces, the grey literature wassearched to create a preliminary timeline for each that described the evolution of HPC beginning in 1970. Keyinformants (n = 42) were then interviewed to verify the content of each provincial timeline and to discuss barriers andfacilitators to the development of HPC. Upon completion of the primary data collection, a face-to-face meeting of theresearch team was then held so as to conduct a comparative study analysis that focused on provincial commonalitiesand differences.Results: Findings point to the fact that HPC continues to remain at the margins of the health care system. Thedevelopment of HPC has encountered structural inheritances that have both sped up progress as well as slowed itdown. These structural inheritances are: (1) foundational health policies (e.g., the Canada Health Act); (2) servicestructures and planning (e.g., the dominance of urban-focused initiatives); and (3) health system decisions (e.g.,regionalization). As a response to these inheritances, circumventions of the established system of care were taken,often out of necessity. Three kinds of circumventions were identified from the data: (1) interventions to shift the system(e.g., the role of advocacy); (2) service innovations (e.g., educational initiatives); and (3) new alternative structures (e.g.,the establishment of independent hospice organizations). Overall, the evolution of HPC across the case studyprovinces has been markedly slow, but steady and continuous.Conclusions: HPC in Canada remains at the margins of the health care system. Its integration into the primary healthcare system may ensure dedicated and ongoing funding, enhanced access, quality and service responsiveness.Though demographics are expected to influence HPC demand in Canada, our study confirms that concerned citizens,advocacy organizations and local champions will continue to be the agents of change that make the necessary andlasting impacts on HPC in Canada.