The Current - What does it mean to die well in Canada?

Episode Date: October 16, 2025

When Dr. Balfour Mount — the physician who pioneered palliative care in Canada — passed away, it sparked a question: how far have we come in caring for patients with serious illness? We look at what a “good death” means today, why access to palliative care is still so uneven across the country, and how the rise of MAID has changed the conversation.

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Hello, I'm Matt Galloway, and this is the current podcast. We really are privileged as physicians or nurses or health care providers because the people we care for are so ready to let us in, so ready to be open. And that degree of openness may be new for them, both with others and with themselves. That's Dr. Balfour Mount, the man who coined the term palliative care. Dr. Mount was a cancer surgeon in Montreal who saw patients dying in hospitals,

often ignored once their illness was considered untreatable. He believed there had to be a better way to die. He founded North America's first hospital-based palliative care unit at Montreal's Royal Victoria Hospital, and his work went on to change how medicine thinks about death, dignity, and compassion. Last month, Dr. Mount died at the age of 86, and the very unit named after him, and his death is making many in his field reflect on the state of palliative care across this country. Dr. Justin Sanders is the Cappy and Eric M. Flanders Chair of Palliative Care at McGill University, and Director of the Division of Supportive and Palliative Care at the McGill University Health Center. Dr. Leonie Hirks is a palliative medicine specialist and clinical professor in the coming school of medicine at the University of Calgary,

and Mahogany Hines is president of the Canadian palliative care Nurses Association and a clinical nurse specialist at St. Peter's Hospital in Hamilton, Ontario. Good morning, everyone. Good morning. Dr. Sanders, let me start with you. It's been said that it's rare that somebody who founds an entire field of medicine is around to see its impact in many ways and is around to see the lives of people change. You practiced in Montreal, and Dr. Mount was your predecessor in the position that you helped you occupy now.

Tell me a little bit about, as you understand, what he was trying to achieve in introducing the idea of palliative care to this country. So, yes, I continue to practice here in Montreal, and 50 years ago, what Balfourmet was trying to achieve was really to be able to provide the kind of care that was being provided

in hospice within the context of a hospital to patients who had advanced cancer and were dying. And what's extraordinary in the 50 years sense is what's become of palliative care. He really catalyzed 50 years of innovation in the field that leads us to a place that now we know that caring for people with serious illness requires palliative care to ensure that we're providing the best care to those people. It's interesting. Even the name, the phrase palliative care came from, I mean, there was a linguistic concern, right? that if you called it hospice care, that that could turn people away.

Exactly. He was warned by his frankphone colleagues that if he called at hospice, this association with almshouses for the poor would drive people away. It's interesting that 50 years on, we continue to wrestle with fear about the term palliative care, but really that's about how it's been practiced historically. And we have so much evidence to show that if we practice palliative care in the way that that evidence supports, patients would be clamoring for what we have to offer. I'm going to come back to that fear idea in a moment. Dr. Herks, Balfouramount, said that it is possible to die healed. What do you think he meant by that?

Yeah, very good question. I think that, you know, the period of end of life we know can be truly transformative in a time of growth, both for the person who's experiencing the dying process and their family and friends. And there's healing and flourishing possible even while we're dying. And he recognized that, you know, complex interoperative. play between mind, body, and spirit, and that actually end of life can be an opportunity to experience relationships, transcendence, in different ways than you can at other times of life. And so to provide the supports that allow people to achieve that type of healing in that time of exquisite tenderness was something profound that he and both Cicely Saunders really amplified. Transcendence is a really powerful word in that. Why did you use that word? Well, I use that word because the spiritual experiences we see as palliative care clinicians day-to-day in our work, and it's different for every person.

It might be an experience with nature. It might be a religious understanding of a God. And that was certainly rooted in both his work and Cicely Saunders' work, that they truly understood the spiritual dimension of what makes us human and how intertwined all of that is with our day-to-day experiences of family. meaning and purpose in life, which really comes to the forefront when we're facing the possibility of our own death. So how did, just briefly, how did he create the conditions for that in the work that he did? Because I ask you this, you knew him. And so when you talk about philosophy, that's one thing.

But how did that translate into the work that he did as a doctor? Yeah, so I knew him professionally and had great opportunities to receive mentorship in my work through the Canadian Society of Health Care Physicians, which he founded. And so he really, like Cicely Saunders, taught about this concept of total suffering and total pain and that in order to provide good care and rigorous assessment, I would say, and treatments to the level of any other area of medicine with this academic rigor, we actually had to attend to the whole person, this philosophy of mind, body, spirit, being intertwined. And so coming at it from that holistic perspective, suffering is a complex dimension. of all those aspects of our humanity. And so approaching palliative care that way. And that's why it's great that we have Justin here

that Vizzi founded the McGill Whole Person Care Program to really bring education and research and those academic rigors of medicine to all these aspects of what makes us uniquely human. Mahogany Hinds, you work in palliative care through the Nurses Association. What do you love about the work that you do? That's a loaded question.

I'm incredibly fortunate and privileged to be able to participate and support not only nurses, but also patients and their family, whoever they identify as family throughout their care journey. And you really get to see the spectrum, like the beautiful spectrum of humanity, some people that they're very best and some people that they're very worst and kind of everything in between. And it really is a privilege because people trust us. And they bring us in and we have this opportunity to really connect with people. in a really beautiful and relational way. What is the role of nursing in achieving what we've been talking about, the philosophy but also the goals that Dr. Mount had for end-of-life care? Yeah, I think there's a magnificent role for nurses within like the healthcare team.

We all work interprofessionally and the crux of really excellent palliative care requires an interprofessional team that includes nursing, social work, OTPT, respiratory therapy, family, volunteers, obviously physicians as well, but also includes the family and the patient and whoever they identify as their community. And the role of nursing is really to be able to look at that bigger picture and really understand like Dr. Leonie Hurks was talking about that whole picture of who is this person as a person and how do we meet them where they are and support them in ways that are meaningful for them to live really well until they die. Justin Sanders, can you talk a little bit more about that whole person?

Part of this is about how we define what palliative care is, right? The assumption is that this is about dying, but he and the people who have followed in his wake have kind of interrogated whether this is really about dying or whether it's about something else. That's true. I mean, to speak to the point about whole person care, you know, there's some who say that medicine takes people apart in order to cure the diseases that they have. have and that palliative care puts them back together. And one of the ways that we do that

in meeting people in the context in which we meet them, whether it's the hospital, the community, is we try to understand all the dimensions of their life, what is it that makes this person who they are? Because in knowing that, we can help them make the best decisions for what they face, and they all face complex decision-making. And it gives them an opportunity to be seen, heard, and understood as a whole person in ways that sort of nurture that integrity or wholeness that Balfournout thought of as healing. healing. He thought of it as a relational construct. It was something that took place in the context of a relationship. And what I think clinicians underestimate is the importance of their

own ability to participate in those relationships and the impact it has on patients and families' lives. How does hope factor into that? Hope is something that, again, at the end of life, can be complicated for people. But that was wrapped up in what he was trying to achieve. Absolutely. Hope is an extraordinary part of our, an integral part of our work. And part of what we do, both in taking expert care of patients' symptoms, the things that make them feel bad at any one moment in time, is we help them understand, you know, what is possible to hope for.

We help hope alongside with them for whatever it is that they are aiming for. And patients' goals form the basis of hope and are asking them what is important to them and what they're looking forward to, sort of ignites within them hope when there are many times where they feel based on their interactions with other clinicians, because treatment is gone or because treatment of cancer, for example, is gone, that there is no more hope.

Leonie Herks, how do you understand that idea of hope? Because it's what we're all kind of grasping for, but often at that point in someone's life, it's difficult to see. And despair can be the thing that seems on the horizon. How do you understand the idea of hope? Yes, I think that in palliative care, what we're helping people focus on is that their lives still matter every day until they're very last breath. And Balframount really espouse that, that each day can be meaningful if we treat the person with dignity affirming their inherent worth and that their life has value. And every person in our life is in a codependent relationship with other people. And sometimes we are the

carer and sometimes we need to be cared for. And that doesn't mean that we're a burden or have anything less to offer the world. And so when we can be fully present to that person as they go through this journey facing dying and death, we can support them being hopeful for the very best days possible and finding that meaning and relationship with other people. And again, back to the spiritual realm that allows them to have the most best life through to their last breath. How does that change how we think about death and how we talk about death? We don't like to talk about death. And we certainly don't like to think about it. And yet it's coming. That happens. So how does that change how we think about death?

Well, I think, you know, dying and death has become so misunderstood. And I think, you know, Bell would say we're back to where we were when he first started in terms of the stories that perpetuate in the media that have really perpetuated these myths that death is this terrifying, excruciating time of agony. And the only way to die with dignity is to have a lethal dose of drugs. And Bell would say, like, most deaths are peaceful. And there are palliative specialists. like us who can help deal with the suffering that might come about through physical, psychosocial and emotional, spiritual struggles as we face the end of our life. And that those symptoms can be carried and alleviated by accompaniment and by the tender, exquisite care with the same academic rigor, which is what Bell brought to the table, of any other discipline of medicine. And truly, people can be at find peace and be comfortable at the end of life. And now we know that that also has the benefit throughout the spectrum of journey with serious illness. So because of Bell's work

in academic palliative care, we have evidence now that earlier palliative care actually provides that same benefit throughout the course of a serious illness journey. Chambers Plan employee benefits is not for profit, and that's great for your business. Chambers

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The Secret of Secrets. A romantic rendezvous in Prague turns deadly, and Robert Langdon must unlock a shocking secret that changes everything we believe. The Secret of Secrets by Dan Brown. In Stores Now, also available as an audiobook and e-book. Justin Sanders, you hinted at this idea that there are people, perhaps in the medical community, but certainly beyond who are afraid of that concept of palliative care. There's the phrase, you know, you're going into palliative care, which to people suggest the end is near. How well do you think people understand the role of palliative care?

And people, not just, you know, outside patients, but also people, in the end. in the medical community. We have a long way to go, I think, in terms of the public and our own colleagues' understanding of what palliative care is. And what I see every day is a sort of collusion in which even when the doctors understand what palliative care is and how it may benefit their patients, their worries that it may spark fear in their patients or take away hope to mention palliative care leads them not to do that.

And what this leads to is a situation in which patients receive palliative care at the very end of life. They then associate palliative care with death and the cycle repeats. And unfortunately, we know that we have evidence that suggests when patients get palliative care early. They not only feel better, have better quality of life, the same is true for their caregivers, but they may also live longer. And I think if we're serious as a society about ensuring that we provide care that gives people the best quality time for the longest time, we have to include palliative care and invest in that as a society. One of the phrases that I keep reading about in preparation for this conversation is palliative care is the umbrella, not the rain. what does that what does that mean jessna yeah that's a beautiful metaphor that was

written about by camilla zimmerman at princess margaret hospital in toronto and it was this idea that people often associate palliative care with the rain we say oh palliative care is here and they think oh am i going to die but in fact we should think about palliative care is the umbrella that shelters us from the rain and often the metaphor that she illustrated in a beautiful article showed a patient with advanced cancer sort of being handed an umbrella as after they'd been soaked in a torrent of rain and saying, I wish I'd had this earlier versus the oncologist or other clinician who gives the umbrella to the patient and says, why don't you have this just in case? And then the family finds themselves in the torrential rain, but dry because

they have the umbrella. So palliative care is the umbrella, not the rain. Mahogany Heinz, do you worry that that umbrella is not available as widely as it should be in this country? No. So I think we've made great advances with regard to palliative care across the country in the last 50 years. I think there's a lot of opportunity. for us to continue to grow what palliative care looks like. I think both of my colleagues very beautifully and eloquently spoke to the fact that we need to be doing it earlier. We really need to be identifying people earlier so we can support them and give them that

umbrella earlier and give them access. But I think there's a lot of marginalized and underservice populations throughout our communities that are often overlooked. And sometimes I call them the afterthought within the afterthought. Because we sometimes think of palliative care as kind of this. after thought, oh, there's nothing more we can do for you. Here's palliative care. And that's actually a failure of our system, right?

We need to be doing it earlier so we can support people in a more holistic way substantially earlier and really get to know who are you and what does this care journey look like for you. And some of those populations are people that are on house throughout our communities. A lot of like our, we even need to start having bigger conversations about bridging ministries, right? the Ministry of Health, in Ontario specifically, bridging over to the Ministry of Community and Child and Support of Services to support people with intellectual developmental disability.

Like some of our ministries don't speak to each other. And because of that, it creates these inequities and inaccessibility and difficulty and funding and support and resource allocation that we really just miss these really golden opportunities to support people to live and die where they want, when they want, and kind of how they want. Leone-Hurks, do you worry about that, about how available this is, not just even in urban centers, but right across the country,

just how available what we're talking about is to Canadians? Absolutely. And, you know, I agree with Mahogany that compared to where Balsh founded this discipline 50 years ago, we've made significant advances in terms of academic programs and evidence building for the benefits of palliative care, but we haven't really made the progress that we need to make, in the last five years since, well, seven years since the framework of palliative care in Canada

identified, you know, the urgent need to increase palliative care across the country for all people, regardless of age, diagnosis, stage of illness and location of care. And, you know, the Kai Hai report, so the Canadian information of health information is frankly the best evidence that we have, and it's very poor. It really only captures information from a few provinces with very inconsistent ways that it reports. And even that evidence shows very modest improvements, still about 50% of people who die don't receive any type of palliative care. And if you're indigenous, poor, homeless, incarcerated, if you're young, pediatric populations, and if you live in rural and remote areas, you really don't have access, very limited access.

But truly, we don't have a current map that captures the current service development of palliative care, and that's what the Canadian Atlas of palliative care is trying to do. We have recent publications of the Atlas led by Pallion, which use standardized international indicators to be able to compare jurisdiction to jurisdiction, the state of palliative care. It has been privately funded in Ontario and British Columbia, and fortunately the Alberta government funded it, but we still are missing all the other provinces and territories to really have a rigorous understanding of where we're starting from and where the priorities and urgent needs are to direct funding and policy development for palliative care.

And so that's, you know, something that's a very poor outcome of the federal framework because it identified the need for this, but there's been no federal funding to make this possible. We just have a few minutes left. The context that we're having this conversation in, and you've hinted at it already, Leone, is in the rise of medical assistance in dying. This is something that Dr. Mount was very vocally opposed to. He said that he deeply resented what he called a manipulative phrase medically assisted in dying. It has no connection with what he does, that his goal is quality of life.

How has the legalization of Maid impacted his vision for palliative care, do you think? I mean, substantially, I think what was so difficult for him, and this is something we communicated about, was the kind of rapid uptake of this being seen as a priority to be made available, when, you know, at that time, 98% of people dying weren't getting an assisted death. And now, you know, 95% of people. And so there's been this push to make this kind of be seen as an essential service and it has to be provided in every setting of care and available to every person when we do not have that same access to palliative care.

And then it's been put into funding buckets that are considered end-of-life care and has impacted because palliative care and made in sometimes coming out of the same bucket of funding, There's competing use of funds, and that's been evidence in recent studies that have shown that tension in palliative care and made. Dr. Sanders, do the two necessarily need to be at odds with each other? I absolutely not, in the sense that I have had patients who receive expert palliative care in our context and who still choose to have medical aid and dying, but they don't do so under duress. And I worry that we leave people in a situation where without access to palliative care, they're more likely to choose medical aid and dying and to see that as the only route to a death with dignity. And, you know, this is in a time of global uncertainty, we all understand, I think, to some degree,

what if we can connect in some way to the profound uncertainty of living with a serious illness and the desire to have control in some way. And this is what people are seeking. the things that we give them and trying to understand them to help them articulate what's important to them and live to see those things is control in a different way and a way that's really beautiful for them and for their families. And so I worry about the resources, you know, that there's a competing resource potentially, but they shouldn't be. It's interesting. We've spent 20 minutes or so talking about something that people don't often talk about, which is dying.

And I just wonder, I'll ask you, Mahogany, how do you think, or what can, or what can we learn? How does that change us when we talk about how we care for the dying? How does that influence us, do you think? And I love this question because I think it's such a beautiful opportunity to talk about, talking about death doesn't just mean talking about death. It's actually talking about how we live and how we support one another in larger communities. I think this is an opportunity for us to take a bit of a dive. I always am challenged with the thought that we're a death-denying society, because I don't actually think that we deny that it happens. I think we're death-phobic.

We're fearful of it, and we're fearful of things that we don't know and maybe don't understand. But as palliative care clinicians, we've seen kind of what you might consider a good death, what you might consider maybe a less good death, and everything kind of in between. But I think it opens a dialogue about what does it look like to live really well. And I think it also brings in some conversations about legacy and our connections to our community. So when we talk about this legacy concept, it's what am I leaving behind? One of the things I often teach my students and other nurses when I'm working on the floor is like one of the comforts that we can bring to people is often making sure that the people that they love are going to be okay after the person dies and that they're going to be remembered in ways that are meaningful and important to them. And I think that I'm very fortunate as a nurse, like, I think we're great advocates and I think

we're really great as agents of change and knowledge brokers as well. But I think we also have this gift of being able to marry the art and the science of what palliative care really means. And it's really to connect with people and understand, like, what is important to you? How do I understand you, even if I might disagree with you? and how do we connect on a way that is incredibly human and really quite beautiful? Dr. Sanders, we're out of time, but last word to you. And again, it goes back to that idea of hope in thinking about the hope that I think we all have

for a good death and what that means. Yeah, well, thank you so much for the opportunity to be here today. I think that what I would emphasize to people is that if you have a serious illness and you don't have access to palliative care, you really don't have access to the best care, best quality care. And we need a, we need provincial governments and national, federal governments to really support this through resources to ensure that every patient with a serious illness has access to palliative care. This may not, this will not stop medical aid and dying. And for some people, this is a choice that feels like the, the right choice. And we have to support

that as well. But what I would say is if people are making that choice because they don't have because they're suffering in ways that we might be able to address, then that's an injustice. Thank you all for the work that you do, and thank you for being here to talk to us about it. It's important, even if we don't talk about it enough. Thank you. Thank you. Dr. Justin Sanders is the Cappy and Eric M. Flanders chair of palliative care of McGill University, Director of the Division of Supportive and Palliative Care at the McGill University Health Center.

Dr. Leone Herks is a palliative medicine specialist and clinical professor in the coming school of medicine at the University of Calgary. And Mahogany Hines is president of the Canadian Palliative Care Nurses Association and a clinical nurse specialist at St. Peter's Hospital in Hamilton. You've been listening to the current podcast. My name is Matt Galloway. Thanks for listening. I'll talk to you soon. For more CBC podcasts, go to cbc.ca.ca slash podcasts.