The document examines the financial impact of end-of-life care on healthcare spending in Ontario. It finds that the average Ontarian in their final year of life utilizes $53,661 in healthcare resources, costing the province $4.8 billion annually or 10.7% of the budget. Legalizing physician-assisted suicide could reduce costs, but even if 8% of decedents participated, it would only lower spending by 0.2% per year due to the small number of people that would opt for this. The aging population will also increase healthcare costs substantially in the future if changes are not made.

1. The Cost of Holding On
AN INVESTIGATION INTO THE FINANCIAL IMPACT OF END-OF-LIFE
CARE AS IT RELATES TO HEALTHCARE SPENDING IN ONTARIO
Bryan Stuart –bryan.stuart@ryerson.ca
Dr. Franklin Ramsoomair – franklin.ramsoomair@ryerson.ca
Ryerson University, Ted Rogers MBA
The average Ontarian – in their final 12 months of life – utilizes $53,661 in OHIP
resources, for a total government expenditure of $4,800,000,000 per year. This
represents 10.7% of Provincial healthcare spending, and 4.3% of the entire annual
budget for the province of Ontario.
In countries where euthanasia and physician-assisted suicide are legal, the rate of
participation in these practices is as high as 8% of the total deaths per year.
Of those 8% of deaths, it has been observed that the practice is typically applied 1 month
prior to the projected ‘natural’ time of demise.
In a patient who does not participate in euthanasia or physician-assisted suicide, the final
month of care for that patient represents 33% of the costs for the entire year.
The average cost to care for a patient in their final year – if they opt for physician-assisted
suicide, would be 67% that of a patient who did not (i.e. $35,952).
Across the province of Ontario, if 8% of decedents opted for physician-assisted suicide, it
would only reduce provincial spending by 0.20% per year.
Introduction
In order to address the issue of the cost burden placed upon OHIP by end-of-life care,
secondary research was conducted using various sources to create a clearer picture of
the various common causes of death among Ontarians, and as accurately as possible, the
cost incurred during the last year of their life.
Due to the breadth of this subject matter, numerous sources conducted over numerous
years needed to be included. Costs have been adjusted to reflect the price for 2016 in
Canadian dollars, according to inflation. Precedence was given to sources from Ontario,
in the absence of domestic research, data from other Canadian sources took precedence
over international studies, and historical currency conversion tables were utilized when
necessary.
Methods and Materials
Ontario faces an aging population of baby-boomers, the healthcare industry in particular
will need to address the subsequent influx of patients in need of medical assistance. It
has been observed that an individual utilizes an ever-greater share of healthcare dollars
as they age. Up to 13.5x as much money is spent caring for patients in their final year, as
that of an average individual would use over the course of 12 months.
As a patient enters their finals days, aside from conventional treatment, there are three
types of care a patient may avail themselves: Results
Palliative Care: the sum of all efforts and services rendered unto a
patient who is believed to be beyond recovery, thus
expected to die in the near-future
Euthanasia: the painless killing of a patient suffering from an
incurable and painful disease or in an irreversible
Physician-Assisted
Suicide:
a scenario in which a physician provides a
prescription, or advice to a patient, so that the patient
has means to end their own life
0
500
1000
1500
2000
2500
Population(in000s)
Age Cohort
Ontario's Population Profile, 2010 and 2036
2036
2010
Background
Of the causes of death most common to Ontarians, Cancer, Diseases of the Heart, and
Alzheimer’s have been identified as those which represent the majority of Assisted
Suicide cases in such countries where the practice is legal.
Bill C-14: Canada’s Assisted Dying Law, passed June 2016, this law added Canada to the
list of countries where physician-assisted suicide is legal under circumstances in which a
patient has:
“[…]a grievous and irremediable medical condition that
causes them enduring and intolerable suffering”
Leading Causes of Death in Ontario, 2009 Number Percent
1. Malignant Neoplasms 26,117 29.5
2. Diseases of Heart 18,494 20.9
3. Cerebrovascular Diseases 5,451 6.2
4. Accidents (unintentional Injuries) 3,881 4.4
5. Chronic Lower Respiratory Diseases 3,718 4.2
6. Diabetes Mellitus 2,866 3.2
7. Alzheimer’s Disease 2,179 2.5
8. Influenza & Pneumonia 2,128 2.4
9. Nephritis, Nephrotic Syndrome, & Nephrosis 1,238 1.4
10. Intentional Self-Harm (Suicide) 1,197 1.4
All Recorded Deaths 88,468 100
Objectives
Using available data, it was the intention of this study to:
1. quantify the cost burden on OHIP for patients in the last year of their life
2. quantify the potential cost-savings which could be gained if alternative courses of
treatment were applied
3. apply to current population trends forward, to present a picture of the cost of end-of-
life care as it relates to the aging population bubble of baby-boomers
Discussion
The cost of healthcare is largely driven by population, as is the government’s ability to
pay for healthcare. Ontario draws its revenue from three major sources: taxes, federal
transfers, and Government Business Enterprises. All 3 of these in turn, are closely linked
to the population of the province. As the population ages, there will be a push for
potentially limited resources.
The population of Ontario is expected to grow 29.7%, from 13.8 million in 2015 to 17.9
million in 2041. The deaths per year are expected to grow from 94,000 in 2015 to
153,000 – an increase of 62.8%.
If deaths per year were stable between 2011 and 2041, there would be no need to
change the current formula for allocation of provincial dollars towards healthcare.
However, with a population of 17.9 million in 2041, and deaths per year at present levels,
the government would be looking at costs of $6.7 billion for care for Ontarians in their
final year of life.
If Ontarians end up adopting Physician-Assisted Suicide at the observed Dutch rate of 8%
of all deaths, this would represent a decrease in OHIP costs of only $216,717,511.
While it would be advisable for the province of Ontario to take steps to de-stigmatize
public opinion regarding Physician-Assisted suicide, other measures will be necessary in
order to handle the potential boom in healthcare costs, as the population ages.
At the very least, this research stands as evidence that the legalization of physician-
assisted suicide is very unlikely to have been a motivating factor in the passage of Bill C-
14. At it’s heart, the legalization of euthanasia and physician-assisted suicide is one of
individual choice, and compassion, rather than a calculated financial strategy to put a
price-tag on human life.
The decision to participate in physician-assisted suicide is a personal matter for the
patient, and their loved ones. The fact that the financial benefits of this procedure are
negligible helps to underscore the basic human element, that compassion should be the
only motivating factor, as an individual approaches death.
4.50
5.00
5.50
6.00
6.50
7.00
7.50
8.00
8.50
2011 2015 2024 2041
Expenditure(inbillions)
OHIP Spending, Under Three Scenarios
(current growth rate, projected growth rate, and
projected growth rate, with 8% of decedents participating
in physician-assisted suicide)
cost at current rate of deaths/year
cost at projected rate of deaths/year
cost at 8% adoption of euthanasia
1.48 billion
0.22 billion
Selected References
1. Cohen, J. S., Fihn, S. D., Boyko, E. J., Jonsen, A. R., & Wood, R. W. (1994). Attitudes toward assisted suicide and euthanasia among physicians in
washington state. The New England Journal of Medicine, 331(2), 89-94. doi:10.1056/NEJM199407143310206
2. Emanuel, E. J., & Battin, M. P. (1998). What are the potential cost savings from legalizing physician-assisted suicide? The New England Journal of
Medicine, 339(3), 167-172. doi:10.1056/NEJM199807163390306
3. Health Canada. (2016, June 20). End-of-life care. Retrieved from Healthy Canadians: http://healthycanadians.gc.ca/health-system-systeme-
sante/services/end-life-care-soins-fin-vie/index-eng.php
4. National Health Service. (2014, August 11). Euthanasia and Assisted Suicide – NHS Choices. Retrieved November 28, 2016, from
http://www.nhs.uk/conditions/Euthanasiaandassistedsuicide/Pages/Introduction.aspx
5. Polder, J. J., Barendregt, J. J., & van Oers, H. (2006). Health care costs in the last year of life—The dutch experience. Social Science & Medicine, 63(7),
1720-1731. doi:10.1016/j.socscimed.2006.04.018
6. Statistics Canada. (2015). Table 12-7 Population by age group and sex, medium-growth - 2006 to 2008 trends scenario (M2), July 1st — Ontario,
2010 to 2036. Last updated November 27, 2015. http://www.statcan.gc.ca/pub/91-520-x/2010001/t376-eng.htm (retrieved: November 30, 2016).
7. Tanuseputro, P., Wodchis, W. P., Fowler, R., Walker, P., Bai, Y. Q., Bronskill, S. E., & Manuel, D. (2015). The health care cost of dying: A population-
based retrospective cohort study of the last year of life in Ontario, Canada: E0121759. PLoS One, 10(3) doi:10.1371/journal.pone.0121759
55.16%
0.20%
4.15%
35.76%
Breakdown of Provincial Government Expenditures
Non-Healthcare Spending
Savings if 8% of decedents participate in Euthanasia/Physician-Assisted
Suicide
Spending for Patients in their final year of life
Healthcare Spending (excluding care for patients in their final year)