Review finds lack of evidence for decision to deny hospice care to 102-year-old veteran

Katherine Houston was desperate when she requested hospice care for her 102-year-old mother, Margaret MacDonald, in October 2020.

Houston had always planned for her mother to die at home in Vancouver's West End, where she'd been caring for her for eight years. But the pandemic was making it tough to find homecare help, and MacDonald's health problems were escalating.

"I was just really burnt out," Houston said. "I was watching my mom die, and it was emotionally too much for me and physically too much for me."

MacDonald, a former officer in the Air Force and veteran of the Second World War, had a tumour the size of a hamburger on her forehead, bladder cancer, congestive heart failure and chronic antibiotic-resistant urinary tract infections.

Houston thought there would be no problem getting her into hospice.

But within 24 hours of making a request at Three Bridges Community Health Centre downtown, Houston learned her mother didn't meet the criteria, which require a life expectancy under three months. Neither she nor any of MacDonald's doctors had been consulted by the palliative care nurse performing the assessment.

"I hit the roof. I couldn't believe it," Houston said.

Her astonishment appears to have been justified, according to a recently completed review from B.C.'s Patient Care Quality Review Boards. The board is appointed by the Ministry of Health to review unresolved complaints about care provided by the health authorities, and makes recommendations for improvement.

In a Jan. 28 letter to Houston, the board said it was unable to find documentation showing MacDonald was properly assessed, despite "several requests" to Vancouver Coastal Health (VCH), which operates Three Bridges.

"We have no corroborating evidence to confirm that assessments were properly conducted and support the decision that your mother did not meet hospice criteria," the letter says.

"This oversight resulted in considerable distress for you and your family." 

The letter acknowledges that Houston was not consulted at any point or given information about how to appeal the decision.

'I feel cheated'

On Oct. 15, 2020, about 10 days after Houston's request was rejected, her mother was taken to St. Paul's Hospital in an ambulance. MacDonald was finally admitted to hospice and died on Nov. 3.

Houston said allowing the situation to reach emergency levels caused unnecessary stress for her elderly mom.

"She was so sick. All these things could have been avoided had they just gently taken her from home into hospice, but instead she had to go off … into an ambulance, and during COVID, so I wasn't with her," Houston said.

It was a relief to finally give up her role as caregiver and spend the last few days of MacDonald's life just being a daughter, but Houston still feels like she missed out on precious time.

"By the time my mom got to hospice, I think she had maybe one or two days where she was somewhat conscious," Houston said.

"I feel cheated out of that time with her when she still had enough consciousness to have the conversation that we want to have with our dying parents."

Houston's first step after learning her mom was denied hospice was to file a complaint to VCH's Patient Care Quality Office (PCQO).

The review board also identified issues with how that was handled — particularly "factual errors" in a Nov. 19, 2020 response to Houston's complaint.

Though a PCQO manager apologized in that response and said the health authority regretted the decision to deny hospice, she also claimed MacDonald's family doctor and cardiologist had been consulted during the assessment.

That wasn't true.

The PCQO later acknowledged in emails to Houston that the nurse conducting the assessment only contacted those doctors after the complaint was filed. The cardiologist also confirmed in a message to Houston that when he spoke to the nurse, she did not inform him about MacDonald's cancer or UTIs.

Houston has filed a separate complaint to the College of Nurses and Midwives, but that has yet to be resolved.

The review board's recommendations for VCH include making sure assessments are fully documented, and that an audit be performed to find any gaps.

The board also calls for the health authority to be more flexible and consistent in its criteria for hospice admissions.

'It's not just an error'

In the time since MacDonald died, VCH has updated its criteria to focus more on complexity of care rather than life expectancy, according to the board's letter.

A spokesperson for the health authority said it "immediately applied" the recommendations for improvements to its criteria for hospice admissions, and is conducting a full review to make sure caregivers are involved in the process.

Despite everything that happened, Houston has nothing but praise for the hospice team that cared for MacDonald. She's grateful for those last moments with her mom, whom she remembers as fun-loving and warm-hearted, as well as an understated trailblazer for women's equality.

But she also believes what happened to MacDonald raises larger questions about whether there are enough checks and balances in place to protect patients from unjustified decisions by individual medical professionals.

"It's not just an error," she said. "Somebody made an arbitrary decision for other reasons and then stood by it and at no time took accountability. And I think that's very frightening."