“I broke down. I thought I was ready to talk to them, but I wasn't," she said.

Since that afternoon, West has been working with St. Elizabeth Health Care chaplain Susan Morgan – writing letters her grandchildren will read when they approach adulthood, remembering her 64 years in the context of a whole life and her faith. And she's finally had that talk with her adopted son and daughter-in-law. West lives with them and her two grandchildren in a separate apartment in their Aurora home.

Though West is still in pretty good shape, and has even made plans for a last grand vacation in France with one of her oldest friends, there's nothing about facing death that's easy.

“I'm not necessarily feeling right about every decision I've made," she said of the recollection of her life that she has undertaken with Morgan.

As cancer creeps up on her, West knows that her final arrangements won't be a burden on her son.

“He just has to put it in motion – a couple of phone calls," she said.

Adding spiritual care to the in-home medical care West receives is a joint project of the archdiocese of Toronto and Saint Elizabeth Health Care, the Catholic service that sends nurses to people's homes. Morgan, who used to work for the archdiocese's Office of Lay Ministry, does exactly the job a hospital chaplain would do, but her office is her Subaru Forester and her rounds take her up and down Highway 404.

Morgan's travelling chaplaincy job is an experiment, and there aren't many like her anywhere in Canada. Like any institutional chaplain, her services are available to anyone who requests her. West is an Anglican convert from the United Church of Canada. Morgan has no difficulty reaching across the church divide from her Catholic perspective, and the two pray together using the Psalms. Psalm 121 has particularly reached West in recent weeks.

“The LORD will keep your going out and your coming in from this time on and forever more," concludes the psalm.

{sidebar id=2}Once West had her will and funeral arrangements sorted and understood the nature of the palliative medical care she would receive, she made a decision.

“I was going to live from that moment on," she said. “I'm not going to die every day."

There  can be no doubt West is dying with true dignity. But she's one of the lucky ones.

According to the Canadian Hospice Palliative Care Association, only 15 per cent of Canadians have access to palliative care either in their home or in a hospice. Seventy-five per cent of the 220,000 Canadians who die each year die in acute care hospitals or long-term care facilities. Delivering palliative care in hospitals is stretching hospital and provincial health care budgets to the limit, and that limit is about to hit us all at 200 km an hour.

By 2020 it's expected the number of people who die in Canada each year will increase 40 per cent. We're not ready for those numbers, says Senator Sharon Carstairs, the minister with special responsibility for palliative care in the last government.

“The gaps are generally in rural communities," she said, particularly in northern communities and aboriginal communities.

Carstairs thinks the 15-per-cent with palliative care figure may be a little low, but she believes good progress is being made in finding sensible ways to deliver hospice care, particularly in Ontario where the province announced a three-year, $115 million “End-of-Life Care Strategy" in October. But that 40-per-cent number just over the horizon haunts her.

“What we need, and what we haven't had up to this point, is flexibility. Because, when hospice palliative care began in this country it was hospital-based care," Carstairs said.

Palliative care in the home is 40-to 75-per-cent less expensive than the same care in a hospital. A 2003 survey by the Canadian Hospice Palliative Care Association found that 86 per cent of Canadians would prefer to die at home. An earlier Angus Reid poll, however, found that only six per cent of Canadians felt they could adequately care for a loved one without some help from outside.

The idea isn't to kick every dying patient out of their hospital bed and download their care onto the free labour of their families. Hospitals and nursing homes will continue to be the best place for people who have no families, or whose spouses are too old and frail to shoulder the burden, or whose care is so invasive and complex that it requires constant medical supervision.

But more hospice care should be delivered at home, and that can't happen unless provincial health care systems ramp up capacity, said Carstairs.

“I have to spend more and more time with (provincial) finance ministers, quite frankly," Carstairs told The Catholic Register. “If you think about it, we know that the most amount of money spent on a person's health care occurs in the last six months of their life. If that last six months of their life is spent predominantly in a hospital setting, or a near-to-hospital setting, that's a 40-per-cent increase in costs of running our health care system. We have to convince them that if they don't look at alternatives their health care budget, which is already their most expensive budget, is going to go through the roof."

Churches also have an interest in a fully funded hospice care system as a way to recapture the definition of “dying with dignity" as something other than assisted suicide or euthanasia. In response to Bill C-407 – a now defunct private members' bill to legalize and regulate euthanasia introduced in the pre-election Parliament – the Canadian Catholic Bioethics Institute told politicians, “We do not need euthanasia and assisted suicide. Our hearts long for recognition, respect, friendship, community, a sense of worth and a feeling of belonging.... Look after our real needs as people and life will continue to have meaning, no matter what hardships and health problems befall us. Make sure the infirm, the vulnerable and the poor receive good long-term care in respectful and dignified surroundings. Make sure that they have adequate comfort, care and end-of-life care. Make sure they are never thought of as burdens to society. If these things are in place, would we still think that euthanasia and assisted suicide are the only ways to end our problems?"

The CCBI is so convinced that more and better palliative care can change the parameters of the euthanasia and assisted suicide debate they have invited Carstairs to deliver the annual Cardinal Ambrozic Lecture on the state of palliative care in Canada (March 3, 7 p.m., Alumni Hall, St. Michael's College, 121 St. Joseph St., Toronto). The CCBI is also dedicating its June 1-3 bioethics conference in Calgary to the issue under the title “True Compassion: End-of-Life Care for Body and Soul."

Carstairs understands that churches may wish to extend their long history of providing health care by concentrating future efforts in palliative care, but she doubts their capacity to make a contribution.

“The problem as I see it is that people have moved away from the churches as being the major vehicle by which they will provide service," she said. “Certainly it is no accident that the first palliative care hospice in Canada was at St. Boniface Hospital (in Winnipeg), which was founded by the Grey Nuns. There's nothing accidental about that. It's just one more example of church services reaching out. But (churches) could at one point count on a lot of their parishioners to be volunteers. Just as every organization is struggling with volunteers, so is the church struggling with volunteers. What fascinates me is that the group that is growing in volunteers by leaps and bounds is the whole hospice movement."

At best the churches might be able to encourage parishioners to volunteer with existing hospices, Carstairs said.

Meanwhile Marlene West is looking forward to her trip to France as soon as her old friend and travelling companion gets over her own cancer surgery. She's grateful that Morgan will be with her throughout her palliative care “to walk with me." Morgan is grateful for the opportunity to be there.

“It's really been inspiring to me," said Morgan. “To see all the ways in which Marlene has prepared."