Consultation Underway on End-of-Life Care Policy
Council is inviting feedback on a draft policy that sets clear expectations and guidance for physicians on decision-making for the end of life.
The new draft policy, Decision-Making for End-of-Life Care, is an update of the current policy, Planning for and Providing Quality End-of-Life Care.
In aligning with case law, the draft policy further clarifies the expectations for physicians with respect to withholding resuscitative measures. In August 2019, the Ontario Superior Court released Wawrzyniak v Livingstone, which determined that physicians are required to provide cardiopulmonary resuscitation (CPR) to a patient only when doing so is within the standard of care.
Where a physician determines it is not appropriate to provide resuscitative measures to a patient, such as CPR, the physician is not required to obtain consent from the patient and/or substitute decision maker prior to withholding resuscitative measures or writing a do not resuscitate (DNR) order.
The draft policy recognizes physicians may consider a range of factors when deciding to withhold resuscitative measures or write DNR orders, and sets out different expectations depending on the relative risks and benefits of the resuscitation. This is consistent with guidance offered by other Canadian medical regulators and is supported by the research literature in this field.
Where providing resuscitative measures would be medically futile (i.e., no intervention could successfully resuscitate the patient), the draft policy enables physicians to write a DNR order but requires them to inform the patient and/or substitute decision-maker of the order “at the earliest opportunity.”
The new draft expectations are a departure from the current policy, which does not permit physicians to unilaterally make a decision regarding a no-CPR order and requires physicians to inform the patient and/or substitute decision-maker before writing an order.
Where the risks of providing resuscitative measures would outweigh the potential benefits (i.e., even if the patient could be resuscitated in the immediate term, it would cause them more harm than good), the draft policy enables physicians to write a DNR order, but requires them to first consider the individual patient’s wishes, values and beliefs as part of the risk-benefit calculation, and then inform the patient and/or substitute decision-maker of the DNR order before writing one. The draft policy does carve out an exception, permitting physicians to instead inform the patient and/or substitute decision-maker “at the earliest opportunity” when there is an imminent need to write a DNR order.
“Because risk-benefit calculations involve subjective value judgments, the Working Group felt it was important for patients and/or substitute decision-makers to know about and understand the rationale for a DNR order prior to it being written, unless the situation is urgent,” said Dr. Janet van Vlymen, CPSO President and member of the Policy Review Working Group.
The aim of the draft policy’s revisions is to strike a balance that both supports physicians’ professional judgment, while also respecting patient autonomy and the diversity of patient values regarding these important end-of-life decisions.
“The new expectation requiring physicians to seek to balance their medical expertise, and patient wishes, values and beliefs whenever making decisions about end-of-life care acknowledges that there is sometimes a tension between physician expertise and patient autonomy, particularly in this context,” said Dr. van Vlymen. “In looking at end-of-life care issues through an equity, diversity and inclusion lens, the Working Group felt the need to stress the importance of engaging in this kind of analysis.”
The draft policy also strengthens its expectations of physicians as it pertains to engaging with patients in advance care planning and goals of care discussions. It proposes requiring physicians to determine whether it is appropriate to initiate an advance care planning discussion, depending on a patient’s illness or medical condition, and, where possible, to initiate goals of care discussions when providing care to patients who are palliative, receiving non-curative treatment or at risk of clinical deterioration in the foreseeable future.