Decision-Making for End-of Life-Care
Striking a balance that supports physicians’ professional judgment, while respecting patient autonomy
Following consultation, Council approved a policy that aligns with recent case law and sets clear expectations that physicians must consider a patient’s wishes, values and beliefs, while exercising their professional judgment when withholding resuscitative measures.
The Decision-Making for End-of-Life Care policy’s stance on resuscitative measures is informed by the Ontario Superior Court’s August 2019 decision. In Wawrzyniak v Livingstone, the Court clarified physicians are required to provide cardiopulmonary resuscitation (CPR) to a patient only when doing so is within the standard of care. A physician’s decision to withhold resuscitative measures is not “treatment” and, therefore, does not require the patient or substitute decision maker’s (SDM) consent, stated the Court.
There are times where it may be possible to resuscitate a patient, but the physician may determine the risk of harm in providing resuscitative measures outweighs the potential benefits. This risk-benefit calculation involves subjective value judgments. As a result, before making these determinations, the policy requires physicians to consider the patient’s wishes, as well as the patient’s personal, cultural, and religious/spiritual values and beliefs, if they can be ascertained or the physician is aware of them.
Given how important these decisions are for patients and their families, the policy also requires physicians do the following before writing an order to withhold resuscitative measures:
- inform the patient and/or SDM that the order will be written;
- communicate information regarding the patient’s diagnosis and/or prognosis, and explain to the patient and/or SDM why resuscitative measures are not appropriate, including the risk of harm in providing those interventions and the likely clinical outcomes if the patient is resuscitated; and
- provide details to the patient and/or SDM regarding clinically appropriate care or treatments they propose to provide.
When a patient’s condition is deteriorating rapidly and there is an imminent need for an order to be written, the physician can first write the order, and then, at the earliest opportunity, inform the patient and/or SDM that the order was written.
The aim of the policy 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, with patient’s 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, especially in this context. “In looking at end-of-life care issues through an equity, diversity and inclusion lens, the Working Group felt the need to emphasize the importance of clinicians engaging in this kind of analysis,” said Dr. Sarah Reid, a member of the Policy Working Group.
The policy provides direction on how to provide support should the patient or SDM disagree with the writing of an order to withhold resuscitation. If there is disagreement, the physician can write the order, but must, at the earliest opportunity after learning of the disagreement, make reasonable efforts to provide support to the patient and/or SDM. This includes identifying the basis for the disagreement, taking reasonable steps to clarify any misunderstandings and answering questions; reassuring the patient and/or SDM the patient will continue to receive clinically appropriate care or treatments; and facilitating an independent second opinion, where appropriate and available.
The policy also strengthens its expectations of physicians as it pertains to engaging with patients in advance care planning and goals of care discussions.