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In my opinion, it is important such a policy encourage early referral to ambulatory palliative care services when patients have advanced illness. There are many instances in which early referral results in better quality of life, reduced visits to the ER for pain and symptom management, and fewer hospitalized days. A randomized control trial of patients with metastatic lung cancer demonstrated early referral to palliative care services was associated with better QoL and even a significant increase in median survival.
Ontario has a shortage of ambulatory palliative care clinics in some regions (Southern Ontario especially). Incorporating early referral to ambulatory PC services into a CPSO policy may help drive additional funding to ambulatory palliative care, thus promoting the underlying principles of the draft document.
Given the complexity of End of Life Decisions and the varying degrees of intervention possilbe (ranging from resuscitative measures including CPR and advanced cardiac medications and intubation in the ICU to fluid resuscitation/volume correction and anti-biotics), one of the issues that might be addressed in a revision of the next policy is institutional use of a “standard DNR” or level of care form as these cannot address the complexity of informed consent and staff’s decisions are often based on a “preception” of consent – (eg. Mr X is a DNR – so he is comfort care, where an appropriate conversation about IV resusitation with Normal Saline may be appropriate)
The present guidelines allow for vague communications between caregivers. I will accept that with more evidence some issues can become reversible, but in the presence of some end of life decisions made elsewhere, a caregiver can frequently contradict the patients documented acceptable limits. This is best illustrated in the DNR for surgery.
I believe it is not by accident that there is a general openness to euthanasia or physician assisted suicide now, at this point in time, when the civilized world is being overrun by old people. This must be happening subconsciously since I have not read anybody discussing it in the open.
The danger of a positive attitude towards suicide, by whatever name, is the pressure that the victims might be subjected to, when arriving at the final decision, to alleviate all sorts of burdens, not only financial, on the younger generations in the family. I am sure that there are many older people living today, who would choose to die to make life easier for others, but are forbidden to even contemplate this course by their religion, morality and/or a general forbidding public attitude towards suicide.
I don’t know whether a psychiatric evaluation would necessarily disclose the true motivation of such an individual.
Otherwise, in my opinion,anybody should be allowed to end his life in a painless manner, provided temporary conditions such as treatable depression or other reversible disease can be ruled out.
I would encourage the college to tackle and hopefully clarify a position on dying with dignity. The policy in some US states where there are good checks and balances with a variety of specialists may help to alleviate some of the valid concerns regarding vulnerable individuals.
I would hope that the fear of some individuals potentially being coerced into making a decision would not prevent the exploration of very competent and rational people making decisions that are in line with their values and needs.
I also would encourage the college to take a comprehensive approach to the policy. The answer is not Palliative Care or assisted suicide – definitely excellent quality palliative care services should be available as well as options for people to decide how and when they die.
I think having this conversation would be very valuable so doctors have some guidance in these difficult situations.
I think it is time to update our position on physician-assisted suicide. There will always be a very few individuals who are facing death and wish to hasten the process. If their condition is progressive, they eventually lose the means to do it themselves. I do believe that this is discriminatory. And I think we can offer more compassion and support than is currently available. It would be a shame to renew this policy without addressing this contentious but extremely important issue.
A category named ‘allow natural death’ may be helpful in the policy, as well as ‘do not resucitate’ even though this sounds so negative, as if natural death is unnatural.
End of Life care ought to be broadened from the current management of an acute crisis (reference to discussion around CPR and ventilator support) to a more holistic approach to management of patients ‘Approaching the End of Life’. To often we see dramatic interventions (tracheostomy, oncological drugs and surgery, vascular repairs, orthopedic procedures ) in patients that have profound co-morbid conditions that make recovery to a reasonable baseline impossible. The emphasis on NOT offering futile care and a policy defense to the “do everything” approach must be provided to physicians. We struggle to find the courage to have these discussions and often are left offering ‘everything’ for fear of College complaints, allegations of inadequate care or litigation.
Your background may be strengthened by reference to 2 Canadian papers defining what quality EOL is to Canadians and what there high priorities are for improving EOL care.
1) Defining priorities for improving end-of-life care in Canada
2) What matters most in end-of-life care: perceptions of seriously ill patients and their family members
Your documentation on ‘advance directives’ may be a bit confusing. I don’t think they have legal status in Ontario but you say they do and encourage people to explicate their wishes for EOL care but then back peddle that they are not a substitute for ‘consent’. I think this could be more clearly worded.
Section 3.3 “Expected Death in the Home” is outdated regarding comments related to calling emergency services. Emergency responders are no longer obligated to begin resuscitative efforts provided a MOH-LTC DNR Confirmation form has been completed. The form can be accessed at: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=dnr&NO=014-4519-45 and is available to all physicians in Ontario.
An article outlining the purpose and use of this form was published in the Ontario Medical Review in 2007. Ultimately there should be sufficient caregiver support and resources that emergency services are not called when death is imminent or has recently occurred. Caregivers should be specifically counselled about this and planning should occur in advance regarding a person’s final moments.
A call to 911 often results from a failure to plan around the terminal event and results in a response from EMS,Fire and Police. Without a DNR Confirmation form unwanted attempts at resuscitation can occur but even if this doesn’t happen, the 911 response can be intrusive, unsettling and usually does not meet the deceased and caregiver’s needs.
3.4 Euthanasia and Assisted Suicide
Euthanasia is a deliberate act undertaken by a person with the intention of ending the life of another person to relieve that person’s suffering where that act is the cause of death.10 Euthanasia is prohibited under the Canadian Criminal Code.
Assisted suicide is the act of intentionally killing oneself with the assistance of another who provides the knowledge, means, or both.11 Under the Criminal Code, counselling, aiding or abetting suicide is an offence, and the consent of the deceased to his or her own death does not prevent criminal liability from attaching to the person who assisted in bringing about the death.
None of this is to suggest that physicians should refrain from the aggressive management of a patient’s pain and symptoms, as appropriate.
I would like to comment on this section of the CPSO Decision Making for the End of Life Policy statements.
I would like to see the CPSO come out in support of medically assisted dying for grievously ill patients who have requested help in ending their suffering.
Since this is currently unlawful, I would like to see the CPSO lobby for changes in legislation that would allow for this treatment.
I believe that medically assisted dying for grievously ill patients who have requested it to end their suffering should be part of a comprehensive palliative care treatment plan available to dying patients.
Thank you for the opportunity to express this opinion.
I think while extending life is a noble cause extending death or dying is a cruel thing to do. I think Euthanasia should be allowed on a case by case basis and a jury of 3 physicians should review the request and grant it if there is merit to it. This will be a good start and prevent coercion. There are truly sufferers like Dr. Lowe for whom life was an ongoing misery at some point.
I strongly believe that euthanasia should be an option in end of life care. I watched my mother die an excruciatingly painful death. Had she been an animal, we could have ended her suffering much sooner. There was no hope that she would recover, only continue to suffer. Why do we have the ability to treat our animals much more humanely than our loved ones?
I’m not so sure that statements like we euthanize animals because of compassion is in any way equivalent to being non compassionate in regards to humans. Many time animals are euthanized and not treated till the end b/c it is basically too expensive and there is not hospital system whereby this can be done nor should it be done at the expense the vast needs of many in our society.
Compassion is providing the very best palliative treatment at end of life and ensuring all people have access to this. Otherwise as with many things the ‘economic factor’ will eventually permeate this area of care if assisted suicide is comtemplated.
Then comment that euthanizing animals due to compassion equals being non compassionate if not done with humans. In fact animals are ‘euthanized’ in many cases due to costs and lack of a universal hospital system whereby this can be done. Nor should such a system be contemplated because it would take away money needed for the vast needs of humanity. Compassionate care means providing the very best palliative treatment(including all facets of life such as family support, clergy, dying in the home etc) being provided in a very timely manner and made available to everyone. Economics are bound to eventually ‘muddy the water’ if euthanasia is every contemplated no matter how many checks and balances anyone proposes.
I believe every one has terminal illness should have the right to end his or her live . We as physicians have a lots of limitation to treat and make people healthy and happy, these limitation related to the nature of the human physiology and human pathology. We can put the patient on coma by using medication but we can not cure the pain and other symptoms coming with it in terminal illness or advance disability. We respect the peoples wishes every day when we are not transfusing them blood if they refuse , or giving them chemotherapy if they reject it, or making them DNR if they want that.we should also sympathetic to those how are suffering for terminal illness , they need our help to die with dignity and respect. I think we are violating the right of those who wish to die because of advance physical illness.
Documentation of the seriousness of the illness must be articulated very clearly by at least two practicing consultants sending their own written opinion directly to the family physician of the patient.the physician should also obtain a singe consent by the patient and his lawyer.
The EOL policy is very good, I think, & doesn’t require a major overhaul. It should say something more about dispute resolution — In Ontario where a family cannot come to an agreement over the course of care, there is a judicial mechanism in place (The CCB) that ought to be / must be accessed; failing that an MD / hospital can go to the courts. This should only happen in rare circumstances. I also think it is too strong to say the patient has a “right” to any treatment that he / she thinks might be beneficial at the EOL. The patient has a right to be considered for treatment, but the exercise of that right will depend on resources, magnitude of benefit etc — all which can be negotiated.
Often DNR is treated as DNT ie Do Not Treat when simple measures such as IVF for Dehyration or Antibiotics for infection could remedy the situation. Physicians should be clear that a DNR order usually applies to case of Cardiac Arrest although confusion abounds. Otherwise I agree with points made in comment 6 and 8.
I readily confess my ambivalence about Physician assisted Suicide.
I feel strongly that there has to be a way for people with terminal illnesses to be helped to end their life with dignity rather than die in pain or humiliating circumstances.
Despite the teaching that adequate humanitarian care can be provided at the end of life that is certainly not so in Ontario for those with dementia. Just envisage someone with advanced dementia being sent alone to an E.R in Ontario, spending 16 hours strapped to a gurney in a corridor, which unfortunately is a routine occurence, often with worse to follow. There has to be a way that the wishes of the patient , spelled out when fully in control of their faculties & the wishhes of the family should be carried out.
i WATCHE MY MOM SLIPPING INTO DEMENTIA, WHEN DURING A BRIEF LUCID INTERVAL SHE ASKED ME “YOU’RE A DOCTOR, GIVE ME SOMETHING, I WON’T TELL ANYBODY”
SHE CONTINUED THE DOWNHILL PATH, AND SPENT THE LAST WEEK OF HER LIFE ON A GURNEY IN EMERGENCY.
I WAS NOT ABLE TO HELP HER AND NEITHER DID ANY OF OUR COLLEAGUES. SURELY WE CAN DO BETER THAN THAT. SURELY THERE IS A ROLE FOR COMPASSION, HELP TO END LIFE WHEN THERE IS NO REASONABLE PROSPECT OF HAPPIER TIMES AND WHEN THAT IS THE PRIOR EXPRESSED WISH OF THE PERSON.
As a physician i feel it is sad top prolong life when it has reached terminal stage.We are to help not prolong life by longterm life support systym.Like DNR patient should direct care to not prolong life in those situation.Should not be left to the substitute decission makers.It may not be always possible to give that consent but when given we must respect.
It is not assisted sucide but act of mercy.
I visited Dignitas 4 weeks ago in Switzerland as an extension of my practice which is focused on Palliative Care. Just before I went I watched Dr Low’s video made 8 days before he died. I agree with his views that Canada should review it’s position on Assisted Suicide. I also agree with the comment made on this page that very few patients would actually opt for this route. But for those who would like to have the option to orchestrate their demise surrounded by their loved ones,I believe that it is unfortunate that they have to travel to Switzerland to fulfill their wish.
I believe physician assisted suicide should be an option for those,who wish it. This is a freedom,we should give to the sufferers. I agree,that 2 or 3 physicians should be called to support the decision, to rule out a case of helpable depression or an economic issue. Also pressure by family must be ruled out.
When this is done the patient should be able to follow his/her choice. Ww must afford dignity and deceny to the dying.
I am in full support for end of life care at home. Physician presence is extremely important and a source of great comfort for the family. It should be an honour to be part of the “family”.I am also in favour for certification for death process at home.
College of Physicians and Surgeons of SaskatchewanI would suggest that there be a section on withdrawing life sustaining treatment in the policy relating to end of life. Unless the Supreme Court of Canada overturns the Rasouli decision, I understand the Ontario law to state that a physician cannot withdraw life sustaining treatment contrary to the directions of the proxy unless the Capacity and Consent Board makes such an order. If the physician cannot find another physician to provide the care which the first physician thinks inappropriate, they are mandated to continue to provide the life-sustaining treatment they think inappropriate.
This comment is with regard to Euthanasia/assisted suicide (E&AS), as per article 3.4.
Article 3.4 should be maintained as is and never E&AS should be allowed in the medical profession. Killing is not a treatment and therefore is not to be performed by physicians.
There are other professionals trained to kill: commandos, soldiers, etc. Doctors’ mission is to accompany patients in their suffering, sometimes by curing, sometimes by alleviating their symptoms, always by helping them navigate through the illness and difficulties. If someone wants to die, let that person do it on his/her own. For a doctor, suicide is a medical emergency that justifies even forming the patient. If some are for assisted suicide and insist to have E&AS legalized, go forth but allow it only through private companies and make sure no one with a diploma of MD is allowed to do so or becomes obliged to refer for E&AS. CPSO should never allow such situations where the patient-MD trust could become compromised. Patient’s safety and trust in MDs and the CPSO should not be compromised.
A doctor who comes to the conclusion that euthanasia is necessary would be essentially… incompetent in someway- maybe not incompetent in surgical or pharmaceutical skills – but incompetent at the level of emotional intelligence and that of a good understanding of what life is about, why we have to die and why there is suffering in our world.
Doctors often intervene and push treatments on some patients… to treat only but their own anxiety as they face situations they don’t know what to do with!
When a severe situation is happening to a patient, there comes a time to stop, look back with perspective, and realize that it is “OK” that the patient is going to die. Instead of focusing on painful, expensive, useless and more suffering causing medical acts, time should be taken to face death, talk with the family, explain the situation, make the patient comfortable, involve palliative care and arrange for good spiritual care. Palliation can deal with any situation, no matter how hard, and if some members are not convinced that this is the case, I strongly suggest that they bring those cases forward for consultation (through CPSO maybe?) with those who have the expertise to deal with such situations and remain opposed to E&AS.
End of life care is not about pharmacological and surgical interventions so much as about very personal and spiritual (not necessarily religious) accompaniment. The patient needs a team that “really cares”. This is not taught in books. Medicine is first and foremost a vocation (or at least should be), and only then a profession. The first will include the second, not the other way round.
CPSO and all physicians should conscientiously think about the impact of making euthanasia and assisted suicide legal. Do we really want to entrust our lives in the hands of a “lawful killer”?
Or with a physician who is ready to face suffering with his patient, not knowing when the end will be, but making the best of the time left and helping to find meaning in the last struggle.
Well said! My thoughts exactly.
The 2006 regulations of the college addressed physicians’ responsibility in obtaining advanced directives. For groups of patients where prolonged life-support is necessary such as those on dialysis, it is important that meetings with the patients and family be undertaken and documented in the chart. The importance of this is also stressed by other organizations in Canada and the USA. In the update that you are working on I would stress that this is a mandatory obligation for the caring physicians and affiliated caregivers ( nurses, social workers, pastoral care workers). In short, the chart must show a record of these interactions and explicit direction regarding advance care planning decisions for every patient/substitute decision maker for those on long term life support.
As a paramedic with many years of interaction with palliative care teams, emergency room staff and in my own practice, I have encountered end of life situations many times and have participated in the discussions with care providers about rescusitative measures. Physicians are ultimately tasked with the responsibity of these decisions and must live with the consequences. Wishes of a dying patient are too often taken out of their hands when fear of making the decision necessitates full rescusitation attempts and their painful,invasive procedures. Too often I have seen uncomfortable physicians initiate these attempts to relieve their own suffering. Better understanding of the process of dying and more support for palliative care programs will ease the burden on high cost Emergency Rooms and the stress on physicians. Making decisions for patients of this nature will lead to mistrust of the profession and opportunity to do “What’s best” for families and stakeholders rather than the patient.
Provided there is good safeguard for misuse it should be allowed.
I am against any move to legalize euthanasia as I fear it would result in grave abuse. There is the problem with depression in the elderly, which can should be cared for in a more human way than death, e.g. palliative care and psychiatric counselling. There is also the problem that some medications cause depression.
There is also the issue of elder abuse in which the family pressures the elderly person to end his or her life since they are a “burden” on the family.
Regarding Assisted Suicide & Euthanasia:
I think the position should stay as stated. MDs should not be involved in the ending of another human’s life. There is also significant evidence showing that PAS/E cannot be monitored safely enough to prevent unwanted deaths.
Abstract from CMAJ, June 2010, Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey & The role of nurses in physician-assisted deaths in Belgium
“Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request”
66 patients were killed without request, either by themselves or family!
“Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital”
Does that not sound like age discrimination?
“The life-ending drugs were administered by the nurse in 12% of the cases of euthanasia, as compared with 45% of the cases of assisted death without an explicit request”
It is illegal in Belgium for nurses to carry out the act.
In the USA, the fatal doses do not have to be administered in the presence of a healthcare provider. A patient may fill the prescription, and then be coerced, unknown to authorities, to finally do the deed, and there would be no investigation.
Half of euthanasia cases in Belgium are not reported (BMJ, Nov 2010)
“Approximately half (549/1040 (52.8%, 95% CI 43.9% to 60.5%)) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee. Physicians who perceived their case as euthanasia reported it in 93.1% (67/72) of cases. Cases of euthanasia were reported less often when the time by which life was shortened was less than one week compared with when the perceived life shortening was greater (37.3% v 74.1%; P<0.001). Unreported cases were generally dealt with less carefully than reported cases: a written request for euthanasia was more often absent (87.7% v 17.6% verbal request only; P<0.001), other physicians and caregivers specialised in palliative care were consulted less often (54.6% v 97.5%; 33.0% v 63.9%; P<0.001 for both), the life ending act was more often performed with opioids or sedatives (92.1% v 4.4%; P<0.001), and the drugs were more often administered by a nurse (41.3% v 0.0%; P<0.001)."
Disabil Health J. 2010 Jan. The Oregon Death with Dignity Act: results of a literature review and naturalistic inquiry.
"Review of the empirical literature on DWD in Oregon reveals a number of potential concerns, including inadequate demographic profiling of DWD requesting patients, inadequate mental health evaluations, insufficient duration of physician-patient relationships, potential inaccuracy of the six month prognosis, and inadequate exploration of alternative treatment. These concerns suggest that the DWD reporting system may be inadequate and lack sufficient safeguards"
Finally, I think it is important to emphasize, for ourselves as medical professionals but especially to the general public, the distinction between ACTIVE PAS/E and the withdrawal or discontinuation of medical care. Everyone has the right to a natural death as their illness takes them, and we should not fear death for our patients as they approach the end of their natural life, eased by comfort care.
1. the phrase “and families if there is consent” is problematic. This gives no guidance when the patient has become incapable, and the substitute decision maker attempts to limit communication with or visits from “family”. eg. “don’t let Uncle Fred come to visit, he just wants money” or “don’t let my no-good brother visit he just got out of jail…”etc. etc.
2.1 The definition of Advance Care Planning is also problematic” “……process of communication among patients, their health care providers, their families, and important others regarding the kind of care that will be considered appropriate when the patient cannot make decisions”. It is the capable patient communicating their wishes to their substitute decision makers and health care providers.
If the patient is incapable, and no previous advance directive exists, only a “treatment plan” can be made and the PG&T will not give advice on things like No CPR.
3.2 “Physicians are not obliged to provide treatments that will almost certainly not be of benefit to the patient.” – we need clarification on this with reference to the outcome of the Rassouli case. It seems that we are obliged to provide life-sustaining treatments that cannot possibly be of benefit.
3.3 Expected Death at Home
Some mention should be made of the need to fill out one of those ambulance transfer forms indicating ‘No CPR” so that it is kept handy at home in the event of a transfer. Without it, paramedics are obliged to initiate CPR even if instructed not do by the SDM
5.1 what are the designated health facilities? Do they include long term care or complex continuing care? Is this required in designated palliative care units or beds?
As a general surgeon of 34 years and having had extensive experience with cancer patients and end-of -life situations I would endorse the End of Life Policy. It is comprehensive and balanced with sufficient specificity where needed and avoidance of detail when it might confound or limit the wise approach in a particular situation.
One suggestion to consider under section 3.2: The writing of a “Do Not Resuscitate (DNR)” order. It is clear in the existing document that the physician is not obligated to provide treatment which will almost certainly not be of benefit to the patient. Due discussion, of course, is essential when refraining to offer/provide treatment in such a situation. However, I have been in situations where the family is adamant that all should be done, including CPR, in even futile situations such as terminal cancer. I have been in situations when 5 family members are on one side of the decision and 5 on the other side. There are, indeed, variable levels of understanding amongst patients and family members. In some situations, is the physician ever free to write the DNR order without patient or family consent, when a disagreement about CPR cannot be resolved by discussion? Also, there may be situations when patient/family discussion cannot be achieved due to various factors. In many parts of remote Ontario and other parts of Canada, referrals and second opinions are difficult to come by. Thus, a section clarifying a policy of writing a “DNR” order might be helpful. Some institutions have a form which provides options that are graduated in their resuscitation intensity. Regardless, there should always be a statement that a DNR order never displaces the need for compassionate and dedicated symptomatic and supportive ongoing care of patient and family alike.
I fully endorse the unequivocal statements in section 3.4 “Euthanasia and Assisted Suicide”. I sincerely hope that we never go the route of the Netherlands or Oregon. The last paragraph is also important but may provide a loop-hole for some to be over-aggressive with the unstated intention to speed a demise. At the same time, aggressive and appropriate palliation for intolerable pain may legitimately result in accelerated death which is only a secondary and non-intended effect. Matters of the heart (intention) are difficult to read! It might be good to place the section on Palliative Care just after the statement on Euthanasia and Assisted Suicide since the two need to be linked. Without doubt, our ability to control pain and suffering these days is very effective when knowledgeably applied. Not sure if universal Practice Guidelines for terminal palliative care are available. A separate policy or reference to such would be helpful in our current technological and economic climate. Are patient/family materials available to address these issues?
I am currently a medical student in Ontario and would like to comment on Section 3.4 – Euthanasia and Assisted Suicide.
I believe that the current position on Euthanasia and Assisted Suicide is appropriate and correct. It would be beneficial, however, if the current position were strengthened by providing an ethical rationale behind the prohibition of euthanasia and assisted suicide, instead of simply stating that these acts are prohibited under the Criminal Code.
For example, it would be helpful to explain that physicians’ primary goal is to improve the health of their patients, and that assisting a patient in their death would be contrary to that goal in all circumstances. Since euthanasia and assisted suicide involve the administration of death, the CPSO should remain firm in its current position. Euthanasia and assisted suicide should not be allowed on moral grounds.
In addition to the obvious ethical problem associated with both of these acts, any changes made to allow them would introduce the danger of euthanasia and assisted suicide being administered in inappropriate situations.
Compassion and respect for life are the foundations of medicine and thus Section 3.4 should be maintained as is.
Thanks for putting together this committee and consultation for CPSO’s policy on End-Of-Life care. I think this is an extremely important subject especially at this time in our society when this topic is heavily debated and there have been recent patients cases and law changes regarding it. After reading the CPSO policy, I think it is very succinct and provides useful information, especially the part about quality care at the EOL, with a focus on medical care, personal issues and relationships as all these are especially important to the patient care at EOL.
As a family doctor, it’s important to provide holistic care to patients at EOL especially when they are so vulnerable. I do not support physician assisted suicide or euthanasia. These options are not considered good care, but are rather a quick end to suffering at EOL rather than focusing on those areas I mentioned above relating to quality care at EOL. Many elderly and disabled patients will be taken advantage of if physician assisted suicide or euthanasia were allowed. It should be clear on the policy that withdrawing treatment in sick patients and administering high doses of pain medications to alleviate pain is not physician assisted suicide. Many people in the public and physicians are confused about these terms.
I look forward to reading an update to the policy. Thanks for your attention.
I have always believed that we have life as a gift from God, and it is He who will tells us it is time to go, and not some M.D. Because we are taking up a hospital bed. There is no excuse for someone dying in pain which seems to be the mantra of those who espouse euthanasia. It is the first step on the road, just as it was with abortion.
The Canadian Medical Protective AssociationResponse in PDF format
I just filled out the online questionnaire. The policy states that sustaining treatment should not be offered to patients who will be unable to experience and permanent benefit – this needs to be clarified to indicate that ordinary measures such as hydration would still be acceptable to patients in a permanent vegetative state – this has come up in some of my end of life discussions with terminal patients and healthy patients talking about advanced directives.
Board of DIrectors of Drugless Therapy - NaturopathyUnder the “Role of the Physician” section, the need for physicians to facilitate access to interdisciplinary care is emphasized. We support a collaborative approach to palliative care which involves complementary health care practitioners in a meaningful way to assist and support patients at end of life. We look forward to reviewing the revised policy.
I wish to support the end of life policy. I believe in supporting life from conception to natural death. My religious beliefs are very important to me.
As a Cardiologist who has spent many years looking after patients at the end of life We have a huge responsibility to provide good compassionate palliative care THIS DOES NOT MEAN we should assist patients to kill themselves Our emergencies are frequently rescuing patients from attempted suicide For MOST of these patients this act reflected an “emotion of the moment” and NOT a “trend of a lifetime”
Once we define that there exists ” HUMAN LIFE DEVOID OF VALUE” and therefore it can be terminated without legal implications — then HISTORY has already repeatedly shown us that this is rapidly abused DO NOT GO THERE
I am against Euthanasia and Assisted Suicide. I would like the College of Physicians and Surgeons of Ontario to support the dignity of the human person from natural birth to natural death.
A thoughtfully constructed policy, but also glad it is being further enhanced.
The policy would be strengthened if it provided further guidance for physicians when a patient or their substitute decision-maker specifically requests use of CPR or potentially life-sustaining treatments that the physician has judged will almost certainly not benefit the patient.
1. While engaging in conflict resolution measures, in the meantime, is a physician to comply with the patient/SDM and write an order for “full code”? Or is it still permissible for a physician to write a “DNR” order in this situation (and inform the patient/SDM that they are placing this limitation on treatment)? In other words, can a physician be forced to offer a treatment they judge is almost certainly non-beneficial? This seems conceptually different from the requirement to obtain informed consent for a treatment the physician has judged to be medically reasonable and is therefore offering. The policy currently states that “when it is clear from available evidence that treatment will almost certainly not be of benefit …., physicians should refrain from beginning … such treatment”
2. There is a paragraph in Section 4.1 (Conflict Resolution) that mentions a structure within the Health Care Consent Act for managing conflicts about treatment decisions for incapable patients. It would be helpful to also provide a summary that describes this structure and the relevant legislative processes.
Finally, although I am sympathetic to the arguments in favour of euthanasia or physician-assisted suicide, I am personally opposed to it. I do not believe it is ethical for anyone, including physicians, to kill another person because they are suffering. I think that on balance, the potential risks to individual patients (extremely vulnerable patients will be killed as a result of abuses of such a policy) are greater than the benefits it would afford.
Medico-Legal Society of TorontoResponse in PDF format
College of Physicians & Surgeons of AlbertaResponse in PDF format
Advocacy Centre for the ElderlyResponse in PDF format
Ontario Medical AssociationResponse in PDF format
Canadian Critical Care SocietyResponse in PDF format
I am saddened by what I see around me. Cases of terminal cancer are often simpler. But I see patients made palliative when there may be treatable reversible illnesses. This occurs especially in the elderly patients with dementia. I am not suggesting this is intentional. There is a lack of understanding, education and process. It is a complex and emotional situation where the needs of the patient, family and health care providers can become blurred.
Providers may end up responding based on their own biases and influenced by the “group opinion”. It is very hard to advocate for the patient in this situation. It is complex and their should be a process in place that has available resources such as an ethics committee. We all need principles and guidelines on which to base decisions. We do not have the right to project our own biases or play God in the lives of others.
I applaud the care with which the CPSO forms policies and, in particular, the policy regarding obligations of physicians in the provision of end of life care. I am concerned with any policy that would restrict the freedom of physicians to follow their conscience in refusing to provide non-emergency care or to refuse to make referrals in matters such as abortion, contraception, or other procedures which are contrary to the physician’s conscience. I believe that persons choosing abortion, euthanasia, or assisted suicide are usually making choices consistent with their beliefs and I have no objection to this. Personally, I believe that abortion, euthanasia, and assisted suicide are immoral and that I must act accordingly. While every effort should be made to provide compassionate care to those contemplating euthanasia or assisted suicide, including adequate pain medication, palliative care, spiritual and emotional support, any involvement in abortion, euthanasia or assisted suicide would be a grave offence for many physicians and nurses. In practicing nursing in Ontario and in nursing stations in the north (where I was the sole health provider}, I could not assist or participate in such actions. Legislation obliging me to do so or to make referrals for abortion or euthanasia would result in civil disobedience.
I urge the CPSO to respect the consciences of physicians in any policy pertaining to abortion of end-of-life care.