We would like to thank all those who submitted their feedback and contributed to this policy review. While not every comment or suggested edit was incorporated into the final policy, all comments were carefully considered in light of current practice issues, the values and duties of medical professionalism, and the College’s mandate to protect the public.
Below is a brief summary of the policy review process, including an overview of the feedback received and revisions undertaken:
Who we heard from
658 submissions were received in response to this consultation.
Feedback was primarily submitted by members of the public, but we also heard from physicians, ethicists and a number of organizations such as the Ontario Medical Association, the Canadian Critical Care Society, Dying with Dignity, the Advocacy Centre for the Elderly, the Medico-Legal Society of Toronto, and health care regulators from other provinces.
Many respondents indicated support for the draft policy, even among those who had concerns with respect to specific sections or expectations.
The majority of survey respondents thought the policy was clear and easy to understand, and the vast majority of survey respondents supported specific draft policy expectations including those related to communication, advance care planning, and responding to wishes or requests to hasten death.
Much of the feedback focused on the draft policy requirement that consent be obtained for a do not resuscitate or no-cardiopulmonary resuscitation (CPR) order.
Those critical of the draft policy requirement argued that the law does not require physicians to obtain consent for a no-CPR order and that requiring consent to withhold CPR treats CPR differently than any other treatment and would oblige physicians to provide treatment against their professional judgment and outside the standard of care.
Those in favour of the draft policy requirement argued that CPR is unlike any other treatment as it is considered a default treatment option and that because decisions regarding CPR are inherently value laden, they should not be made unilaterally by physicians.
In addition to the feedback, we considered a wide range of other information while developing the final policy. This included:
A review of recent jurisprudence regarding end-of-life decision-making and in particular, the Supreme Court of Canada’s decision in Cuthberston v. Rasolui, 2013 and the Health Professions Appeal and Review Board decision in EGJW v. MGC, 2014.
Policies and guidelines of other medical regulators within Canada and internationally and other relevant documents from organizations such as the Canadian Medical Association and the Ontario Medical Association.
An extensive literature review which focused on a range of issues related to end-of-life care.
How we responded to your feedback
A number of revisions and additions were made to the draft policy in response to feedback. The majority aimed to improve the overall clarity of the policy and the expectations set out within.
Two of the more significant revisions are highlighted below, as is one important instance where revisions were not made:
The Advance Care Planning section of the policy has been updated to include a clear statement that advance care plans are not a substitute for consent and that they are meant to guide substitute decision-making.
Stakeholder feedback suggested there may sometimes be confusion about the relationship between consent to treatment and advance care plans.
Physicians must be aware of the role advance care plans can play in helping to inform or guide substitute decision-making.
The draft policy requirement that consent be obtained for a no-CPR order has been revised.
The policy requires physicians to engage patients or substitute decision-makers in a discussion before writing a no-CPR order and to engage in conflict resolution if there is disagreement.
While conflict resolution is underway, if the patient arrests, physicians are required to provide CPR in good faith and in accordance with their professional judgment.
The College is of the view that the legal requirements regarding consent and no-CPR orders are currently unclear.
In light of the lack of legal clarity and in response to feedback, new requirements regarding no-CPR orders have been developed that protect the public’s interest in having meaningful involvement and participation in these decisions, while being responsive to the critical feedback received through the consultation with respect to this provision.
Expectations regarding physician-assisted death have not been articulated in this policy.
While the Supreme Court of Canada’s Carter decision has implications for content within this policy, this decision is not yet in force and physician-assisted death is just one among many elements of end-of-life care addressed in this policy.
Expectations regarding physician-assisted death will be articulated in a separate document.
As the requirements regarding no-CPR orders were an area of significant controversy in the consultation and leading up to the Council meeting, these requirements were the subject of a rigorous discussion and deliberation by Council Members. In particular, one key issue Council debated was the requirement that physicians provide CPR, should the patient arrest, while conflict resolution regarding a no-CPR order is underway.
Members of Council recognized the difficult position this requirement may put physician in, but ultimately believed that the policy position was the best compromise position the College could achieve. Council Members reflected that:
The policy requirements place an important emphasis on early, good and thorough communication and education to avoid conflicts regarding no-CPR orders.
The policy respects patient autonomy in decision-making regarding end-of-life care and is responsive to the publics’ expectation that they be involved in these types of decisions.
To allow physicians to not provide CPR during conflict resolution regarding a no-CPR order would significantly undermine the conflict resolution process and the public may wonder how genuine or sincere the conflict resolution process is when physicians can make a decision at the bedside to just not provide CPR.
The final policy
The final Planning for and Providing Quality End-of-Life Care policy received final approval from CPSO Council on September 10, 2015. It is now a formal policy of the College of Physicians and Surgeons of Ontario.
The policy emphasizes that in end-of-life care situations, communication is of paramount importance. The policy requires that physicians communicate effectively and compassionately with patients and/or substitute decision-makers, in a manner and tone that is suitable to the decisions they may be facing.
Since advance care planning can lead to improved outcomes and quality of life at end of life, the policy encourages physicians to discuss the importance and benefits of advance care planning with their patients as a part of routine care.
In recognition that many physicians (including most family physicians) may have the knowledge, skill and judgment necessary to provide basic palliative care, the policy states that palliative care does not have to be provided by specialists in palliative care. Physicians are also advised that early integration of palliative care into a treatment plan can lead to improved quality of life for patients.
The policy encourages physicians to discuss options with respect to potentially life-saving and life-sustaining treatment as early as possible and where appropriate, as it is beneficial for these discussion to happen before events requiring a decision occur. The policy sets out the legal requirement that physicians obtain consent prior to withdrawing life-sustaining treatment. The policy also sets out the professional requirement that physicians discuss no-CPR orders with patients and/or substitute decision-makers and engage in conflict resolution when there is disagreement, including identifying and resolving misunderstandings or misinformation. If while conflict resolution is underway, the patient arrests, physicians are required to provide CPR in good faith and in accordance with their professional judgment.
Physicians are required to sensitively engage patients in a discussion when they express a wish or request for their death to be hastened in order to seek to understand the motivation for their expression and to resolve any underlying issues that can be treated or otherwise addressed.