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I have been licensed for independent practice in Ontario for over 20 years, and my clinical practice is exclusively in critical care medicine. My comments will therefore largely relate to this draft policy’s potential implementation in ICU areas and for patients considered for admission to same.
If the CPSO is willing to provide this information publicly, I would be very interested to learn which Ontario intensivist(s) if any provided input to this document prior to its posting, and the names of the working group members or individual(s) principally responsible for its drafting for consultation.
line 221 “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.”
In light of the Rasouli decision, I would suggest this be changed to ‘propose or initiate’, as the Supreme Court has seen fit to require physicians to ‘provide’ same once initiated, barring SDM consent otherwise.
line 228 “Physicians are advised that patients and substitute decision-makers may assess the proposed treatment options differently than the physician as they may consider, for example, whether the treatment prolongs life even if there is no clinical benefit … ”
This is not a helpful ‘example’. If an intervention is anticipated to provide no clinical benefit, I believe most Ontario physicians would not consider such an intervention as within the standard of care, and would not propose or initiate it. I don’t think it reflects well on the CPSO to suggest tacitly that physicians SHOULD offer such interventions. While I accept that a reasonable physician might CHOOSE to offer a clinically useless intervention, and perhaps they should not be censured for same if there is some other purpose being met, I think the CPSO’s wording here may suggest to some physicians that the CPSO sees it as unreasonable to NOT offer clinically useless interventions, i.e. that a decision to NOT offer same is outside the standard of care.
240 “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.”
This statement (which has not been College policy to date, and I believe is a gross misinterpretation of the Rasouli decision) suggests that physicians are obliged to propose or initiate life-saving or life-sustaining treatments REGARDLESS of whether such interventions are within the standard of care, which violates the statement on line 221 and to my mind the Hippocratic oath as well. Given the statement in line 221, I believe the CPSO’s intent here was instead to suggest that 1) CPR must be offered as a treatment if CPR is within the standard of practice for a particular patient, and 2) if a physician does not feel that CPR is within the standard of practice for a particular patient, and therefore does not intend to offer CPR, then the patient or SDM must be informed that the physician is not offering CPR, and a No CPR or equivalent order must be written in the chart.
In light of the Rasouli decision, can I suggest that the CPSO also advise Ontario physicians how to tackle consent for discontinuation of CPR, which is most assuredly a life sustaining intervention. Conflict resolution strategies are obviously impractical during CPR, and yet a decision to unilaterally stop CPR (over the objections of an SDM who is completely unreasonable or unwilling to decide, after 20 minutes, or 1 hour, or 6 hours of CPR …, or when the SDM simply cannot be reached, and the PGT will not make a decision over the telephone) would presumably put the physician at odds with the law. Does the CPSO feel that Ontario physicians should break the law and make a unilateral decision to stop CPR when it is clear that the treatment is ineffective and therefore outside the standard of practice, or should the care team be obliged to continue CPR until the Consent and Capacity Board can convene to hold a hearing on the matter? While this situation seems bizarre to contemplate, the Supreme Court has created a real problem here and advice from the College would be welcome.
356 In order to minimize and/or resolve conflicts that arise, physicians must: … Transfer the care of the patient to another facility or health care provider as a last resort and only when all appropriate and available methods of resolving conflict have been exhausted.
How does the CPSO recommend that Ontario physicians pursue this recommendation? The CritiCall program deals with finding resources for patients who do not have a bed yet the physician feels they will benefit from treatment, not the converse. The CritiCall program therefore routinely refuses to coordinate transfer for this sort of patient. Does the CPSO feel that in such circumstances, Ontario physicians should be obliged to call one, or two, or all of the hospitals that the SDM provides on a list, or every other hospital in Ontario and elsewhere, when such calls will likely not result in acceptance given the circumstances? Some advice on what is reasonable and practical in the eyes of the CPSO would be a welcome addition to the document.
College of Physicians and Surgeons of OntarioThank you for your feedback. Your comments will be carefully reviewed as the draft policy is finalized.
In response to your questions, the development of this draft policy was overseen by a Working Group that included physician and public members of College Council as well as non-Council physicians, including two palliative care specialists. The draft policy was also developed in response to feedback we heard through a preliminary consultation on the current Decision-making for the End of Life policy. Through this preliminary consultation we heard from members of the public, physicians (including some who specialize in critical care), and a number of organizations (including the Critical Care Society of Canada). We don’t reveal the names of individual contributors, but a list of organizations and all of the feedback received through the Preliminary Consultation can be found at the following two links: http://policyconsult.cpso.on.ca/?page_id=2371 & http://policyconsult.cpso.on.ca/wp-content/uploads/2013/12/Decision-making-for-the-End-of-Life-Survey-Report_Final.pdf
Thank you for your insight. I agree
Well said. Whole-heartedly agree on the irregularities you highlight in the draft document.
I worry that the draft policy requirement around DNR orders is misunderstood. HPARBs decision was flawed in that it relied on the SCC decision to apply principles around withdraw of life sustaining treatment to withholding (the SCC went to lengths to say they were NOT commenting on withholding).
Please review the following paper: http://www.cmaj.ca/content/186/16/E622.full
ALSO… even if a DNR were a treatment, it would not be considered one under the HCCA where it posed “little or no risk to the patient”. In cases where it would be appropriate to unilaterally implement such an order (ie. where it falls outside the std of care), it is not the order that poses risk to the patient, but the resuscitation we’re trying to avoid.
I am a professor of health law and bioethics. I have two comments about Line 221: “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.”
There are two main problems with this statement:
1. Once offered or provided, physicians are indeed “obligated to provide” LST even if outside the standard of care at the time. This is core to the HCCA and the several Rasouli court decisions.
2. It is very difficult to ascertain the standard of care in the ICU context. There is remarkable variability from clinician to clinician and institution to institution. How should a treatment’s being “outside” the standard of care be ex ante determined? Yes, there may be some black and white cases. But should there be some review mechanism for grey cases?
I support clarification of terms used in the policy and in the absence of permission by the patient wherein a substitute decision maker would make choices and decisions regarding the final life stages or, in the case where physician(s) determine that the best interest of the patient is not being met by said decision makers, the empowerment of physicians to follow protocols allowing cessation of life supports enabling the patient to expire with dignity and the least amount of discomfort possible and not face criminal prosecution as it exists at this time. It will not mean more people dying, it will mean more people will be able to die with dignity.
The draft policy takes stands against “euthanasia” and “physician-assisted suicide”, but it says nothing about other life-ending decisions that might be recommended by physicians: 1. increasing pain-medication with the knowledge that the process of dying might be shortened. 2. terminal sedation—keeping the patient permanently asleep until natural death comes. 3. medical dehydration—ending all food and water when they are no longer helpful.
I am an intensivist. I 100% agree with response 1 and also share the concern that the draft does not reflect clinical reality in the ICU.
Explicitly stating after line 240 that if consent for a DNR is not obtained that the patient must be ASSESSED for CPR in event of cardiopulmonary arrest helps protect patients and also clarifies that extreme cases (decapitation, for example) would not qualify for CPR no matter what the SDM requests.
A physician who wishes to stop “futile” treatment could certainly be compelled in Ontario to go to the CCB as the Supreme Court implied – that is perfectly acceptable.
However, a physician who wishes not to offer “futile” treatment should be compelled to go through some reasonable steps (for example, communicate the decision to the family, get a second opinion, consult with facility policy if applicable, seek another provider willing to provide “futile” treatment). Once these steps are undertaken, all the regulatory agencies should explicitly endorse this stance in Ontario. The CCB process, while fast, cannot deal with these situations that need resolution within hours.
This needs to become a public health issue!
End-of-life planning is fraught with all kinds of problems if it is left until end-of-life, which is so often the case. Advanced care planning needs to take place through discussion with family and friends in homes and coffee shops not in doctors office or hospital ER. We have to make a cultural shift to accept death as inevitable and stop trying, as a medical profession, to convince people we can cheat death. I think the medical profession can take the lead by providing some of the many tools that already exist to help individuals and families start the discussion. We need to empower patients and make it clear we will respect their wishes. We need to make it clear that having a POA for personal care is not the end of advanced care planning but only the beginning. We need to stop talking about DNR and start talking about “allowing natural death”. We need to help families find ways to keep the care planning discussion alive over time. It is not a one time conversation. End-of-life discussions are much less stressful for everyone involved if they have started months or years earlier.
We need to understand that being compassionate is not easy. Nouwen says: “Let us not underestimate how hard it is to be compassionate. Compassion is hard because it requires the inner disposition to go with others to place where they are weak, vulnerable, lonely, and broken. But this is not our spontaneous response to suffering. What we desire most is to do away with suffering by fleeing from it or finding a quick cure for it.” Too often, in medicine, we try the quick cure or run away rather than going to the place where are patients are with their fears and vulnerability at end of life. Who decides what “loved ones” would want when there are no “loved ones”?
In 36 years of practice, I have never had a patient express a desire to die in hospital if home or hospice was an option..
Palliative care is just good medical care and patients shouldn’t have to be near death to receive it. We should stop suggesting the “standard of care” is good enough until the standard becomes much higher than it is today. I have never seen any document that tells me what the “standard” is in providing compassionate care to patients.
The section under “conscientious objection” makes me very nervous. Does this mean if I am morally opposed to assisted suicide I could be disciplined by The College?
I am a professor in the Faculty of Law at a university in Southern Ontario, where I teach an undergraduate and a graduate course in health law and policy. I have had a long standing interest in end-of-life decision making. I have been troubled by the often convoluted and questionable analysis provided by many judges and legal commentators. Their analysis often reflects their unstated ideological positions on these issues. Consequently, I read with great interest your discussion draft on Planning for and Providing Quality End-of-Life Care.
I was extremely impressed with the draft report. Although the cases and issues are complex, you have provided a succinct, accurate and clear explanation of the law. The document is easy to read and will be understandable to informed members of the public. The policy positions that the College has taken are eminently reasonable and legally justifiable.
I wish that the courts, legal commentators and other government agencies produced documents of this quality.
I’m a member of the public immersed in – and dedicated to – bringing to light the nuances of education around end of life issues[for patients, families and often healthcare professionals]. I feel privileged to sit on steering committees, advisory boards and am active in the ‘virtual’ world of palliative meds(twitter, blogs,youtube) I submit that as part of physician communications, a key component is acknowledgment that end of life planning is any one/and all of the following:
- often takes many conversations
- often no one right answer
- can be dissatisfying for both parties
- medical options and repercussions often confusing for patients
I would like to see the words – as essential to effective communication
- listening (power of, and importance of)
- Acknowledging personhood (as per Dr Harvey Chochinov’s Patient Dignity Question)
see also:Goals of care conversations: fact or emotion?
Thanks for the opportunity to comment!
I am a palliative care physician working in an acute care hospital. I am struggling with the apparent conflict between line 221 and line 240: “Physicians are not obliged to propose or provide life-saving or life-sustaining treatment that are not within the standard of care” and “The College requires consent for a Do Not Resuscitate order”.
In hospital, with some regularity, we work with patients and their families where the patient is actively dying from a progressive, irreversible illness where there are no longer any medically reversible issues. Some patients and/or their families struggle to accept this idea and continue to request aggressive intervention including CPR. I don’t believe that to offer CPR in these instances is or should be the standard of care. I agree with the policy statement that a physician can offer that if he/she decides to do so but where is the moment when the physician says “no, this isn’t the standard of care.” Does it have to wait until the moment of death when an team is called to assess that or should it be earlier which allows for more dialogue with the patient and family about what to expect and how to prepare. However, this latter approach would bring us into conflict with the requirement of line 240. Or, is the policy suggesting the we need to engage the CCRB in these instances.
I am an intensivist/internist and I agree with this comment entirely.
Re: 221 – Who defines “standard of care”?
If a “full code” (lack of DNR) approach is felt to be outside the standard of care, then is consent still required for this approach – per 240?
I also agree with the points in the first comment.
I feel strongly that certain life-sustaining measures should be able to be decided by the care team (e.g. CPR, use of invasive mechanical ventilation), especially when families may only be able to make decisions that focus on emotional needs, instead of achievable goals.
Forcing physicians to try to revive suffering patients at the insistence of a grief-racked family member would be a really big problem. Really big.
It sickens me to realize the ramifications of euthanasia. For thousands of years human kind has honoured the statement THOU SHALL NOT KILL. Too terribly simple.
Nowhere have I seen it said “my will be done”
Yes, but if I am on an apparently irreversible decline toward death, I am not interested in your will or your god’s will.
You are welcome to set whatever criteria you want for the end of your life, but when it comes to my life I insist on the right to say halt, enough.
Firstly, you can already say halt at any time. Today, you can refuse treatment. No doctor can treat you without your consent. Secondly, you can also kill yourself at any time in hundreds of different ways. And thirdly, you already are on an irreversible decline towards death, as I am too, and as all living things on this planet are.
Under the present law (apparently supported by the CPSO) one cannot call a halt to their life or suffering, they can only choose to halt treatment. This may still condemn an individual to a long, drawn out and unspeakably grotesque death. There are NOT “hundreds of different ways” to kill oneself in a RESPONSIBLE AND HUMANE manner. Due to the withdrawal of barbiturates from the Canadian market, there are now few methods readily available to end one’s life in a safe and painless way (excepting the use of helium & an exit bag), and those whose health is already impaired may not be able to carry out such measures. Also, please don’t intentionally misconstrue what the previous contributor was intending to say: it is obvious that when they say “an irreversible decline towards death”, their comment refers to untreatable chronic or terminal illness. I completely agree that the disrespectful attempt to impose one’s religious views on others is at the heart of most resistance to physician-assisted suicide.
I appreciate the work that has gone into this policy.
Unfortunately, no policy will be able to avoid or cover every medical/ethical dilemma. End of life circumstances are unique.
I read with great interest the many comments in the forum, and appreciate you really have your work cut out for you. Many of them brought up relevant items that I would like to see addressed.
1. I found the wording in Section 4 and in particular 4.1 confusing. We jump from no treatment without consent and then going into the withdrawal of life sustaining treatment requiring consent. I understand what you are saying but I almost prefer that the next section 4.2 deal with the fact that withdrawal of treatment requires consent as well.
2. Line 128. reassess capacity as appropriate. I think you should provide us with info how to properly assess capacity, what we should document that would support that someone is capable or who can do this for us in a timely fashion. (Neuropscyh testing, consent and capacity board?)
3. In section 5.2 Is paragraph 2 and 3 starting line 221 to 235 – not helpful paragraphs. As many commented on discussion forum – Rasouli case kind of said the opposite. Further standard of care…who defines that in these ethically ambiguous situations. It’s just not helpful.
4. Section 7 Wishes to Hasten death; I think well done, especially with respect to resolve any underlying issues. But what if with all the underlying issues resolved the patient still wishes to hasten death. I think with all the media attention on Death with Dignity with certain recent cases in the news, it would be nice for the college to comment at least . I think even to say we currently have no policy for this or there may be a role for death with dignity but requires further collaboration and consultation.
5. I don’t what understand section 8.3 is getting at
Just on a personal opinion note. We are in a public system that is as very patient centred. This in itself is hard to reconcile in terms of limited resources. I feel the college does not ever attempts to address this – the focus is always very patient centric only.
I have reviewed your policy line-by-line and have considerable commentary and questions, which I have inserted into the document. (Click here to access the document).
I am concerned about lines 236-240, which compel a physician to obtain consent for a DNR order. I have always believed that it would be unethical for me to provide a service that I felt was not clinically indicated. If in my considered professional judgement a patient could not benefit from a procedure, then providing it would not constitute medical care, but assault. So if I were to judge that a patient was dying, and CPR could not possibly be of benefit to the patient and was below the standard of care, for me to carry out CPR would not only be profoundly unethical, but quite possibly illegal. Doing CPR on a patient actively dying of an irreversible condition can only be described as beating someone to death. How can the CPSO compel me, under threat of losing my license, to carry out a procedure that I know is wrong? Can I be forced to act unethically? What mechanism does the CPSO, or the courts have to force me to act against my own professional judgement?
And as a medical professional, plus a person who has had numerous medical issues, I would NOT want someone to perform CPR on me, (if my power of attorney had not gotten to the appropriate person in time to say I did not want CPR)
,… And then have to be held accountable in any way shape or form, because they withheld trying to save my life, by performing CPR and maybe extending my life into a worse condition!
Is it ethical and standard of current care to provide CPR to 88 yrs old patient in Nursing Home with advanced dementia when family requests it?
I would like a clear answer to that question as I ,as a physician and a human being would never be able to attempt it.Staff and paramedics are first responders in above circumstances and it is a tremendous stress for them….
the courts have any sanction other than the legal threat of fines or a contempt citation with jail time I suppose. I was involved in a real life case where i was ordered by court to provide potentially painful “care” to a patient who had no hope of benefiting. I refused as did my colleagues. In the end, you have to be able to live with yourself.
I mostly agree with comments made by response #1. In particular I’d like to expand on the very frustrating concept brought by line 228, where physicians shall be obliged to prolong life even if there is no clinical benefit.
The College is responsible for making a more clear distinction of who is benefiting from treatment. When SDMs solicit LST for an incapable patient AND a clinician believes the treatment is not standard of care (no clinical benefit), the prolongation of life is only supporting a selfish demand from SDM, while prolonging suffering and offering poor end-of-life care. While a capable patient may wish for prolongation of life to allow for family, religious or other activities, an incapable patient will not benefit from this extend period of time. I agree with others that being forced to provide such therapies violate the Hippocratic oath.
This policy should consider the following cases:
1. Will a surgeon be forced to operate on a patient with multiple organ failure and a perforated, dead bowel if they believe there is no possibility of recovery?
2. Will an intensivist be forced to provide hemodialysis for the same patient, if a surgeon has already decided not to operate?
3. Can a neurosurgeon be forced to perform a decompressive craniectomy for a patient deemed unsalvageable? It’d certainly prolong life for a few days/hours.
4. Should an oncologist be forced to deliver chemotherapy for a dying patient in the ICU if he/she believes there is no clinical benefit?
5. Are we going to be forced to consider ECMO for all patients with refractory shock? It would certainly prolong life for a few hours/days as well.
The college should provide a real example of how this piece of the policy would help patients (not their SDMs) in achieving good end-of-life care. It will be important to make a distinction between requests to prolong life (w/o clinical benefit) from a capable patient, who can interact versus requests from SDMs of patients who cannot interact and are only at risk of non-beneficence and potential harm. Harming a patient to satisfy the SDMs wishes is something that we should be ashamed of doing.
First of all I don’t believe there is such a thing as dying with dignity as society calls it. We all should die when God permits it and or wills it Although I realize that some people really suffer there is or should be palliative care and help for depression . As for physician assisted suicide : no doctor should be asked to help another kill themselves and definitely no government law should coerce a doctor to kill another human being and this by the way includes abortion
What about those who do not consider such an entity as God exists?
There are hundreds of different gods in this world and I have chosen not to follow any of them. Please keep your biases in favour of your own specific gods for yourselves and do not impose your beliefs on other human beings.I would not impose mine on you but I believe that you and I must have options that will allow us to die with assistance from our physicians when the time comes and the safeguards have been respected.
I do understand that arguments based on religious authority do not appeal to people who do not accept that authority, but persons of religious belief do have a place in the discussion: persons with religious belief constitute a huge proportion of the public, and not a few physicians too. For those in this discussion who have no religious belief, it is probably best not to react with antipathy to the belief, but simply to treat religious arguments as ethical ones, and address then accordingly.
I do not react with “antipathy” when someone of religious belief tries to impact public policy in such a way that it impairs the rights of secular people to choose for themselves. We don’t just have freedom of religion in Canada, we are supposed to have freedom FROM it to! Please do not equate logical ethical arguments with religious belief…they are very different things.
There are truly reflective and educated responses shared on this discussion board, and I believe there are some clear commonalities among the feedback that speak to the health care professionals’ desire to provide the best patient/family experience possible during the one of the most difficult times in life.
I am writing to share my thoughts specifically about section 240 “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.”
In my work as an ICU social worker years ago, I witnessed physicians that had differing practices related to DNR. Some physicians did not offer treatment or resuscitation to those patients where the treatment would not be of benefit (or futile), and other physicians who would go to the families to ask to “make the decision’ on whether to perform CPR or not, even where it would be considered futile by many.
Of the situations where physicians would turn to the families for a ‘decision’, these families were often left with lasting questions and the burden of whether or not they made the ‘right decision’. This burden is extremely emotionally difficult and often remains with the decision-maker for years.
The expertise & knowledge of the physician should guide what treatment is offered, based on the medical evidence, allowing the natural progression of the illness to take place.
I believe that this section requires a change, as many of the others earlier have noted.
I am also a CC physician, and I would echo the statements that line 240 is a gross misinterpretation. I believe we have to duty and obligation to disclose and inform, but if a treatment is not indicated, consent is not required to not offer that treatment. Consent is required for withdrawal of existing treatment, no one would argue or debate this point.
We do not require consent when we do not offer any other treatment (e.g. surgery for a patient with non-operable disease). CPR is a treatment with cases where it is not indicated.
The need for dialogue is absolute. However, consent is not always part of this discussion, as reflected in line 221. Line 240 is not appropriate, as it inherently contradicts line 221.
Clarification is required here: is CPR “not indicated” because it is believed that it will not be effective in resuscitating the patient, or is it “not indicated” because the physician believes the patient’s overall prognosis and/or quality of life is poor. The latter is a value judgement on the life of the patient, and it is simply not appropriate for physicians to make such judgments on their own.
I am an intensivist in Ontario. I provide care to many critically ill patients every year, many of whom are in the process of dying. When it is obviously outside the standard of care to provide CPR, how can we be required to obtain consent for a DNR order?
I must obtain consent not to resuscitate a patient with diffusely metastatic cancer without components of their illness that are reversible if the patient is in the process of dying unless I have consent? This is inconsistent with current medical practice and would represent exceedingly poor end of life care. Currently, CPR would not be indicated (line 221-222). However, if I don’t have consent (line 240), I must resuscitate. This is contradictory and will not serve our patients or our families well. I would strongly recommend revision of line 240.
Of particular concern to me is the circumstance where invasive physiologic support is clearly not indicated yet I must provide CPR. This will harm patients, harm families and affect our ability to provide quality end of life care.
I also think the CPSO should be stronger in their language around organ and tissue donation (item 10). Every family should be provided with the opportunity to communicate their loved one’s wishes prior to withdrawal of invasive support. Physicians should strive to ensure TGLN has the opportunity to evaluate (and subsequently approach) all families who have consented with withdrawal of support if they are eligible for organ and/or tissue donation. This is an integral part of end of life care. We should stop making this decision for families – we have stated emphatically in many other areas that we cannot make decisions at the end of life for families. By withdrawing without referring to TGLN, we make the decision that the patient would not have wanted organ and tissue donation as a component of their end-of-life care. The CPSO must advocate for patients and families in this circumstance.
I am an academic intensivist and have concerns about the new policy outlined in line 240 regarding consent being obligatory for DNR. This is contradictory with other policy lines and is disadvantageous for patients and for physicians. Cardiac arrest is most commonly a terminal event and requiring consent to NOT resuscitate implies to patients that they are opting out of some kind of program that could otherwise extend their life (only happens in a minority of cases). Further, the fact that so few consent discussions for DNR will be provided by experts in resuscitation will all but ensure that the dialogue about this topic will be heterogeneously delivered by providers of all levels and specialties. Further, the absence of fee schedule incentives to have these discussions with primary care providers will result in a high proportion of these discussions happening, as they do now, under duress during acute illness.
I suggest if you wish to change the culture of our practice, that you do so in an organized fashion that could make this a quality improvement initiative (i.e. DNR discussions held by GPs, web-based resources for patients on the topic) rather than a unilateral, controversial and isolated policy change.
Thank you for your consideration.
Agree with this completely.
Line 240 is misguided. If a patient is dying, DNR is implicit. Resuscitation would only serve to harm (or torture) the dying patient. This line must be removed.
The college mandating physicians seeking a DNR not only sends contradictory messages to family, who now get a message that “something” can be done, but in so doing undermines the team.
I think the guidance is acceptable as is. Line 240 only serves to weaponize a misguided statement into what will be enforced as law.
Lastly, the Rassouli case dealt with withdrawal of life support. Even the supreme court justices could not come to concensus, and they did state that the structures for dealing with these scenarios exist and should be used.
The implication here is that the life of a dying patient is of value sufficiently small that attempted resuscitation is of no merit simply because the patient is dying. It is not so simple. Time at the end of life can be precious: time to reconcile, time to say goodbye, time to stop doing and simply be. I understand the frustration of a physician who saves life facing a patient whose life (s)he cannot save, but can, at best, simply extend for a while. But the value of that extension of life, however short, is not solely a question of medical judgment, and should not be left to the physician alone.
But who is that extended time for? The patient who receive CPR for irreversible/terminal cases are not in any shape to participate in that “extended time”. While I understand that emotional value for their loved ones, we would be doing that at the cost of the patients well-being. In the end, HCP are obligated to provide care for the patient.
Every death in human history has a common pathway of cardiopulmonary cessation. To state that the default is to be compelled to provide CPR in all cases does not make sense.
As a practicing intensivist, I am very conflicted by the statements made regarding line 221 and line 240. They are, for all intent and purpose contradictory. DNR implies CPR, defibrillation, and life sustaining therapy. You cannot, in a draft policy state that as physicians we are not obliged to propose or provide, but in the case of DNR, we MUST consent. This is inherently misleading.
As an intensivist, many of us have these difficult end-of-life discussions with SDM’s after having gone through a period of very aggressive, life-sustaining therapies in patients that for many, would have been considered hopeless. In light of the recent Rasouli case, it appears that the Consent and Capacity Board will be busy, as we may need to constatntly call upon them when there is a conflict between the medical treating team and the patients. Thankfully, these incidences are rare, but it leads to a potential for physicians to practice in an inherantly defensive manner. In an ideal world, these decisions should be discussed and made in advance. It may be more worthwhile for the executives to focus more time on creating a draft to mandate advanced directive planning with primary care physicians rather than having the bottle neck take place when patients are on the cusp in hospital.
As an intensivist but also a member of society, the contradictory statements made in this document, namely “no obligation to offer or provide care LST outside of standard” and “must obtain consent for DNR” are harmful to the profession, healthcare users and the harmonious relationship between them that we continuously try to cultivate. The many excellent points raised in this discussion I hope serve well to have the CPSO further reflect on the wording of this document and more importantly support the healthcare professionals and the patients they treat who navigate through these gross contradictions and poorly anticipated holes. Perhaps more involvement from grassroots/frontline providers could have avoided such profound oversights?
Thank you for highlighting the importance of medically indicated care. However medically indication usually ties together some idea of benefit.
Need to clarify ‘medical benefit’
vs ‘health related purpose’
228-230. I don’t think the example is fitting. Rather I’d focus on that the simple fact that SDM/Patient may identify benefit in a manner that differs from the physician.
240 Consent in this circumstance can conflict with 221-222.
Two interesting statements: 1. Canadian Critical Care Society 2. a recent article.
It is generally better to provide treatment, with a strategy in place for later withdrawal if it is either of no medical benefit or proves too burdensome… – Witholding or Withdrawl of Life Support – The Canadian Critical Care Society Position Paper.
Critical care physicians must continue to offer trials of therapy in which medical benefit is uncertain or improbable, because a given patient may ‘beat the odds’ and this outcome is to be celebrated – Can J Anesth 2014 61:951-958
I am an intensivist and, therefore, will address the policy from the perspective of the ICU. My concerns echo those articulated in response #1. To emphasize, I believe that CPR should be considered a treatment like any other, that is, an intervention to be offered by a physician if deemed to be of benefit to the patient. Requesting consent for a DNR order goes against this principle. Physicians are trained not only to establish diagnosis, but also to develop an appropriate plan of care based on the treatment options available and the particular circumstances of each individual patient, which includes of course the patient’s own preferences and beliefs. Forcing consent to be obtained for a DNR order suggests that physicians must be coerced into practicing proper medicine and, further, violates their professional autonomy. It is a misguided attempt to protect the patient, where no additional protection is required beyond the existing code of ethics of the profession.
More generally, the Rasouli decision, which requires physicians to obtain consent to stop a treatment once initiated, even if the treatment, while originally potentially useful, has since proven itself futile, has introduced a new barrier to providing appropriate care to some patients. Similar to the DNR order issue above, the physician’s knowledge, experience and recommendations are made subordinate to the decisions of the SDM — even when a choice should not exist if the best interest of the patient were truly at the center of the decision-making process.
I was touched by the comment of a social worker: that physicians, by placing the burden of decision-making on a grieved relative, caused that person immense distress that could last a lifetime.
In summary, I believe the policy must be amended to restore appropriate physician autonomy. Under the pretense of protecting the patient, the policy may actually lead to increased patient harm, increased distress and grief for the SDM and other relatives of the patient. It also sets the stage for inappropriate use of limited resources, causing harm to society at large and specifically to those patients who would otherwise benefit from the resources now squandered to no benefit.
The resource argument is a classic utilitarian one: dying patients take up resources that would better be used to preserve the lives of patients who are not dying. This is a key reason why physicians should not be the sole decision-makers about life-sustaining treatment: if other patients being treated or potentially being treated by the physician stand to benefit from the freeing-up of resources used by the dying patient, the physician is in a conflict of interest. This makes it all the more important to have others involved in the decision-making.
I am an intensivist. EOL care is part of my daily work. In fact, it is probably the most important and the most prevalent aspect of my daily work in the ICU. I have had the opportunity to observe and participate in countless examples of futile care at the EOL. Such “care” is well known to be associated with increased suffering and decreased quality of death for patients, as well as significant stress for families.
I meet on a daily basis with patients and families to discuss the pros and cons of life support and CPR. In the vast majority of cases, lay people are uninformed regarding the processes and the expected outcomes of life sustaining treatments. As such, they have entirely unrealistic and often unachievable expectations regarding the application of aggressive interventions, such as CPR, in attempts to overcome natural processes of death. This is not an opinion, but a well documented phenomenon in the literature. In my practice, it is a DAILY event for family members to refuse to consent to witholding CPR in futile situations, where it can only lead to harm.
I am very concerned about the statement, “The College requires physicians to obtain consent for a “Do Not Resuscitate” order”; which conflicts directly with the statement, “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care”.
I think it is essential to involve patients and their substitute decision makers in decisions regarding their care at EOL. Advanced care planning, undertaken in advance of critical illness is the ideal way to do this. However, when things go wrong quickly and these complicated discussions have not been had ahead of time, it is wrong to handcuff care providers and oblige them to provide interventions that are likely to cause harm and increase suffering at EOL.
If the government and the public want to know why the costs of healthcare are skyrocketing, they need not look any further than this issue. The provision of futile, often painful, interventions to attempt to prolong life in the face of natural processes of death, at the expense of patient comfort and dignity, is the biggest problem facing our healthcare system today. The contradictory wording of this policy will, unfortunately, perpetuate the situation.
I both agree and disagree. While I agree that excessive interventions to prolong life can be and often are a problem, I don’t think the wording of the policy will perpetuate the situation. Rather, I think it will help: it will require physicians to engage earlier in conversations with family members, knowing that the difficult questions about life-sustaining treatment cannot be dodged by unilateral decision, but must be made in consultation with them.
This policy needs clarification on several issues:
1) Section 5.2, lines 221/2
“Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care”
My interpretation of this is that any patient who is made palliative should automatically be also made DNAR/no life-saving interventions given that the policy statements by CCO and palliative care societies consider dying in critical care as substandard palliation care – is this correct? If it is, why is this not made explicity clear in the previous section on palliation? If this interpretation is correct, then physicians who speak to patients about palliation should include in that conversation that they will not be resuscitated when they die and no further conversations around DNAR or life-saving interventions should have to occur as they commonly do now.
2) Section 5.2, line 240
“The College requires physicians to obtain consent for a “Do Not Resuscitate” order.”
I am confused. When a neurosurgeon tells a family that an operation will provide no benefit for a catastrophic ICH, do they need to obtain written consent for a “No neurosurgical intervention?” The witholding of interventions that could be considered life-saving and life-sustaining is done every day throughout our entire healthcare system without the need for consent, why is the CPSO only creating this requirement for ICU-directed care? This policy will ultimately require the same of every discipline throughout our healthcare system. This policy statement is the entry point for every patient and their family to insist/litigate on every kind of intervention no matter how futile as it sets a legal precedent for argumentation.
I hope the CPSO does not move forward with this policy as is as I fear it will result in catastrophic consequences for the entire healthcare system.
Line 240 currently reads “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.29″
I suggest a much more reasonable statement should read “The College requires physicians to inform the patient/SDM about a “Do Not Resuscitate” or “no CPR” order. This allows the physician and the patient/SDM an opportunity to clarify values and goals with respect to CPR as a prescribed intervention at the end of life.
I fully support the work you are trying to do
It is with great concern that I see your discussion paper on Quality and en of Life
I urge you to take this to all people in Ontario and Canada and be transparent and have an open dialogue.
We should not be forcing physicians to quickly agree with someone who has not tried to take other measure to recover their health back before they want to end what they think may be a present terrible senseless life.
We need strong measure to ensure those with elderly parents, who have the” POWER of Attorney”, will not step in to end their lives as it inconvenient and they will sooner get their inheritance or holiday trip of a life time. There are so many issues to guard when we look at LIFE, your life and my life.
You were not responsible for beginning a life, You are to protect it and assist those who are sick. Is it really a physicians right to End someone’s life? And to do no harm.
You are killing the body, when you assist suicide. The body does that naturally. Can all not accept that and help make our sick people comfortable not just ‘end it” You are taking the quick way out. I have a feeling you have looked at amount of money you can save our health care system and the ” Saving our Dollar spent” heavily in mind.
Again, why not promote healthy living so people will not become so ill and use up money. Let the body do what the body does naturally and stay out of the End of life but administer to the sick to make the sick as comfortable as possible.
There is already an Almighty Power that deigns this , and it is not the responsibility of the College of Physicians and Surgeons to end someone’s life.
Your Almighty Power may design your death, but I neither have nor want one, so I guess I am stuck with the College and its policy.
Obviously my body will die eventually. But if I want to die earlier, I politely ask that you and your Almighty Power do not butt in.
Totally agree the smartest and profound comment
I am a strong proponent of End-of Life assisted dying. I witnessed this first hand with the passing of my terminally ill wife in 2011. I wish this on nobody. My final wish is that “I” can have the legal right to make my own decision, at end of life. I respect your possession, but hope and pray that the Government at some time “soon”, will pass this law to allow End-of-Life assisted dying.
Assisted suicide is an issue that needs discussion and action. It is egregious that an individual cannot determine when she/he wants to die. There are several countries/states which permit this and we could use them as a guide as to the best way to handle and to eliminate any negative aspects to it if they exist. Surely a system could be set in place where doctors who are willing to assist do so and those opposed to it may abstain from the program. It would allow individuals to determine when they wanted to die, as opposed to heading to Quebec of Switzerland.
Ethicist with 10 years of practice in health care organizations, mostly in acute care hospitals. Along with many others here, my feedback relates specifically to the section on CPR and life-sustaining treatment.
While we had a complete lack of legal clarity on these issues several years ago, the recent Rasouli and HPARB decisions have provided clarity in some areas but have also left Ontario physicians in an extremely difficult position for the following reasons.
1) There has long been a professional ethical consensus that physicians should not be obligated to provide non-beneficial treatment, and some court decisions (including Rasouli) affirm this.
2) Rasouli has established that physicians must obtain consent to withdraw life-sustaining treatment, but did not address withholding treatment.
3) The judgment in the Cefarelli case suggests that not offering CPR as part of a treatment plan can fall within the discretion of the physician.
4) The recent HPARB decision suggests that physicians must inform substitute decision makers about a decision to not offer CPR.
So if a physician uses his/her discretion to not offer CPR (or any other life-sustaining treatment), informs the SDM of that decision, and the SDM insists on CPR (or other life-sustaining treatment), we find ourselves back to square one. Negotiation, communication, ethics consultation, etc. can sometimes help in these situations, but there is still legal clarity lacking regarding the physician’s authority to withhold treatment in spite of the SDM’s demand. I suppose the answer is to take the case to the Consent and Capacity Board, but that’s an avenue that many physicians aren’t willing to take.
One other comment: reliance on the concept of “standard of care” is problematic because it depends on the reasonable physician’s practice. The reality however is that most physicians do admit to providing treatment they perceive as futile or non-beneficial because they feel forced to do so. I would recommend using an alternative concept, such as “not clinically indicated” or “not medically beneficial”.
It is hard to see how going to the Consent and Capacity Board in such a case would be helpful.
Patient has died. SDM wants patient beaten back to life. Doctor says it is futile. Doctor won’t start because then he can’t stop. Everyone traipses off to a hearing. Win, lose or draw, by the time they get back the patient is truly dead.
There has to be some better way of adjudicating it.
It’s time to deal with this issue once and for all. It is my life and my body and if I choose to die with dignity, I want to be able to count on physicians to carry out my wishes. I will gladly sign legally enforceable documentation to protect all medical professionals from post-death actions by any family members or friends. Ironically, my family are all of the same opinion on this issue regarding their own lives.
The thing that scares me most isn’t dying – it’s the fact that religious individuals could have a say in whether or not I can die with dignity, in a way of my own choosing. If the religious people out there want to be beholden to a made-up God, then be my guest but stay out of my life. As so often happens, religious organizations impose their ugly dogma on others, then walk off into the sunset. They never consider the misery they leave behind as this part isn’t their problem.
Animus against persons of religious belief is not helpful in this discussion.
I would suggest that what is “unhelpful” in this discussion is the continuing attempt by those of religious conviction to impose their chosen faith on other people.
Please refer to comment #31, in which a person of religious belief suggests that their belief be applied to all.
Animosity towards such attitudes should not be mistaken as hostility to religion nor to the religious. Rather, it is the correct response of those who would not be subject to the belief system of another person. I do not see DWD advocates suggesting that everyone must commit suicide, but there are several religious opinions on this forum that effectively state that nobody should have access to assisted suicide. Like it or not, we live in a secular state. You are welcome to your beliefs and your gods. Do not interfere with mine.
The College of Physicians and Surgeons must adopt a policy in support of individuals with terminal illnesses who have chosen to end their lives in order to minimize the agony and at times length of the dying process. Palliative care is not for everyone and this cannot be used as an excuse to impose a lengthy dying process on individuals who are suffering either physically or emotionally or both. Governments need to create and adopt policies allowing individuals who develop dementias but have previously decided to die secondary to a terminal illness, to receive the help from their doctors to end their lives in a dignified way even though they may be incompetent at the time chosen to die.
Is it wrong to call assisted suicide dying with dignity. I have worked on Palliative unit for over 20 years and Patients with terminal illnesses rarely said they want to die. They focus on being alive not dying. With proper palliative care addressing physical, spiritual, emotional, and social distress quality of life of those terminally ill and their family could profoundly improve.
You are working with people to whom palliative care, and dying at a palliative care facility, is acceptable. Palliative care is not for everyone. I find the very notion abhorrent, and would never choose to live or die that way. Your definition of dying with dignity is obviously very different than mine. Why should your choice be respected and mine not? I don’t seek to tell you how you should be allowed to die, so please refrain from limiting my choices for ME.
The CPSO needs to take a clear stance on, and have clear protocols in place for, aid-in-dying. Considering the recent challenges to the lack of legal aid-in-dying in Canada at both the Senate and Supreme Court – and the fact that the vast majority of Canadians support aid-in-dying – section 7 of the draft report seems inadequate.
Section 7.1 needs to be clearer in its guidelines for how physicians might respond “in a sensitive manner” (line 315). It should also clearly acknowledge the fact that not all requests for a hastened death can be resolved by dealing with “an issue that can be treated or addressed” (line 316). This is out of touch with research in this area – the Oregon Public Health Division, for example, provides annual reports on the DwD Act that demonstrate how this section of the draft does not necessarily speak to patients’ needs and experiences.
As mentioned in the report (lines 324-25), aid-in-dying is not currently legal in Canada. However, with numerous challenges to this law in Canada (as well as widespread popular support), the various similar challenges springing up throughout the US, and Quebec’s Bill 52, it would be wonderful to see the CPSO be a bit more proactive in its stance toward aid-in-dying.
As the widow of a physician who chose to end his life rather than become a chronic invalid I applaud the College’s efforts to open this dialogue. It is gratifying to read the thoughtful comments of many physicians. I believe that each person should be able to decide to depart this life when illness makes the end inevitable.
Having reached the age of 85 and now living with three chronic conditions, I care deeply about end-of-life care. My family experiences in the 1930s and 40s (physician father who died young) made me aware that doctors can face difficult treatment (or non-treatment) choices. Quality of life is important since new technologies offer even greater challenges than in my father’s time.
I do not want to have my life prolonged if there is little hope of a meaningful recovery. I’ve supported the aims of Dying with Dignity Canada since it’s inception. I admired Dr. Donald Low’s plea for a change in the Criminal Code. I’ve watched the court cases like Robert Latimer and Suzanne Rodriguez. I support a change in the criminal code and the necessary changes in the physician code of conduct with regard to end-of-life care.
As a Canadian citizen I am expected make my own choices in order to lead a responsible life, care for my own needs and be supportive of family and friends. Why should any organization, religious, secular or governmental, prevent that choice at the end of my life? I have written a living will and my sons are well aware of my views.
Whatever the ruling of the Supreme Court in the pending case, there will be more controversy. I hope everyone will become informed, support a change in the Criminal Code and discuss with family their end-of-life care choices.
I believe the CPSO should play urgently a strong role in developing a regulatory framework on the issue of medically assisted dying because:
–the matter is in Parliament and the Supreme Court already
–poll after poll confirmed that the vast majority of Canadians is in favour of legislation on this issue
–physicians have prestige and proven weight on this matter as shown by Bill 52 in Quebec
–this issue has to revolve around the patient requesting the assistance and NOT THE MORAL OR ETHICAL VIEWS OF THOSE BEHIND A DESK. Physicians are here TO SERVE THEIR PATIENTS AND THEY ARE REQUESTING BY LARGE MAJORITY THIS SERVICE.
We as individuals should decide our own end not government or anyone else. Doctors are our advisors only and must follow our wishes.
I have studied and listened to many compelling arguments for a patient to have the right to die in a way of their choosing.
I have known many examples where this has not happened, most recently a friend on her way to the operating room, telling the accompanying doctor that she had a DNR and being told that the doctors took no notice of such things.
My own family doctor refused to put my Action Care Plan in my file or to discuss further.
I also dislike the term “euthanasia” which I think is used to frighten those not in favour. What is wrong with “medically assisted dying”? Which is what we want.
Please remember the upcoming Supreme Court decision which will have to take into account the Quebec rights that will take effect by the end of this year. The time for this is NOW.
I want to add some feedback about the revised policy. In particular I want to recommend an addition to section 3. Advance Care Planning – line 126 to 152. I am pleased to see this section with the strong emphasis on physician’s responsibility to engage patients in advance care planning.
Recommended Addition to Section 3: This section should also include a recommendation that physicians add to their advance care planning (ACP) discussions information about appointing an attorney for care (POA for Care). This could be done by the physician or links to resources about how, why and who should be a POA for care provided.
Whom a patient has as a substitute decision maker when they are unable to make their own treatment decisions is pivotal to the patients receiving treatments that are consistent with their wishes and values. As we know the role of the substitute decision maker is very important as advance care plans often have to be interpreted as all treatment possibilities cannot be anticipated and proposed treatment plans have to be interpreted in respect of a patient’s values.
In the absence of a POA for care the person(s) identified in the section 20 of the Health Care Consent Act as the patient’s may be in conflict with the person and may not respresent the patient’s wishes or values accurately or adequately. Additionally with many families reconstituted due to divorce, separation and loss appointing a POA for care can diminish some conflict and make identifying the correct decision maker easier for healthcare providers when substitute decision making has to occur.
Role of Consent and Capacity Board
The Consent and Capacity Board (CCB) can be a valuable resource when wishes are unclear, if a person wishes to be appointed a decision maker or when the treating person or team does not believe SDMs are acting according to a patient’s wishes or their best interest. I believe that physicians should refer to the CCB more frequently to help give direction when there are conflicts about a treatment plan between the SDM and the treatment proposer. There are a number of benefits to having a third party review and give direction which the CCB does in timely way.
Physicians who are fee for service should know that time spent in a hearing can be claimed through Ontario’s Health Boards Secretariat.
Thanks for the opportunity to give feedback.
I have read your draft policy and found many good points relating to communication however I was disappointed that CPSO does not take a strong stand on ” assisted dying in Ontario ”
Patients need to be able to take control of their end of life and should be able to ask for and receive assistance from their physician.
Please don’t simply state that ” it is illegal ” and leave it like that. This issue needs to be inserted in your policy . Physicians have an important role to play as they did in Quebec with Bill 52.
When my time comes, I do not want to have to throw myself under a subway train !
No need to be a burden to the poor subway train operator. Find yourself a decent hospice or someone else to take care of you. Stop eating and drinking. Use mild sedation for discomfort. Have someone swab your mouth out several times a day. You’ll be dead in a couple of weeks with little or no distress.
Dying from dehydration (and starvation) causes “little or no distress”???? Really? What an incredibly uninformed and callous statement this is. I agree that nobody should be forced to die in a violent way which might distress an innocent person. That is one reason why introducing physician-assisted suicide for those who wish it is so important.
I strongly support the content/purpose of the information in the document “Planning for and Providing Quality of End-of-Life Care and that it serve as a blueprint for how Doctors in Ontario care for and interact with dying patients and their families.
While I applaud the attempt to improve our health care system, I firmly believe that contradictions inherent in this document will actually prevent any positive change for those patients at the end of their lives or for their families who also suffer in prolonged death situations.
The desire to acknowledge the wishes of the patient and to provide quality care are in direct contradiction with the options provided for those patients. The option to die at the time of one’s choosing during an illness or ailment from which the patient is not going to recover is dismissed even though many countries, states in the USA and Quebec all have legislation allowing physician assisted death. This is very short sighted. Given that this legislation is being considered now in the Supreme Court and will very likely be passed in the next year at least warrants acknowledgement and response in this document. Do you really want to have to rewrite this document when the legislation is passed and renders this document invalid and irrelevant?
Let me use personal experiences to highlight the contradictions in this document (Lines 208-214).Palliative care as outlined did not occur in either case of my grandparents. My grandparents were refused palliative care on the grounds that there was nothing to palliate. At 99, my grandfather refused hip surgery after a fall and died of dehydration and starvation as that was the only course available to him. This process took 5 weeks and the hospital staff, doctors and nurses, all resisted his sound decision to refuse surgery and treatment. His express wish was to die after his long and full life and instead he suffered through 5 weeks in hospital, no alternative location was ever made available or suggested, in a dreary, dark and generally miserable wing. I do not believe that a patient who does not regain consciousness whilst dying of starvation and dehydration does not suffer. The staff all assured me that the muscle spasms and facial grimaces were simply muscular in nature. Nobody truly knows this answer. What about the soul of this man who wanted peace to say nothing of what the rest of the family went through? To honour and fight for the wishes of a person who wants to die and does not want to try and recover from their illness or ailment is treated as a pariah in our system. Add that on top of grieving violates lines 87, 88 and 99 in your document.
My grandmother at age 99 also went through a similar experience and doctors would not palliate her even though her express wish was to die. The hospital effectively guilted the family into hip surgery that my grandmother didn’t want because otherwise we would be condemning my grandmother to months waiting for death to occur which would include bed sores, painful infection, catheters etc. Pariah indeed. The hospital staff directly contravened her End of Life Directive. She had the surgery and hospital staff were all rejoicing its success and pumping her full of antibiotics and medication unless one of us was physically there to stop them. My grandmother became so depressed at the very idea of having to learn to walk again that she slipped into a deep sleep. Her express wish was to die and quickly so that she could join my grandfather. When nurses tried to revive her and get her to take sustenance, only my mother and I who remained around the clock at her bedside were able to let her at least starve and die of dehydration mostly unconscious. It was her wish to die and to have to do it by means of dehydration and starvation is inhumane. You have no idea the begging and cajoling of doctors and nurses we had to do to increase her pain medication so that she was not feeling the effects of dehydration. The torture of this woman’s soul was 3.5 weeks long.
It is these stories that have gained traction in the legislative community of late but it is time for you to recognize them too and acknowledge the type of care that is required to grant patient’s wishes and to improve the grieving process for the families. While the patient’s wishes are considered, they cannot be granted in this document and yet that is one of the principles outlined and presumably the purpose of Planning Directives and Advocates for the patient. The position of the medical community is also not considered as the medical community came out in favour of physician assisted death in 2014. Why is this perspective so grievously absent here?
Thank you for your time in considering this response to the “Planning For and Providing Quality End-of- Life Care” draft document.
I’ve read your draft policy and I’m not impressed with the equivocation. Let’s get out of the dark ages and end the needless suffering by advocating for the legalization of physician assisted suicide. I watched both my parents die hellish deaths and I don’t understand how any human being, or professional organization, with an ounce of empathy can let the current situation continue in Ontario.
Wayne Sumner in the Walrus Miscellany for November 2014 has ably explained the case for assisted suicide. It is to be hoped that when the Supreme Court completes its consideration of this case, they will approve it.
There is a movement, called ‘Dying With Dignity’, to legalize assisted suicide [AS] for individuals suffering terrible pain from incurable diseases. It may become politically possible before too long.
Looking ahead of what is politically possible at this time, AS for people with little or no disease has merit. Forcing people to stay alive against their will is wrong. Any adult who has no under-age dependents, whose parents are dead or inaccessible, who is free of debt, and does not owe income tax, should be permitted to obtain AS.
A major problem facing society is financing the health care system. So much of its resources are presently dedicated to keeping alive people who would be better off dead, a futile effort that inevitably fails when natural death eventually takes place.
Why deny this freedom? Strong objection can be expected from some religious people, for whom life is sacred. In these days we are not all religious and those who are should not force their opinions on the rest.
Many sick elderly people are physically unable to take their own lives without assistance. Others can foresee that they will eventually be in the same situation, and no doubt many are avoiding it by taking their own lives while they still can. If they had legal access to assisted suicide, the reason for such pre-emptive suicide would vanish.
So freer access to AS would save lives.
Please consider, among your options, an opportunity to teach physicians that patient’s seeking a peaceful, non-violent end to a life they cannot abide should at the very least refer them to Dying with Dignity Canada for information. Years ago when I had lung cancer I was terrified of the awful death that might await me (because my husband had died of that disease only months earlier). My doctor would not even talk to me about how I could get pills or other means to take my own life before it got too agonizing for me. I was able to do my own research and find the help I needed at Exit and at Dying with Dignity. I was lucky enough to survive, but to this day am grateful to know what options exist in other countries and U.S. states that can help me should this terrible disease come back again. Not all patients are capable of researching the issue. Their doctor should give them a pamphlet from DwD for information purposes and perhaps another about hospice care, while remaining steadfast in their support of the dying patient.
Please add my name in support of DWD…..there is a great need for this….let us catch up with Europe and the U.S.A. in providing an important supplement to end-of-life decision making.
With my thanks for your kind attention to the above I am.
I watched my husband die of prostate cancer When he was in the palliative care hospice, our dog was sitting on his bed. I realized at that time that we would never let the dog suffer like this, why did we have to let our loved ones suffer. There were at least two times, (6 months before his death and again about three weeks before his death) that I’m sure he would have chosen to end his life, if it was possible.
I’m 84 and the thought of having to go through a painful end scares me. I would like to be able to say “enough!” Please try to make our laws kinder to us.
I’m pleased to see that the CPSO is taking steps to provide updated guidance to Ontario physicians on end of life care.
As I hope you are fully aware, there is a large gap between the views of over 80% of Ontarians and the guidance provided by professional bodies on doctor assisted death. It is becoming common place for your members to quietly speak on the need to address the reality of the unnecessary pain and suffering caused by the current restrictions placed on physicians that prevent them from properly addressing the needs of dying patients whose death is inevitable and wish to die with dignity on their own terms.
Experience elsewhere has shown that doctor assisted death can be managed in a way that addresses potential issues.
While I recognize the current dilemma you face because of the illegality of assisted suicide in Canada, Canada’s Supreme Court is currently considering this matter and your End of Life guidance could well be severely lacking on release should the Court rule in the appropriate manner.
I urge you to not release your paper until after the Supreme Court ruling has been released and to prepare clearer guidance for physicians that can be inserted into section seven of your document.
With the current strength of views of voting Canadians and the step taking by Quebec to legalize assisted death, it is inevitable that Ontarians will gain access as well.
Finally, I ask that the CPSO stand with Ontarians – your patients – on the matter of doctor assisted death. While it is a sensitive matter with diverse opinions, research shows the clear majority of Ontarians support doctor assisted death if proper controls are in place. Your organization has a critical role to play in the dialogue and policy formation on this issue.
It is time your organization came out of the shadows and provided the leadership that is sorely needed to ensure we get it right.
I am writing to note my support for the College’s expanding your capacity to incorporate a wider range of end of life care by doctors. I especially promote a policy that will allow your members to offer physician-assisted dying to patients who request it when they are terminally ill or suffering to the point where they consider that they no longer have a positive quality of life.
I am a member of “Dying with Dignity “.
At meetings I attend , there are people in anguish having lost loved ones who have had needlessly painful deaths , with no where to turn for help .
While animals get assistance human beings don’t, why is that ?
While the argument against assisted dying , which can be regulated , is always to improve palliative care , can it truly be done ?
Are patients of Illnesses such as Huntington’s disease or ALS, to suffer without being able to choose an alternative for themselves?
Can’t we show some empathy , is this beyond us as Human Beings , are we too fearful ?
I appeal to your kindness towards others…….. please change the law, so that we have choice .
With public interest in the issue of End-of-Life Care growing, physicians must surely feel pressured to respond to changing attitudes. It is wonderful that the CPSO is seeking to provide legal and regulatory guidelines to physicians concerning this issue. With Quebec in the forefront, other provinces must very soon formulate policies, and the medical profession must be prepared to take a lead in drafting appropriate legislation.
Both professionally as a Speech/Language Pathologist and personally as the widow of a Physician who suffered Parkinson’s Disease, I have experienced the trauma and tragedy for patients and families faced with terminal, debilitating illness. In addition, my daughter-in-law is now working as a Personal Support Worker in hospitals, where she works with aged, demented patients filling active treatment beds.
It is essential that physicians, hospitals, health agencies and governments work to solve, or at least ameliorate, the enormous problems arising as our population ages. I congratulate the CPSO for opening this discussion to the public.
Your document does not address the provision or need for assisted suicide in sufficient detail.
I provide palliative care, and have taken several detailed courses on this. There is no question in my mind that even with the best palliative care, there is still a role for assisted suicide to eliminate suffering in end of life care. The College should not issue any final statements or policies until the Supreme Court rules on this, and should recognize that the general public, and many of the College’s members are supportive and willing to be part of this aspect of overall care to our patients.
I believe you are asking for feedback on your draft policy on end-of-life care. I offer the following comments, although I have not seen your policy.
It was my sad privilege to be a caregiver to an elderly friend who died in a Retirement Home. She was 95.
Thankfully, in Ontario, there is a scheme for supplying “palliative care” during the last month of life. However, prior to that service, the medical care seemed too light.
I hope and assume that there are established rules and procedures for the adequate staffing of Physicians for those in Retirement Homes.
It appears the ratio of Doctors to Patients is too low.
It also appears that doctors are “assigned or contracted” to specific retirement homes, thus limiting the choices of doctors for individual patients. Many family doctors and specialists seem to “drop” patients when they enter a Retirement Home.
The contracted doctors for any special Retirement Home are commonly available on-site only once a week, and yet a simple calculation of availability would show that such a doctor would be on site 50 days, dealing with 4 cases per day = 200 resident-file-reviews per year. Thus, in a home with 100 residents, each resident would receive an average of only 2 contact-visits, maximum. This is insufficient, since there are additional duties required by the Home and the residents and families (joint caregivers).
Doctors also must review the files and patients upon (a) admission, (b) nurse communications, (c) paperwork, (d) liaison with OHIP, CCAC, specialists, hospitals, (e) consultations with family, Home management and other caregivers.
I suspect that the problems above relate to OHIP funding, so I ask that you address this issue as you see fit. One suggestion is that you ask that there be assigned an additional “Junior doctor or intern (recent graduate in geriatrics & end-of-life care) for every “x-number” of Retirement Home residents. The nursing staff at these homes is overburdened and ill qualified to fill this gap.
Thank you for bringing this important topic in the open for discussion. 15 years ago, I worked with a woman from Holland and she encouraged each of us to write the federal govt. re. Dying with Dignity. Until now, the subject has been avoided. This Dutch lady’s old, sick mother was comforted in her senior years because she could die how and when she was ready. Our population is aging and housing accommodation is more limited for long term patients. Terminally ill seniors may prefer doctor assisted relief to suffering the last few months or years of life. Hopefully, eventually, they will legally be given that choice.
Yes, let’s get rid of the “old folks” who will be taking up our housing and all our health care services! Let’s bump of Granny and Grampa!
That’s what our future will hold.
My dutch grandmother, after her retirement, spent many years visiting seniors in Amsterdam living alone. All too often, they would go to the hospital with non-life-threatening illnesses, and end up unexpectedly dead. Many of the seniors she visited were afraid of hospitalization, especially seniors who had no family members nearby: they believed the “care” they would receive there would not be in their best interest. This is not a situation we want in Ontario.
I have carefully reviewed the draft policy on end-of-life care. Although I believe it is a good starting point it does not address the issue of medically assisted dying.
The CPSO needs to provide a comprehensive policy in developing a legal framework that would allow Physicians to medically assist patients with the dying process. This would apply to patients who have a terminal illness and/or chronic disorder that drastically effects their quality of life and who request this.
As there are end-of-life bills on the table in Parliament, and the Supreme Court is set to weigh in on the criminal code ban on medically assisted dying, I believe the time to develop this policy is now. It cannot wait. It should become part of the ‘planning for and providing quality end-of-life care’ policy that is currently being drafted.
Please take into consideration that Physicians in Quebec were instrumental in developing Bill 52, an end-of-life care bill that will come into effect the end of this year. This bill gives Quebecers the right to choose medically assisted dying as long as they meet the criteria.
I, like many others, have seen too many people suffer terribly at the end of their life. In addition to the pain and suffering of the patient, it takes a tremendous emotional toll on family and friends. This is not only un-necessary, but I strongly believe it is cruel. Prolonging life un-necessarily also takes a financial toll on our health care system.
Personally, if/when I am faced with a terminal illness, I want the right to choose when, where and how I end my life. As it stands now I do not have the right to make that choice. I want to be able to make the decision to end my life in a manner that eliminates as much pain and suffering as possible.
In closing, I hope you will give my beliefs serious consideration.
Thank you for the opportunity to provide input to this policy.
I am a member of Dying with Dignity Canada for a reason. I saw my mother die in extreme pain of metastatic melanoma which had invaded her vital organs and her brain. Unfortunately, her heart was strong, and she had to endure this pain far longer than was her wish, despite all efforts to mitigate the pain through morphine. Although she survived only a few weeks after diagnosis, and the treating physicians were well aware of her prognosis, they nevertheless intervened surgically, leaving her with a weeping wound that could not heal and in the end offered no reduction in her pain. Why did we, her children allow this? She was deemed mentally competent and she, and we, trusted the medical team to take the most appropriate action in her care. We were wrong, all of us. We were able to take her home from the hospital for a couple of weeks, but eventually she had to go into a care residence. She died there, waking up each mornng to tell me that she wished she had died in her sleep, and eventually having to be put in a morphine-induced coma to try, and not successfully, to mitigate her pain. And still, interventions continued, such as catheterization, which caused her to scream with pain.
It is unbearable to watch a loved one go through this; and I never want to witness this again, or have to experience it myself. This is why I strongly believe that every Canadian should have choice at end of life. They should have the choice to access quality palliative care, they should have the choice to request a hastened death, delivered by a compassionate and trusted health care professional, if they wish to end their suffering. No one should have to starve themselves to death, or experience a violent suicide, or have to travel far from their family to obtain a gentle assisted death.
Quebec’s Bill 52 was developed through extensive consultation with the public, and with the guidance and support of Quebec physicians. There is a bill before the Senate and before the House of Commons, and the Supreme Court is currently considering the appeal associated with the Carter case, all with the goal of striking down the current law against assisted suicide.
Please take this opportunity to show the compassion and leadership we need from the medical profession, and particularly from our physicians. This policy is an opportunity to come forward on the side of history – 84% of Canadians supported medically-assisted dying, and we are looking to you to develop the guidelines and protocol to ensure that medically-assisted dying can be offered to those who choose it in a compassionate, medically appropriate and safe way.
Polls are misleading, because the response depends on the question asked. If the issue is posed in terms of ending horrible suffering, as it is here, the public’s lack of knowledge of palliative care leads to an artificially high expression of support for assisted suicide, because who would want someone to suffer horribly? What the public generally does not realize is that the legalization of assisted suicide makes it legitimate for individuals and groups to attempt to persuade dying individuals to choose suicide, and this pressure can continue until the individual gives in. This fundamentally changes the experience of end-of-life for dying individuals in general in ways that are far from positive.
I attended to my mother 10 years ago when she had terminal breast cancer. She suffered for 10 months before she passed away. And although she likely wouldn’t have chosen end of life options for herself, she believed that anyone should be able to make that choice should they find themselves in the same situation.
Since then, four additional family members have been diagnosed with breast cancer. So far, we have all/are all being treated successfully, but should it come to the point when I am faced with the choice, I would hope that it’s available without criminalizing all involved. End of life experiences are traumatic enough on everyone. Being able to end it peacefully at a time of our own choosing, with safeguards in place should be a right granted to everyone who has any compassion for those suffering.
It is my sincere hope that this decision is made in favour of compassionate end of life doctor-assisted care. It’s truly barbaric what people have to cope with in situations where they want, but don’t have, that choice.
Thank you for your kind consideration.
Thanks for being open to receiving feedback on this topic.
I’m a former hospital chaplain. I have watched people die horrible inhuman deaths. I’m sure you agree that to treat people with less dignity than we treat suffering animals is unacceptable. As we await the Supreme Court ‘s ruling on assisted suicide, (I prefer to call it dying with dignity), I think it important for the physicians and surgeons of Ontario to consider the Oregon model with all its checks and balances. I also think its outcomes should be reviewed, such as the fact that only 1 out of 10 people who registered for that program actually uses it to end their suffering.
Living is more than taking the next breath.
Thank you for listening.
From what I’ve read in the draft on end-of-life care, it all looks good. I’m so glad that the College is looking at these issues. I am a 64-year-old retired teacher, and a hospice volunteer. I have a will and a power-of-attorney through my lawyer. I need to get a DNR form signed at my doctor’s office. My doctor has never initiated this discussion, but I will bring it up with her.
My main concern in this conversation, as regards to my own end-of-life care, is that physician-assisted death be an option. I definitely don’t want to suffer or have my end dragged out. I don’t want to have to go overseas to die; that would be terrible for my family as well as myself. I trust my physician to provide adequate pain medication, but I need more than that. I need peace of mind that if I get to the point where I want/need to hasten my death, my wishes will be respected and my passing will be as comfortable as possible. I pray that when my time comes, physician-assisted death will be legalized.
My family already knows my wishes and agrees with them, but I need to get it in writing. I wish there was a form that I could fill out and keep on file regarding my views and wishes for physician-assisted death. Do you think that the College of Physicians and Surgeons could take on the task of designing and providing such a form?
Thank you for inviting the public to provide feedback about your draft on end-of-life care.
This draft policy should include information on physician assisted death. This should be an option for those with a terminal or incurable illness.
Some patients would choose this option, myself included as I have terminal cancer and would opt for this instead of a slow descent into death which can be very painful despite pain killers.
I believe general practitioners need to be ready to speak with patients about end of life decisions. They should be well informed and have tools on hand to assist those dealing with a terminal or life limiting condition (i.e. legal options,protocol, required documents in case of a medical emergency). It is important that they are prepared and comfortable in supporting patients who are facing these challenges themselves or on behalf of a loved one.
They should NOT, however, be compelled to act against their consciences in this or any other area of medical practice.
People should not have to leave their home and country to seek physician-assisted suicide elsewhere. As it stands today, terminal patients, who fear a lingering and cruel death, must act prematurely while they are still in a position to act independently. Our medical care system should support us in dying as well as living, and respect the choice of the patient so long as that has been made clear.
in lines 172 to 178, can you please clarify the use of “capacity” and “capable.” My understanding from but not limited to CME, self-directed reading and personal communication with our hospital expert on consent, is that everyday physicians decide if patients are capable of decision making. When it comes to using the word “capacity,” that refers to an Act.
Could you please clarify that these 2 words are used correctly in lines 172 to 178, so that in the middle of the night when I am trying to read this policy it is clear.
Thank you for considering.
Almost two years ago, a medical professional asked me if I wanted to kill my mother.
Not in those words exactly, but that was the intent.
The conversation went something like this:
She: You know things cannot go on like this. Some decisions are going to have to be made.
To this statement I could only nod my head in agreement. I was only too well aware that my mother’s condition had deteriorated, but in truth, I was receiving very little input from her attending medical staff other than to point out symptoms that were all too self-evident. What I needed, but could not seem to obtain, were clinical diagnoses with their attending prognoses.
(So much for sections 109-123: ….communication is of paramount importance. Physicians must communicate effectively and compassionately….)
She: Your mother’s feeding tube – it can’t stay in there forever – it’s going to have to be removed.
Again, at first, I said nothing, because I had never been told this information before. In later conversations (after my mother died) with different medical professionals, I learned that what I had been told was untrue; feeding tubes can be left in almost indefinitely (they are changed regularly for hygiene reasons). Fragile neonates and people with anorexia are two groups for which this is common.
(So much for sections 168-171: In order for consent to be valid it must…… not be obtained through misrepresentation or fraud.)
Me: But if you remove my mother’s feeding tube that means she won’t be receiving food and fluids. She will dehydrate to death!
The woman looked stunned, not because it suddenly dawned on her that that would be the consequence of the removal of the feeding tube, but because I knew what would happen. Nothing of consequence was said afterwards and the conversation ended less than one minute after my statement.
There are times when providing nutrition and hydration are not the standard of care, but that is usually when the patient’s death is immanent. No doctor had ever described my mother’s situation as such, so why the need to remove the feeding tube? Just one of the many unanswered questions I have surrounding my mother’s death.
Reading through the comments on this Discussion page, it is obvious that death by dehydration is common, that it is a horrendous way to die for the patient, and that it is equally terrible death to watch as a family or loved one. But euthanasia and physician assisted suicide are not the answer. Physician assisted suicide makes a mockery of the anti-suicide campaigns and strategies that governments and organizations have put in place. If it is not OK to kill yourself when you are healthy, then why is OK to kill yourself when you are ill? And euthanasia, once accepted, cannot be contained. One need only look to Belgium and the Netherlands. Euthanasia deaths have increased annually between 13 and 26.8%, and the criteria for which euthanasia is granted has also dramatically increased. Discussions in favor of euthanasia and assisted suicide are cloaked in soothing terms of “autonomy” (What would your mother have wanted?), “dying with dignity” (Would your mother want to live like this?) and “quality of life”, the latter simply being one individual’s supposed right to determine whether another’s life is good enough or not. This is what I heard as I was discussing my mother’s care with the hospital staff. Palliative care becomes an afterthought in jurisdictions where physician assisted suicide and euthanasia are allowed.
Good palliative care is the only answer to end-of-life issues. The problem is that,
“Currently, only 16-30 per cent of Canadians, have access to comprehensive quality end-of-life care. We should focus on improving end of life care across the country before we introduce bills allowing physician assisted dying.” stated Sharon Baxter, Executive Director of the CHPCA.
Sections 204 to 207 suggest that palliative care need not be provided by specialists; physicians are advised to seek the support or involvement of these specialists. That needs to be changed to must seek. Veterinarians are given more in-class training in pain management than general practitioners; psychologists and psychotherapists are eminently more qualified to address emotional and psychological pain; and spiritual care is best left to chaplains whose entire training has focussed on this one area. While the Federal government has pledged more money for palliative care training for doctors, it is impossible for the average physician to be all things to all people, especially at the critical end-of-life time.
When we recall the second anniversary of Mom’s passing, I will do so knowing that I honoured her wishes regarding what she wanted and did not want concerning her death, but will do so with too many unanswered questions regarding the care she received, and in some cases, didn’t receive. The lack of good communication between the attending medical staff and ourselves certainly did not build trust and confidence in the physician-patient relationship (Section 115), and it certainly did not reduce suffering…..and lessen conflict and distress (Section 12). I have walked away from the tragic events of my mother’s death with a clear conscience; you need to provide extremely clear guidelines so that physicians can do the same.
Re: Responding to Wishes and Requests to Hasten Death
The otherwise excellent policy document falls apart in this section. It lists many reasons why a person might seek to hasten his or her death, but gives the doctor no direction about what to do except try to find the patient some other solution.
The patient has a legal right to hasten his or her own death and, even though the doctor is not permitted to help the patient do so or counsel the patient to do so, the doctor is not precluded from giving the patient medical information such as that, if he or she stops eating and drinking, and if any discomfort is controlled by medication, and if the mouth is swabbed regularly to remove mucous buildup, death without distress within a couple of weeks can be achieved.
A doctor who, as the patient’s gatekeeper to medical information, is not prepared to share such information with his or her patient is failing to care for the patient at possibly the most critical point in the patient’s life in a manner that a patient should be entitled to expect.
The college’s policy can do better. A lot better.
Thank you for allowing the public to comment on this very difficult topic. I have 2 comments.
A)-Section 7.1, “Responding to Wishes and Requests to Hasten Death”
This should mention that, if a patient has expressed a wish to hasten death many times over many years, that wish should be complied with and not discouraged. This may include terminal sedation or witholding nourishment/medication after consultation with a capable patient and/or the substitute decision-maker.
B)- Lines 185-188 suggest that requests made while under care and medication today override those made many times in the past months and years while fully capable. I believe that the phrase “Later wishes expressed while capable” needs to be augmented to ensure that the true wishes of the patient and substitute decision-maker are honoured.
Point four would be MUCH better if it was: ” Collaborate effectively. Recognize the unique roles of other physicians, health care providers and non- health care providers. ”
We should NOT accept proposed ideas, plans or actions that ate NOT in the patients best interest. Ie “accepting” is to strong or at best ambiguous.
I’m an intensivist and general internist. Frankly speaking, policy/line 240 is ridiculous and is contradictory to policy 221/222 and more importantly will result in situations where CPR is clearly not indicated and we will be forced to perform a procedure that clearly offers zero benefit and only adds undo harm. I suspect this policy stems from the recent court ruling involving the patient in Toronto and I suspect your policy makers are misinterpreting the result of the ruling.
This policy must be resolved as soon as possible and the ultimate decision should be in the hands of physician much like policy 221-222. If I wasn’t clear enough I completely disagree with line 240 and although it is our current practice to seek consent in the majority of cases regarding CPR the ultimate decision should rest with the MRP. Here is a hypothetical example, a 99 year old demented individual completely dependent on others for care, with PEG feeding, and is bed bound with zero quality of life and is clearly dying and is palliative yet the family requests “everything” including CPR. I would under no circumstance offer CPR in the first place but based on your policy I would have to ask the family and if they refuse a DNR status we are obliged to run a code. This is just one of many examples in my practice that CPR would be completely useless. This is just another example of patient centered care/autonomy going to far. What will be next? Every person regardless of their medical condition gets to choose whether or not they are admitted to ICU? Undergoes cardiac surgery? Get’s to choose the imaging modality of their choice? This proposed policy is so infuriating that it has made me consider giving up clinical practice.
This is a clear value judgment on the value of a patient’s life, and an illustration of why physicians should not be solely responsible for such decisions. In the example, the family (and perhaps the patient too) desire more time, so the additional life extension, however short, is clearly of value to them. But because it is not of value to the physician, the physician proposes unilaterally imposing his or her value judgement on them. I would welcome the decision of such a physician to give up clinical practice.
Member of public – You’re missing the point. The family shouldn’t be making decisions in their own interest (wanting “more time”, in your reply/example) but in the interest of the patient.
“More time” is irrelevant to the example listed by the physician (99 year old with advanced dementia and poor quality of life). How could that patient benefit from “more time”?
In cases like these, the physician must be able to decide on what constitutes “best practice” and decide that a “full code” approach (lack of DNR) is not best practice and withhold this “treatment”.
This is where the CPSO document is contradictory and needs clarification.
While this is certainly something that the CPSO should have a stand on, requiring consent for “Do Not Resuscitate” orders is unrealistic and, in a health care system with limited financial resources, simply impossible. There is not enough critical care capacity to accommodate the wishes of unrealistic families, and the current legal requirement to obtain consent for withdrawal of advanced life-sustaining therapy means that Ontario’s critical care resources will become even more strained (if not overwhelmed) by patients with no real opportunity to recover. This technicality will be seized upon by the media and ethics boards, and once instituted will not be able to be withdrawn.
As a provider who deals with these cases on a daily basis, in a region with very limited resuscitation and life support resources, it is insulting as well as tragic to imagine a situation in which grief, fear and guilt will outrank clinical experience and demonstrated expertise in allocating resources. Requiring consent to withhold resuscitation in clearly hopeless cases will serve only to promote burnout among critical care teams already involved in prolonging death in a significant number of our patients.
I was disappointed in Section 7 (Wishes and Requests to Hasten Death), which was just the usual reference to the Criminal Code Of Canada. We need to be more forward looking, in light of changes in society and public attitudes about assisted dying. The new CMA document Euthanasia and Assisted Death (Update 2014) confronts to-day’s realities much more directly:
“… the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying…”
I hope that Section 7 can be expanded and improved, or a new section added on Aid in Dying.
I am a pastor of a 500+ person congregation and, as part of my calling, work with medical practitioners with regard to end-of-life decisions.
It appears the proposed changes do not give sufficient leeway to physicians who themselves, for conscience reasons, do not wish to be involved in euthanasia or assisted suicide, especially when confronted with emergency situations which are common in ER and ICU units.
If euthanasia and/or assisted suicide does becomes legal in Canada, I know that almost all members of our faith community would feel unsafe if their physician participated in in these practices and/or did not have the option to refuse involvement.
Finally, there appears to be little or no discussion about the intrinsic value human beings have, rather than value placed on “quality of life” issues which could have negative consequences on the elderly or developmentally-challenged individuals, particularly when such persons do not have the capacity to make end of life decisions for themselves.
Physicians need to uphold their promise to “Do no harm”.
If euthanasia or assisted suicide is legalized, physicians must maintain their right of conscience to refuse to participate in any way.
I would not feel safe if my physician were to participate in euthanasia or assisted suicide in any way.
God our Creator is the initiator, Maker, and Owner of every life. None of us has the right to terminate a life without His written permission!
I believe the best care is the one we can give at a palliative level.Doctors need to uphold their hippocratic oath and not induce death by any means. Euthanasia by any means is to subject to subjectivity.
I am disappointed to learn that the CPSO is proposing to require physicians to obtain permission to withhold CPR from patients and their substitute decision makers. This policy seems wrong-headed and bound to inflict significant distress upon families needlessly forced to make decisions over which there is really no decision to make.
When intensivists choose to withhold CPR, they do so because in their professional opinion it offers no meaningful benefit. Given that some families will not be prepared to make decisions that they often misinterpret as deciding whether or not to end their loved ones’ life, critical care teams may be forced to provide CPR when it is clearly inappropriate to them. This will only further exacerbate the moral distress that ICU nurses and physicians experience over futile care at the end of life.
The logical corollary of requiring permission to withhold CPR would be to require permission to withdraw or discontinue CPR. But to do so would be absurd—what if families refused to provide consent to stop CPR? How long would we continue delivering it? Could we ever unilaterally declare it futile? By reductio ad absurdum this policy proposal is misguided.
The sense that my colleagues and I have is that this proposal is based on a misinterpretation and misapplication of the Rasouli decision rendered by the Supreme Court of Canada. Careful analysis as provided by Downar and Kavanagh in CMAJ clearly shows that the decision is not relevant to CPR.
The college’s proposal will inflict needless harm on patients, their families, and medical teams. To be frank, I would rather face censure from the College than be forced to provide CPR to patients who, irrespective of families’ desperate wishes and best intentions, will not survive a cardiac arrest in any meaningful sense of that term.
Palliative care is the way to go.This gives the patient proper and loving care.Also physicians should never be asked to put an end to anyone’s life.Their job is to treat their patients with respect and dignity.
To whom it may concern;
It very much annoys me that I have to even take time to address this issue.
What kind of barbaric society have we even devoled too, when the question of whether doctors should assist with assisted suicide or euthanasia is even raised in a serious manner?
Both procedures involve killing. One is as bad as the other.
A doctors job is to aid with living. Nature will kill us all eventually anyway.
Doctors need help us live.
Doctors do not kill patients!!!!!!!!!!!!!!!
I am not going to elaborate further. Is really that difficult to understand?
Those who wish to kill themselves need mental help, love, compassion or some combination of all three.
They do not need killing.
I am totally against Ontario being involved in physician assisted suicide or euthanasia . I have been involved with the care of five terminally ill persons and it has been my experience that treating people for depression and good pain management are of the utmost importance. Canada as a whole has to look at better pain management.
My husband is the sixth person person I am caring for thru cancer and he is also fighting to stay alive not to have his life ended. He has ling cancer and colon cancer, both being primary. Proper palliative care without the threat of assisted suicide or euthanasia are of the utmost importance.
I have followed the euthanasia facts in Denmark and Holland and I am appalled at the slippery slope of atrocities that are being committed. This should not be allowed in Ontario or Canada,
Our physicians should be concentrating on better pain management and proper palliative care.
Dear Members of the College of Physicians and Surgeons of Ontario (CPSO),
You, better than anyone, already know how to provide quality end-of-life care. With the full armamentarium of medicines available to you for easing pain and suffering, you, as doctors, can give your patients life with dignity instead of the misnamed “death with dignity,” which is really shorthand for assisted suicide.
For centuries, the Hippocratic Oath governed the behavior of every physician—to protect all life. Deep down, isn’t that the expectation we patients have when we come to you for help? You are in the business of healing, not killing. You need to uphold that sole mission and not be a death monger. I’m sure that I’m not alone in feeling unsafe if you decide to alter your principles.
The Second General Assembly of the World Medical Association adopted the Declaration of Geneva, which, in part, stated, “I will practice my profession with conscience and dignity.” Even if euthanasia becomes the law, every doctor should have the right to follow his or her conscience. Didn’t the Nuremberg trials settle that question once and for all?
Please do not surrender to the forces of death on this all-important issue, which will affect all of us sooner or later.
Thank you for you time and consideration.
As you discuss the important issue of providing quality end-of-life care, I ask that you avoid any mention of assisted suicide or euthanasia.
These are contrary to the promise of physicians to “Do No Harm.”
Given our political climate, Canada could find itself living under a health care system that approves of these.
If so, I believe that physicians must maintain their right of conscience to refuse to participate in these in any way.
I want to know that my doctor will always make decisions aimed at preserving my life and that of my loved ones,
not ending it.
I think that above all our so-called educated should recognise that every person has a conscience, a sense of good and evil, and that in every situation, even in medical situations, issues can arise that challenge us to choose between right and wrong, between good and evil. Freedom, true freedom, necessitates a choice between good and evil, what is noble (as Aristotle calls it) and what is ignoble.
Fortunately, mankind are not automatons, but do have a free will, and conscience rights recognise that free will: remove conscience rights, and de facto you remove or compromise the exercise of free will.
I consider it a sad day when conscience rights will even be in question. I urge you to rise above a culture of pure utilitarianism and give pre-eminence to nobility.
To whom it may concern
I am horrified to see that you are proposing to remove freedom of conscience when it comes to doctors who don’t want participate in euthanasia. To say it as bluntly as possible, you are now proposing that they will not only be killing people but be forced to participate with this gruesome task or face losing their jobs.
Euthanasia is not “end-of-life care” in any sense. Euthanasia is simply ending the life of someone who we have determined to be below a certain quality of life. However the question remains who gets to chose what that quality is?
I believe that you should not be given the option to kill anyone no matter the circumstances. This is because you cannot guarantee that the circumstances or persons involved will not change. A person may become depressed and want to die but killing them has never and will never be a better option than trying to cure them of that depression.
I write this email to remind the College of Physicians and Surgeons of Ontario of the promise which must be upheld known as “Do Not Harm”. I also wish to make it clear that if euthanasia is legalized, physicians must maintain their right of conscience to refuse to participate in any way. As a patient of Ontario, I do not feel comfortable that this issue is even discussed, and consequently become more on edge with this type of conversation. I am 18 years old and as a young, educated voter I express my strong disagreement with euthanasia and expect those who have educated themselves to a doctorate in healing* to feel the same way.
The “do no harm” mantra is completely consistent with physician-assisted dying in my view…it is most definitely harmful to force someone to die slowly, suffering every inch of the way, when they clearly wish otherwise. My father had ALS and had to go to Dignitas in Switzerland in order to get away from the Canadian doctors and politicians who thought it was ethically acceptable to torture another human being to death. That is what a lot of “natural” deaths are presently like in this country: tortuous. The CPSO should be ashamed of their position on this issue. You should be advocating for free patient choice instead of refusing to relinquish the control over patients that you so inappropriately have at the moment. It’s just one more example of the CPSO putting doctors first and patients last.
College of Physicians and Surgeons:
I am writing with regard to the prospect of physicians and surgeons killing their patients by euthanasia or physician-assisted suicide. The Hippocratic Oath states: “First, do no harm.” Why would doctors want to harm the very people on which their livelihood depends?
Doctors should have the freedom of conscience to prevent the deaths of ,not terminate the lives of, their patients. Doctors are not the arbiters of life and death.
Having a family doctor who participates in euthanasia or physician-assisted suicide scares me greatly. Just because I become old and senile does not mean that I have no intrinsic value. You too may be in this condition one day.
Please DO NOT accept euthanasia and/or physician-assisted suicide. The life you save may be your own.
Thank you for sharing my views with your colleagues.
Forcing people to kill people is the most cruel and barbarous thing a “civilized” society could do. When someone is against murder and they are forced to perform it or to refer to a hired killer who will do the job for them, that is unspeakable.
If the conscience rights of the caregivers are trampled over this way, how can anyone expect the rights of the patients to unpressured consent will be anymore respected? This is very symptomatic of the BULLDOZER that State-induced death would be. It’s staring at us right in the face.
Since you are asking for comments about this sensitive topic as it is the end of a human existence, I would like to ask that the right of the physicians to keep their moral values be respected. If it is necessary the creation of two groups of physicians, one that do any medical treatment without any objection, according to the patient wish, and second the physicians who do what they think is better for the patience according to their conscience and faith.
We the public are the ones who should be able to chose what kind of doctor do we want next to us when we are sick.
Thank you for this opportunity.
I hope you have the wisdoms and the courage to do what is right for a human society.
I have attached 2 outlines which constitute my submission as requested by the CPSO regarding the end of life policy discussion currently underway.
Please review both documents carefully. (Document 1 and Document 2)
Conscience Rights. Physicians need to uphold their promise to “Do No Harm.” If euthanasia or assisted suicide is legalized, physicians must maintain their right of conscience to refuse to participate in any way. I would not feel safe if my physician participates in euthanasia or assisted suicide.
Forcer les gens à tuer les gens est la chose la plus cruelle et barbare qu’une société dite « civilisée » puisse faire. Quand une personne s’oppose au meurtre et qu’on la force à le pratiquer ou à référer à un autre pour s’en occuper, c’est innommable.
Si la liberté de conscience des soignants est ainsi écrasée, comment peut-on s’attendre à ce que le droit des patients au consentement sans pression ne soit pas, lui aussi, écrasé ? Cela est très symptomatique du ROULEAU COMPRESSEUR que serait la mort induite par l’État. Ca nous regarde directement dans les yeux
Membre du COLLÈGE des MEDECINS….???SOMMES -NOUS DANS 1 PAYS LIBRE ou pas???« Forcer les gens à tuer les gens est la chose la plus cruelle et barbare qu’une société dite « civilisée » puisse faire. Quand une personne s’oppose au meurtre et qu’on la force à le pratiquer ou à référer à un autre pour s’en occuper, c’est innommable.
Si la liberté de conscience des soignants est ainsi écrasée, comment peut-on s’attendre à ce que le droit des patients au consentement sans pression ne soit pas, lui aussi, écrasé ? Cela est très symptomatique du ROULEAU COMPRESSEUR que serait la mort induite par l’État. Ca nous regarde directement dans les yeux. »LAISSEZ la LIBERTÉ de CONSCIENCE AUX MÉDECINS & INFIRMIÈRES!!! J, ai 77ans..& j’ ai TRÈS PEUR de cette possibilité…..si PLUS TARD… je n’ en peu plus a cause de maladie ..je SAIS que je peux refuser le traitement & cela me suffit..S.V.P. LAISSEZ LA LIBERTÉ DE CONSCIENCE A TOUT LE PERSONNEL DES SOIGNANTS…NON, a l’ euthanasie
We are the civilization which don’t like pains stress and suffering which is understandable. Most rely to much on medical establishment for cures and improvement of the health, without educating themselves about body how it works. Medical doctors don’t have all the answers even with best intentions it is hard to diagnose someone during 10 minute visits. Physicians are usually addressing symptoms and not able to get to root of disease that’s why People should be more educated about their body mind spirit working as one. I feel for physicians they have tremendous responsibilities and have to follow these policies and confusing guidelines instead of focusing on Patient.
y-a-til une idéologie nazie secrète et obscure ici au canada et en ontario et dans toutes le sprovinces, plusieurs et de plus en plus de gens de la population se posent la question et exigent des réponses.
pourquoi vouloir tuer par euthanasie les personnes vulnérables sinon ppur se débarrasser des plus vulnérables comme les nazis l’ont fait.
vous faites pitié vous mombres des gouvernements, en ontario et au québec de vouloir forcer les médecins à tuer leurs patients de force.
Forcer les gens à tuer les concitoyens Québécois, nos racine, nos familles et amis, c’est la chose la plus cruelle et barbare qu’une société dite « civilisée » puisse faire. Quand un médecin s’oppose au meurtre et qu’on la force à le pratiquer ou à référer à un autre médecin pour s’occuper de lui faire la job, c’est lâche, ignoble et minable.
Si la liberté de conscience des médecins est ainsi écrasée, réduite à nul, comment peut-on s’attendre à ce que le droit des patients au consentement sans pression ne soit pas, lui aussi, écrasé et réduit à nul ? Cela est très symptomatique du ROULEAU COMPRESSEUR que serait la mort induite par l’État. Ca nous regarde directement dans les yeux
I am concerned with the proposed law of assisted suicide in our healthcare system and the serious consequences this could bring: a culture that disrespects the elderly, sick or disabled. The pressure it could bring to end one’s life. Also the violation of freedom of conscience for Dr.’s nurses, all those who work in the health care industry.
Who gave right our government institutions to make guidelines how people should think act feel eat behave. Are they experts with healing people now, or know what is right for wellbeing of people?. They try to mess with Canadians minds, by all this unnatural confusing laws to defer their inability to serve the citizens and our country . People should be responsible for themselves and be not passive in their treatment. Government from latin means – mind control- and that’s what our government is doing. Conscience comes from nature and is the highest quality of the human race without conscience human are death or acts as robot or zombie. That why is paramount physicians always should practice with their conscience
I have just read the draft of the document Planning for and Providing Quality End-of-Life Care. I am deeply concerned with lines 364-365, stating that physicians must comply with the College’s Physicians and the Human Rights Code policy. If this means that a physician who is opposed on moral grounds to participating in euthanasia or physician assisted death, if these become legal in Ontario, will be required to participate, I am deeply concerned. Even if the physician does not want, on moral grounds, to refer his patient to another physician who will accommodate a patient who wishes physician assisted death or euthanasia,and if that physician should suffer penalties for his moral position and action, I find this reprehensible.
A physician should be able, in this free country of Canada, to work as a physician and have freedom of conscience.
Please do not rewrite the Hippocratic Code in such a way as it would force a doctor to harm another person, that is, kill or assist in killing that other person. Please remember the rights of competent and trained people to become physicians, and not have to be discriminated against because they hold to the belief that a physician should not take the life of another human being, nor should he/she assist another physician in doing this.
You guys need to keep the physicians conscience rights. No physicians wants to be force to do something. As a future nurse, I do not want to see physicians to be mistreated.
As a member of the public, I am very concerned about some of the comments from physicians in this forum, who imply that CPR is “futile” if the patient’s quality of life and medical prognosis is, in the physician’s judgment, sufficiently poor. CPR is, by definition, futile only if it fails to resuscitate the patient. In general, life-sustaining treatments are futile only if they fail to sustain life. If they sustain life, they
are by definition successful, even if the life they sustain is not pleasant, and if the life expectation of the patient remains short.
I do understand the frustration of a physician who, quite correctly, observes that a successful resuscitation of a patient will only lead to a series of further resuscitation attempts in future, eventually resulting in the patient’s death despite all efforts. But to unilaterally refuse the life-sustaining treatment is, in essence, to make a value judgement on the life of the patient. It is not appropriate for physicians to decide, on their own, whether or not a patient’s life, however unpleasant it may seem, is worth living. That is the wisdom of the Rasouli decision, and it is extremely important that this principle be respected.
Of course, this does not mean that all possible life-sustaining treatments must be tried until the inevitable occurs: suitable decisions about life-sustaining treatments can and should of course be made, just not by physicians on their own.
As for assisted suicide, that is something much more problematic. Such is not a treatment, it is the reverse of a treatment: an intervention that deliberately brings about hastened death. The involvement of a physician in such things seems to be taken for granted: in some places, physician-assisted suicide is commonplace and expected. But this raises fundamental questions about what a physician is: a person who saves life? Or one who takes it? If assisted suicide becomes legal in Ontario, for the sake of clarity about the role of physician, it would be better to have appropriately trained non-medical professionals be the ones assisting, and leave physicians out of it. This is particularly important because any change in the law will result in a fundamental change in end-of-life decision-making: once assisted suicide becomes legal, anyone can attempt to persuade patients to make that choice, and legal issues will abound. Given that a suicide assist-er is not charged with care for the life of a patient (the role by definition involves ending that life, not preserving it), and given the complex array of legal issues involved, and the extremely difficult decision-making environment that legal assisted suicide will lead to for persons at the end of their lives, it seems clear that legal, not medical, training should be the primary requirement. There may be an opportunity, if not now, then soon, for the College to take bold leadership in this area by making this argument.
I am a palliative care physician and would like to provide feedback on your end of life policy. I am quite shocked to see the phrase “The College requires physicians to obtain consent for a “Do Not Resuscitate” order” (line 240). It is my understanding that this has been done in response to the Rasouli case. As you know, the Rasouli ruling states that the care team requires consent to WITHDRAW treatments, including life support. It does not comment on requiring consent to WITHHOLD potentially life prolonging therapies. I have been involved in a few cases where the patient is not capable to make a decision and their family members are adamantly requesting CPR/a code being run when the patient dies.
In a recent example I can recall, the patient was an elderly lady with a very large brain tumour who was responsive only to painful stimuli and was being ventilated through a tracheostomy. She had been more or less unresponsive for almost 3 weeks and there was absolutely no chance of recovery. Doing CPR would most likely have been ineffective and resulted in an extremely painful and traumatic death for her. If CPR was “successful”, it would have restarted her heart and she would have remained in an unresponsive state for possibly several more days to short weeks. Doing CPR would definitely have been against the best interest of this patient, and one of our primary responsibility as physicians is to act in the best interest of our patients. In consultation with ICU and the patient’s neurosurgeon, a medical decision was made to make this woman DNR. Fortunately in this situation, she lived long enough for us to have the opportunity to meet several times with her family and eventually they were in agreement that CPR would have been inappropriate and harmful to her. However, if she had died before this was possible, doing CPR would have absolutely been the wrong thing to do.
It is my understanding that the inclusion of this statement is in reaction to the Rasouli case and that there may have been some legal advice given regarding its inclusion. If this is the case, I would very much hope that you will be seeking an additional legal opinion and the opinion of a medical ethicist.
Thank you for making your draft policies available to us and giving us the opportunity to provide feedback.
Please ensure that end of life care means that physicians will help people LIVE with dignity. There is a real danger that physicians will be asked to help people kill themselves and that is wrong. Even the euphemism DIE with Dignity is offensive and reveals a fundamental bias. It implies that letting the person live is somehow undignified and, therefore, wrong.
I want to know that, as I get older, the doctor I go to see for advice will not have it in the back of his/her mind that maybe it would be better for me to die . . . more “dignified”. How can an older person trust their doctor if the older person knows that the doctor sees human life as a matter of bed-allocation logistics.
Please be careful. I think this proposal is the thin edge of the wedge. It sounds sympathetic, but it opens the door to forcing physicians who are morally opposed to killing in a potentially horrific role and it erodes doctor-patient trust.
I am not a Doctor or a Medical person of any kind. However:
1.I would not feel safe going to Doctors who participate or assist in helping to commit suicide.
2.Physicians and Surgeons need to uphold their promise to ;
“DO NO WRONG” .
3.If euthanasia or assisted suicide is legalized, physicians MUST maintain their right of conscience to REFUSE to participate in any way.
I am writing to you today with my grave concerns about the position Physicians are going to be placed in if the euthanasia and assisted suicide bill is passed here in Ontario. I believe in life from conception to natural death and the only One who has the right to take life is the One who gave it.
At this point in time, when I go to see my Physician, I believe that she too thinks my life is worth keeping whole, healthy and alive because she took an oath, a promise to DO NO HARM. An oath means something to me and it should to you too. There will always be bad apples in the basket who don’t keep their word but my doctor is not one of them. If euthanasia or assisted suicide is legalized there must be a clause in there that stipulates that Physicians must maintain their right of conscience to refuse to participate in any away with this immoral act otherwise, I will not feel safe!! How will I know if she won’t TURN on me and decide I’m too much trouble and end my life. Or worse yet, listen to my family and decide with them that I’m a burden just because I’ve had a stroke and can’t feed myself. You say, “oh no, it won’t come to that!” Yet, it has in countries that have accepted euthanasia and assisted suicide.
To end someone’s life before God ends it is MURDER. Black and white. I believe in palliative care. Managing pain until GOD decides when it is time to bring that person home.
Please protect Physicians whose word is their bond. Help those of us who trust our Physicians NOT TO DO HARM especially to us and our loved ones. You know this is right. Have the courage to speak up. You are not alone.
Dear College of Physicians and Surgeons of Ontario (CPSO):
It is very disturbing to hear that your organization is deliberately and aggressively planning to push out established physicians and future physicians that value all human life from conception to natural death from practicing or planning to practice medicine in Ontario.
As a College please uphold your promise to “Do No Harm”.
If euthanasia or assisted suicide is legally imposed in Canada, physicians have every right of conscience to refuse to participate in any way that compromises or violates their convictions and professional responsibilities to care for and protect ALL human life.
I do not trust and will never knowingly use the services of any so-called physician that condones or participates in abortion, euthanasia or assisted suicide.
Canadians want physicians that can be trusted, your organization’s current trajectory is making that impossible.
I am a Canadian citizen and I oppose these ideas that people should be allowed to end the lives of others, whether it’s because you simply don’t like the person you want to kill because they annoy you or because you don’t think the person you want to kill is worthy of life based on your perception of their quality of life being not quite as good as your life.
If someone has a worse like than you, help them and care for them. Don’t kill them.
Murder is murder no matter how pretty of labels one gives it or how many pages of “medical” or “compassionate” nearly-logical sounding reasons one is able to compile.
If human life is not valued and is not protected, NONE of us are of any value.
Every one of us will be old one day.
Do you really want your caretaker to be ready with an axe (or needle or gas chamber or just ready to “withdraw” care and let you starve or dehydrate to death) the minute your health takes a turn for the worse?
Human life is precious, whether it’s a 99 year old in a coma or a 9-second old fertilized egg in the womb.
If murder is wrong, it’s because someone bigger than humankind says so.
God says so. Thou shalt not murder.
Human life isn’t ours to toy with or destroy because God made it. It belongs to Him.
I know that many people gladly embrace an “atheistic” worldview and choose to believe that 4.6 billion years ago, nothing exploded and became everything you see around you today, but it is a non-sensical story that has no basis in reality and has absolutely no evidence to support crazy notions like the idea that cows decided to go back into the water and become whales. I have many times decided to go for a swim and none of my babies came out with flippers and blowholes. Evolution is a religion and a dangerous religion at that. It is racist as it teaches that white people are more evolved than black people, which is utter nonsense. It is also dangerous because it removes any basis for any kind of morality. If our existence is an accident, then NOTHING can possibly actually be wrong, because there’s no one who says so outside of humankind.
God made the world, man messed it up with sin and disobedience.
God loved the world and Jesus, God’s Son came here to be mocked and rejected and hated and murdered by the people He loved so that He could pay the penalty our sin earned us. All who believe in the name of Jesus will be saved. All who reject Him will perish in hell forever.
No no , please let palliative care do it’s own beautiful work. I saw it in action when I recently lost my brother (87 years old) Please, no, no, no, no to euthanasia. DO NOT FORCE doctors or nurses to do it!!!!
I have read all the comments and over whelming majorities of them are against physician assisted suicide They are very profound and intelligent with deep sense. I wonder if College draft prepares even read those comments they asked for, Or they already know how policy will look like, because is forced by few government lobbyists those pro euthanasia ones, who think conscience of physicians doesn’t count.
We pay so many taxes in Ontario and why there is not enough palliative beds or home support for terminally ill and disable. With proper palliation and support life of those nearing death will be more dignified.
I am very much against euthanasia/physician assisted dying. If this does come to pass, doctors must maintain their conscience rights to refuse to participate. I would not feel safe if my doctor favoured euthanasia or assisted suicide. I could never trust a doctor whose treatment options included killing me. The comments here in favour of “dying with dignity” (as if those of us who die without outside intervention are dying without “dignity”) almost all mention fear of pain. That’s what the medical profession should be concentrating on: improvements in pain management and palliative care for the dying.
The problem with euthanasia and doctor-assisted death, as is amply illustrated by the Dutch and Belgian experiences, is that it’s not just people who want to die who are being killed by doctors. Increasing numbers of people who have not or are unable to consent are being put to death.
If you’re a pro-euthanasia doctor, please advertise it so I can stay away from your practice.
My husband was heavily doped with some chemicals at a hospital. He was not in pain so you cannot say he was sedated. He was no where near dying. There were three doctors involved.
I, his wife, did not recognize the doping. I was too stupid to realize that I should have taken him away for his own safety. I never dreamed that a doctor could do harm to a patient.
Enacting legislation or practice guidelines that allow physicians to kill – for any reason – is a very bad idea. Giving anyone a licence to kill dehumanizes them and those they kill. According to accounts from Belgium and other European countries where this has been allowed for some time, what started as an extremely drastic way to end pain has frequently become licensed murder where practitioners decide who lives and dies based on their own assessment of an individual’s quality of life. Once this practice is well entrenched, the consent of the “target” is neither requested nor required – rather the value of life is rated on arbitrary criteria – for example, life is deemed to be not worth having if one suffers from particular cognitive disorders or other disabilities, if one is too old or infirm, or if one has become inconvenient. So kill them, free up a bed (usually nursing home or hospital), and move on…
It seems that countries typically provide EITHER palliative care OR euthanasia and physician-assisted suicide.
Palliative care helps build a culture of compassion and of appreciation for human life. It fosters strong and positive interpersonal dynamics and helps both those dying and their families and friends deal more easily with life’s inevitable end.
The biggest risk to this country is that the social engineers who want to bring about this kind of change are more tyrannical in making everyone else do things their way than Mussolini was in 1930s Italy. If you doubt that, just look at what the OMA is trying to do to physicians on the issue of care at the beginning of life. Physicians whose beliefs are solidly right-to-life and who want to practice according to their consciences are hounded and threatened. If this end-of-life change is brought in, the same thing will happen, and patients whose values align with mine, right-to-life, will have no where to go.
The worst thing I saw in the comments below was the physician’s comment that the country cannot afford to care for (specifically, to initiate CPR when there is no consent for a DNR order) those he assessed to have too poor a prognosis. I’m all for responsible spending, but there are a lot of other ways to save in health care besides killing patients.
Say NO to euthanasia and physician-assisted suicide.
“DO NOT RESUSCITATE” FORMS (DNR) SHOULD BE PRINTED AHEAD OF TIME. IT IS A WELL KNOWN QUESTION IN ONE SENTENCE. THE PATIENT SHOULD BE ALLOWED TO SIGN IT AND KEEP HIS/HER COPY. THE DNR SHOULD NOT BE USED AS A “LIVING WILL.” IT IS ABOUT “CARDIAC ARREST” ONLY EDUCATED DOCTORS SHOULD BE VERY AWARE OF THIS. THE DNR SHOULD NOT BE USED TO WITHHOLD NUTRITION NOR HYDRATION.
Overall, this policy is a definite improvement on Decision Making at the End of Life.
I believe there are two areas of ambiguity that seriously hampers the effectiveness of the policy in providing clear guidance.
1. The key question “Is CPR a treatment to be proposed or provided as a standard of care in a dying patient?” remains unanswered.
Although you refer to “a standard of care” in lines 9,23,222,223,226,236-240, you have not defined it.
“Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.” Lines 222,223. Does this mean that CPR is not the standard of care for dying patients?
“When physicians propose a “Do Not Resuscitate” order (i.e. that cardiopulmonary resuscitation not be provided if the patient experiences cardiac arrest at some point in the future), they must explain to the patient and/or the substitute decision-maker why they propose not to provide the treatment and provide details regarding the alternative treatment(s) that they propose be provided. The College requires physicians to obtain consent for a “Do Not Resuscitate” order”. Obtaining consent means a patient may refuse so that a dying patient may request CPR. Is this the standard of care the policy proposes? To add to the confusion, if a patient experiences a cardiac arrest sometime in the future, is this the same as an expected death?
This implies that in cases of expected death a physician still has to gain consent to not provide a treatment. This is the only example that I am aware of where a physician needs consent to not do something. A surgeon does not consent to not do an operation. An oncologist does not need permission to not offer a medication he/she does not believe is indicated. When we explain why we are not offering CPR, it is can be received with some confusion and may create doubt that perhaps CPR could be effective.
The implication with the current policy is that offering CPR is the standard of care for dying patients.
2. A clear statement that all suffering cannot be treated at the end of life is needed. This is a form of humility, and an honest acknowledgement of the limits of the care we can provide. Some additional guidance is needed to define the limits of our care in the following situations:
• Requests to hasten death. By omission, the policy implies that all requests can be treated or ameliorated and this is false. This needs to be acknowledged.
• Requests for assistance to patients travelling to other jurisdictions for physician assisted death. You neglected to include other forms of assistance that patients may require- letters of endorsement, opinion regarding presence of depression and assistance in completing forms for assistance in flying. I realize that we are currently in a state of limbo regarding possible legalization of physician assisted death in Canada and in the future, this issue may disappear. Guidance is still required. To be fair to physicians, you should also include a footnote to acknowledge that the CMPA currently advises physicians that they put themselves at legal risk by performing the responsibilities outlined above. Physicians could be advised to consult with CMPA about how to reduce this risk.
• Responding to a capable person’s request to assist when they voluntarily stop eating and drinking. Voluntary stopping of eating and drinking has not been included in the policy and should be. This is a situation that I expect to be more common in the future, regardless of the legislation. Guidance is required.
Given that there are limits to the care we provide, it is not then accurate to say
“Planning for end of life ensures that the care provided to patients aligns with their wishes, values, and beliefs.” Lines 7,8, 127
I acknowledge that the standard of care in dying is an evolving but still nebulous concept. I am glad the College is trying to raise the standard.
I have practiced as an Intensivist for the past 22 years, both in academic and community hospitals. After reading the draft policy I have the following concerns.
I am strongly opposed to the policy that consent be obtained for a “Do Not Resuscitate Order”. Why would a medical professional be forced to obtain consent for a procedure or process that would be of no benefit? For example, a patient dying in the ICU on maximum doses of vasopressors and multi-system organ failure would never respond to CPR and yet even in this instance, we would be forced to obtain consent not to do it. If it was done, it would inflict unnecessary trauma to a dying patient and if consent not to do it was sought it would inflict unnecessary anguish to the family or substitute decision makers. In no other area of medicine do we need to get consent to not to do something.
In addition at the minimum, it needs to be clarified what a “do not resuscitate order” means. Is it no CPR, is it no intubation, is it no vasopressors etc. Resuscitation encompasses many different modalities not just CPR. The line that consent for a “do not resuscitate order” is required is in direct conflict with line 221-222: “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.” This conflict needs to be resolved for the benefit of patients, families and medical professionals.
Commentaires sur le projet de loi sur la légalisation de l’euthanasie :
Sous prétexte de respecter la liberté de tous, on nie aux médecins, dont la conscience serait opprimée en raison de leurs valeurs morales, le droit de s’objecter et de souhaiter ne pas prendre part aux traitements menant sciemment à la fin d’une vie.
Puisque je suis catholique, je ne parlerai que de cette Église dont la position est très claire. Elle a toujours enseigné aux chrétiens d’obéir aux pouvoirs publics légitimement constitués, mais elle a donné en même temps le ferme avertissement qu’« il faut obéir à Dieu plutôt qu’aux hommes » . L’Église considère l’euthanasie comme un crime qu’aucune loi humaine ne peut prétendre légitimer.
Je n’espère pas aujourd’hui convaincre le Collège des médecins d’abandonner ce projet de loi, ce serait trop beau. Ce que je voudrais, tout simplement, c’est que les médecins catholiques ne soient pas forcer de nier Dieu pour vous plaire.
I am a 76 year old lay person.
The draft is clear, thorough ,comprehensive.
It provides useful info for a lay person as to the rules/ policies doctors work under. More should be done by the college to educate the public on the latter, and to promote end- of -life planning by citizens.
Today the Supreme Court struck down the law that criminalizes physician assisted suicide. Whether one agrees with this or not, it had best be addressed by this CPSO policy. Currently, section 7 of the policy is an utter cop-out which avoids the issue entirely. There are obviously going to be patients who, after all underlying issues are addressed, still want to end their lives. The CPSO now has the responsibility of providing guidance / regulation for physicians regarding this newly legal scenario.
The previous comments (Feb 1, member of the public) are very thoughtful. However the fact remains that terminally ill patients will approach their physicians with these requests. Furthermore, physicians are uniquely able to assess and deal with the constellation of issues surrounding this, such as the natural history of the underlying disease, providing appropriate palliative care, treating associated mental health issues and capacity to consent, as well as understanding the physiological mechanism of the methods chosen to end a life. Clearly this will also require specific legal knowledge on the part of the practitioner. This CPSO policy must now include guidance for physician assisted suicide, for the safety of this group of patients and their physicians.
SCC ruling big slap on the face to other care providers Occupational therapists, Physiotherapists, Nursing staff which strive everyday to improve quality of life of their patients living with ill effects of illness and maximizing meaningful life to the end. This ruling is irresponsible promoting degeneration of values and culture same like Belgium and Nederland which is decay of Europe
This is an extremely important topic which has been sensitively discussed by CPSO but is it time to acknowledge the Supreme Court of Canada’s recent decision? The existing law appears to have been struck down regarding assisting or hastening death in end-of-life management.
Hello, thanks for inviting us to provide feedback on such an important policy and topic.
I’m a practicing physician in Ontario who deals with Critically ill patients. I’ve been in practice for about 10 years.
I have read the CPSO Draft Policy regarding Planning for and Providing Quality End-of-Life Care. For the most part it’s a good and fair policy that emphasizes the cooperative nature and therapeutic alliance between the patient/family and Health care providers in order to provide the best care possible for patient who could either be critically ill with a chance of recovery or dying despite of our best efforts due to terminal illness.
All therapies provided to patients are and SHOULD be discussed with patients or substitute decision makers should the actual patient be rendered incapable to make such decision.
Such discussion should be made on behalf of an incapable patient based on what the patient would’ve wished (if those wishes were known).
I do have a couple of issues though with a certain aspect of this policy pertaining to the DNR consent requirement.
I have always discussed this issues with my patients and/or families. I tend not to do unilateral DNR decisions.
Having said this, DNR is NOT a therapy that needs consent as per usual for any therapy (such as surgery etc). It’s a withholding of specific therapy (namely life support such CPR or Intubation).
It’s not logical to ask for consent NOT to offer a treatment especially if it’s believed to be futile (even as per CPSO policy).
Ideally we need a consent to PROVIDE life sustaining therapy but we usually don’t do that given that it’s done on Emergency basis if there was no prior code status discussion of the issue. CPR is the treatment not DNR.
Offering life support measures (therapy) on a dying patients is no different than offering surgery or MI therapy to any patient which needs their consent.
Resuscitation is therapy. It should be offered if there is some hope of a reversible illness that could be treated while the patient is placed on life support.
It’s not an acceptable therapy for someone dying of terminal illness without any hope of recovery. In that case it just delays in the inevitable (slowing down death as opposed to saving a life).
The CPSO and this Draft Policy does emphasize that we should not be offering Futile therapy if such interventions are deemed to be “Futile medically”.
Offering CPR or any life-sustaining measures (which are not always life saving) goes counter to this same Policy regarding performing futile therapy.
Obtaining consent for NOT offering a therapy such as CPR (ie Consent for DNR) runs counter to this same CPSO Policy and counter to our personal ethics as health care providers and human beings.
I place many patients on life support on daily basis in hopes of getting them better and returning them to to some meaningful quality of life that is acceptable to them (they are part of that decision).
But offering “life-support” to prolong the dying process without a chance of survival is both cruel to the patients, misleading to families, and ethically troublesome. This is unfortunately done sometimes to make a grieving family feel better that their loved one is kept “alive” without necessarily keeping the dignity of such patient in perspective and without any realistic hopes of improvements. I’ve seen patients with inoperable & extensive brain cancers in coms be placed on life support just to satisfy a grieving family that’s not accepting of the diagnosis or prognosis (with death happening anyways just later on). Breaking a dying patient’s ribs during CPR and inserting invasive tubes and catheters in them while they are dying to just satisfy a grieving or distraught family is not humane and runs against our medical (and human) ethics.
Sometimes we need to allow a natural and dignified death in terminally ill patients. Our duty as a Health care profession is to save a life when we can and comfort a dying person when we can’t save them. We owe it to our patients. No one should die suffering. This is allowing for a NATURAL process of death to occur when medical therapy is unable to change such course. This has nothing to do with euthanasia as some people have commented in this Forum. Not offering CPR to someone who’s heart stopped naturally when they have a terminal illness is only natural. CPR and life support won’t change that outcome. It’s done when there’s hopes of improving the problem. Most of the time (90%) it doesn’t work anyways.
Of course there’s always a debate about what constitutes “Futile care” etc, but part of this policy should be emphasizing the role of a good and honest discussion with patients and their families about what current medicine can and can’t do. while we should also advice everyone to seek third party assistance and advice (such as the Consent & Capacity Board or other medical opinions) to define reasonable care and expected patient outcomes if there was disagreements.
But to demand a consent for NOT offering a futile therapy (ie consent for Do Not Offer Life support, DNR) for someone who will die no matter what is not a correct demand or good solution for such patients.
The legal decision of the Supreme court Regarding the “Rassouli case” in Toronto is being taken out of context sometimes. The decision was that we need a consent to STOP existing life support and we need consent to start Palliative Care. It did not force Health care providers to offer life-support in the first place if it was believed to be futile.
Hope this policy, albeit good overall, can be slightly revised to provide for a more balanced approach to the DNR consent issue.
The Supreme Court on Feb 6 struck down the laws against physician assisted suicide, to take effect in 12 months. It is timely that this CPSO policy is being debated, as it should now be changed to include guidelines on physician assisted suicide. Section 7 currently avoids comment on this, instead suggesting that physicians approached with such requests deal with underlying issues. That is all well and good – palliative care and attention to mental health are both necessary – however it is clear that some patients will still opt for assisted suicide. It is now the CPSO’s obligation to provide a framework of regulation and guidance on this issue in conjunction with new legislation from federal and provincial governments.
To the concerned members of the public who have commented above, there are no rules that force physicians to provide any treatment to which they are morally opposed (apart from, ironically, the provision of life saving treatment in situations detailed by this policy and the Rasouli decision, which does not seem to be the source of your stated concern). For example, nobody is forced to provide an abortion. There is no reason to expect that physician assisted suicide will be any different, and those who have suggested otherwise are either ill informed or fear mongering. In fact, current CPSO policy does not even force such a physician to make a referal to a colleague who would perform the procedure in question, something that to the minds of many physicians and patients seems dangerously close to interfering with a patient’s right to access services, particularly patients in small or distant communities. I do not want physicians to be forced to act against their consciences. Neither should I impose my beliefs onto a patient by limiting their access to legal medical options in our universal healthcare system.
To the thoughtful commentary from Feb 1st, despite everything, it will be physicians who will be approached with requests for assisted suicide. Physicians are not only the point of access for such sick individuals, they are uniquely positioned to assess the natural history of the underlying disease, ensure appropriate palliative care, address mental health issues and capacity to consent, and understand the mechanism of the method of assisted suicide. Furthermore they are often in a position of trust for the patient. Certainly they will also require specific legal knowledge, and this is why CPSO policy must now address physician assisted suicide in order to avoid a legal and regulatory grey area in this regard.
As physicians we are told that we do not have to provide futile care nor care we believe/know will not benefit our patients. Yet to avoid life support in such patients we feel obligated to obtain the family’s consent. Many families demand and receive futile care for their loved ones with terminal diseases at the end of life and as physicians more often than not we comply because we fear litigation and we feel we are supported politically and legally. That needs to change. The legal system must empower us as physicians-so that our decisions are based on merit and not unrealistic or non-trusting patients or families.
Thank you for your frank and realistic understanding of what life means for human beings. Unfortunately, our province (Quebec) is tearing down all the laws concerning the protection of human rights instead of promoting the indisputable respect that our forefathers rightly had for it.
Congratulations for your standing. We are proud of you.
I have been following, and am greatly concerned about what I see is the momentum being built to deny physicians & surgeons conscience protection in the fulfillment of their duties when it comes to matters such as the inviolability of “doing no harm” or what that may be perceived to look like. While I understand that the medical and ethical groundings have been dissected at an unprecedented rate over the last thirty years or so, I do not believe that denying a physician or surgeon, who for good reasons has ethical or moral reservations concerning a medical or moral act related to their skills and practice, must be expected to act in violation of those reasons or reservations.
As a patient who has experienced some great doctors, I have also had the experience where myself – and my wife more in particular – has experienced degrading and deplorable “doctors.” Those who are great, I believe ARE great because they can act in freedom, thoughtfulness, compassion and knowledge and have honest concerns about my condition or my children’s. By eliminating – even curtailing – it, I believe the stage is set for physicians to have to either deny their own moral code and after a while “erode” their own sense of professional joy, as they will have to work in knowing that they are having to contribute to a recommendation that they believe in their heart is wrong, deadly, destructive or all three.
Given an optimal situation and environment where there were NO moral or ethical concerns regarding modern medicine and its practices, this probably would not be an issue. But there is, and I suspect with the rate of change that will an ever-increasing question of medical moral and ethical practices. In such an environment, is it truly the right time to snuff out anyone’s – a doctor’s or any other professional’s – right to act with good conscience? A doctor or surgeon being directed to set aside their conscience to achieve a “greater good” is for me, and those I love, a clear and present danger to the future of medical practice.
We do not need to go too far into our past to see what can be done when the rights and freedoms of conscience are “legislated away” regardless of the proposed good intent.
I live in a culture whereby I expect physicians to uphold the promise to do no harm. Asking them to set aside their conscience in matters such as euthanasia or assisted suicide is an assault on their dignity. If my doctor was forced to set aside his conscience and had to be forced to recommend or participate actively in end of life death, I would not feel safe, and it would completely change the nature of our patient-doctor relationship. Ending my life would now become an option in his “suggestions” to help “care” for me. That fact would now taint the lense in how I would look at his suggestions and options being presented to me to deal with my “health.” I believe lack of conscience protections would change our relationship to one of patient/doctor to one of client/service-provider – very different indeed.
Please, please, please – protect the dignity of your doctors and surgeons and ensure that their right to act in good conscience is protected.
To Whom It May Concern,
Please ensure if this legislation is passed that all Doctors may choose to opt out of caring for a patient who wishes to be killed.
Doctors promise to ‘do no harm’ and if a doctor does not want to kill someone who asks to be killed, that doctor should have the right not to kill the person. There will probably be enough doctors who are willing to kill on request and that person should be referred to that list of doctors.
Our individual rights should not make someone do something they do not wish to do and that includes abortion. There are enough around who already perform abortions.
Having an abortion or assisted suicide should not be forced on someone who does not want to perform such things. I personally would not want a doctor who chose to kill people who wished it!
People have to wait for hip replacements, transplants, etc. so, a person desiring to die can be referred to someone who wants to be involved.
Let’s not eliminate the rights of some!
It is my understanding you are reviewing the Code of Practice for Doctors regarding services they are required to provide to patients in their care.
With the recent Supreme Court ruling on Friday opening the door for assisted suicide may more doctors who may not have been implicated will now be implicated.
I believe it is even more imperative that the Code of practice retain a recognition of the conscience rights of doctors. With only about of 30% of chronically ill patients able to access palliative care, this is not a request for aid in dying but a plea for better palliative care. It is a failure of our medical system when a patient request death. Please do not change the Code of Practice but allow doctors the freedom of conscience . Outside of self defense, no one should be put in a position where they are being forced to kill another person even if they are asking for it.
As a cancer patient who for the moment is living on blessed borrowed time, I am very concerned that my doctors need to know they are protected from having to participate in any form of euthanasia or assisted suicide. Physicians need to uphold their promise to ” Do No Harm”. If euthanasia or assisted suicide is legalized, you must make it clear that physicians can maintain their right of conscience. I certainly won’t feel safe if I know that my doctors may be forced to participate in euthanasia or assisted suicide. Please protect your doctors from this terrible decline in the respect for end of life care. Rather please promote paliative care which I understand our government is promoting also.
My husband and I are seniors and we are urging you to ,please, protect conscience rights for Physicians. Physicians need to uphold their promise to “DO NO HARM.” Their mandate is to heal not to kill.
I would not feel safe at all if my physician participates in euthanasia or assisted suicide. I would be very afraid to even go to the hospital for treatment.
We need to improve Palliative Care.
I understand that you looking for feedback on the Draft policy on end of life care. It is curious that physicians who are trained to preserve life would now be given the power to end life. I am sure that some doctors would be opposed to assisted suicide and their moral conscience must be protected in some way. Given the recent judgment by the Supreme Court many doctors may find themselves in moral delema. I would not feel safe if my doctor participated in euthanasia
it will be a travesty if a physician is forced to either provide assistance for someone to die or to refer that person to someplace that will kill them.
because if the physician is unable to do either according to their values and beliefs , they will have to abandon the field in which they practice or not enter med school at all.
and that will no doubt be a disservice to people who need doctors.
your draft if adopted will be impossible to be folllowed as most physicians have neither the time nor the training/background to do comprehensive counselling.
Euthanasia Prevention Coalition e-mailed me your e-mail address, in order for folks to be able to communicate their opinions to you about assisted suicide and euthanasia.
I am firmly against the passing of end-of-life legislation, allowing euthanasia and assisted suicide to become legal in Canada. I believe in the sanctity of human life, and as a Christian, believe strongly that God placed each individual on earth for a reason, that we are all valuable to Our Lord and worthwhile to HIm. God has decreed in one of the 10 Commandments passed down to Moses in the Old Testament, “Thou shalt do no murder.” This encompasses killing of any person, whether self-inflicted, so-called “mercy killing” by a physician or nurse, or all-out murder which our legal system has definite laws against and is punishable by our court system. So, in my opinion, killing of any human being by any means, even masked as doing a “favor to the person” through “mercy killing” is a deceptive term, and there is no compassion or mercy shown to that individual.
What seriously ill, handicapped, mentally ill, elderly, or anybody in an unfortunate situation needs is compassionate care, in the way of responsible treatment or counselling, that helps the individual cope with illness or handicap, or tragic situation, and possibly even recovery from an illness. “Mercy killing” is an easy way out and there is no sensitive, caring and respectful treatment shown in this case. It is a convenient way, an easy way, to end someone’s suffering, whereas the health care providers could be using their education and expertise to help the patient cope with or recover from the illness or difficult situation. Health care providers have the knowledge to provide quality care to each and every citizen of Canada, and ought not to shirk on their responsibilities in this area, by finding the easy way out through assisted suicide or euthanasia.
Remember Nazi Germany, the Netherlands and Belgium of today, as well, and Switzerland, where the “death clinics” make lots of money through “mercy killing” for a good price. This is truly taking advantage of vulnerable individuals, and ought to be seen as very immoral and unethical, as well as evil in God’s Sight. He will certainly punish those countries that allow “mercy killing” and make such practices legal. It’s very cheap of humans to stoop to that level to allow such practices to become law in any nation.
When in death row prisons in America, they allow the death penalty by way of lethal injection, I’ll bet the same poisons used in those executions for convicted murderers in some American states would be used for euthanasia or assisted suicide in those countries where it has been made legal. They are now executing the vulnerable, the “damaged people”, and innocent people in Holland and Belgium, and this is legalized murder of innocent people–nothing less! Mistakes in euthanasia of the wrong patients have been made in Holland, and in Belgium not all the deaths by euthanasia or assisted suicide are accounted for–this is very very wrong and evil–they ought to be very ashamed of what they’re doing in those two countries. I’d never set foot in either of the Benelux countries for that #1 reason.
God bless you folks, and I hope you have taken into account what I’ve written here. I’m praying that in Canada legalized murder or “mercy killing” will never be legalized–it is a serious offence and God will not bless our country if we allow this.
I thank you for your draft policy on end-of-life care and I would like to respectfully make the following comments on the issues:
• I am delighted that the CPSO is developing a policy and I hope that in both content and language it will bring more certainty and clarity to the part that physicians, patients and other care-givers should play in end-of-life decisions.
• At the same time as providing guidance to physicians, the policy should also emphasize the need for respecting the values and belief systems of the patient and his/her family. The values and beliefs of the physician should be recognized and respected but they should not take priority over those of the patient.
• The CPSO will obviously want to develop a policy which is recognized as being of high quality and this naturally will take a certain amount of time but I urge the College to expedite the policy as quickly as possible so that it might play an important role in the ever-accelerating discussions around end-of-life care. Please do not allow policy-perfection to stand in the way of moving forward with meaningful decisions that will benefit the citizens of Ontario.
• Quebec has taken a leadership role in advancing choices around end-of-life care and through CPSO I would like to see Ontario lend its voice to the argument for improved end-of-life care.
• The Supreme Court of Canada has lifted the legal impediments to physician-assisted death. This is in line with the position of a large majority of Canadians and it is important to the people of Ontario that CPSO’s policy is conformable with this thinking.
• While fully supporting physician-assisted death, I also believe that palliative care in Canada should be improved and made more available. Physician-assisted death and palliative care are not mutually exclusive.
• I and my wife have made Advanced Care Plans in order for us to have some control over our deaths, in the same way that we had some control over our lives. We want to have the comfort of knowing that physicians will honour Advanced Care Plans and we would like your draft policy to make it clear that this will be the case.
I have a few comments/questions and fears about The College of Physicians and Surgeons of Ontario.
1) Is it the college’s intent to force physicians to go against their conscience?
2) Will the college discourage or expel good doctors from practice, who will not violate their conscience?
3) My wife and I, and my family would not feel safe if our doctor participates in euthanasia or assisted suicide.
4) If euthanasia or assisted suicide is legalized, doctors must maintain their right of conscience to refuse to participate in any way.
5) What does the Hippocratic Oath that doctors take say? Please oblige me with what the Hippocratic Oath says.
6) The headline “PLANNING FOR AND PROVIDING END-OF-LIFE CARE” is misleading if the college intends to include euthanasia and assisted suicide as care.
An Open Letter to the Ontario College of Physicians and Surgeons.
Today the Supreme Court of Canada has struck down the prohibitions against assisted suicide, opening wide the doors for doctors to strip off the white coat of the healer and put on, instead, the black hood of the executioner. From a cursory reading of the responses on the Online Policy Discussion Panel, it would appear that there are a significant number of people willing to avail themselves of doctor-assisted suicide, and an equally significant number of physicians willing to provide such “treatment”.
But what of the doctors who, believing firmly in the Hippocratic dictum “Do no harm”, refuse to participate in aiding and abetting their patients’ deaths?
If the Ontario College of Physicians and Surgeons draft of “Planning for and Providing Quality End-of-Life Care” policy proceeds as written, “physicians who limit their practice on the basis of moral and/or religious grounds” are reminded that they “must comply with the College’s Physicians and the Ontario Human Rights Code policy” (Section 8.3) This latter policy is also under review, but the draft of that document asserts, “although physicians have (freedom of conscience and religion) under the Charter, the Supreme Court of Canada has determined that no rights are absolute,” and the “right to freedom of conscience and religion can be limited.” The policy then enlarges on this idea: “…physicians, who choose to limit the health services they provide on moral or religious grounds, (must) do so in a manner that respects the patient dignity, ensures access to care, and protects patient safety.” It further states, that doctors who are “unwilling to provide certain elements of care due to their moral or religious beliefs” must refer the patient “in good faith” to another who would provide this service. Should such a referral be impossible, the doctor “must provide care that is urgent or otherwise necessary to prevent imminent harm, suffering and/or deterioration, even if that care conflicts with their religious or moral beliefs.”
I have highlighted those two sections for the specific reason of pointing out that in light of the Supreme Court’s decision it is easy to see that physicians who conscientiously object to doctor- assisted suicide could easily be forced into preforming it.
Personally, I find this peculiar in a most terrifying way. I want, indeed need, to trust my doctor; our relationship cannot function without this trust. I need to know that he honours the sanctity of my life and will always do me no harm. I also need to know that the medical profession to which he belongs supports his right to hold these beliefs and will not force him to act against his conscience. Otherwise, how will I ever know whom I am facing, the healer or the executioner?
Today the Ontario College of Physicians and Surgeons is at a major crossroad. To affirm doctor-assisted suicide as “treatment” and at the same time deny doctors the right to conscientious refusal, is for the College to become the agency by which the Dr. Jekylls of Ontario are turned into the Mr. Hydes.
I understand that the Supreme Court of Canada has made a decision approving euthanasia and assisted suicide for those suffering physically and psychologically. This is surely a very sad day for Canada when human life is no longer valued as it ought to be.
Every doctor needs to uphold their promise to ‘Do No Harm’ and must be allowed to maintain their right of conscience to refuse to participate in any way.
If my doctor participates in euthanasia or assisted suicide I would no longer feel safe receiving medical care from her.
I am writing to say that I support Conscience rights for physicians in Ontario, who oppose patient killing.
I urge you to support the physicians right to conscience in this urgent matter.
End of life care the way I look at it should emphasize more funding for palliative pain free care. I don’t believe that we should require doctors to actively assist in suicide more than they do now.
As a 76- year old lay person, I found the draft to be clearly written, thorough and reasonable. It is also useful from a lay person’s perspective to better understand the ground rules doctors must follow.
Anyone with common sense and a knowledge of recent history of medical practice in the Netherlands, Switzerland and other countries, will have realized what a slippery slope is being embarked upon in Canada.
Obviously, to withhold treatment such as painkillers from those who die in agony is to betray one’s calling. To administer medication to hasten or cause death is murder.
Prescription of painkillers, in the knowledge that they might hasten death but done advisedly and with reluctance is very different from active euthanasia.
Does no one teach ethics in Canadian medical schools any more ?
Good as is
Assisted suicide and its cousin, euthanasia, should never be part of the arsenal of physicians. The reason is simple. The trust between doctor and patient is based on an absolute belief that the physician will never actively promote death. If this is breached, the legitimacy of medicine is open to question.
Please note that in a palliative care setting the use of opioids or other powerful analgesics is legitimate only if the aim is comfort. If these substances are given with the explicit intent to kill it is not legitimate. Experience in Belgium and Holland has shown that the physicians there may have started killing for reasons of mercy but that reason was soon superseded by the utilitarian reason that in many of these cases putting pressure on a patient to commit suicide or killing directly with a lethal injection was the cheapest alternative (Euthanasia is not always with consent). Once the barrier is breached, there is no end (as demonstrated in these tow countries) to the enlargement of the circle of victims – in Belgium they even euthanize children for the comfort of their parents. It is futile to think that safeguards, no matter how clever, will stop this progression.
A pro assisted suicide policy will degenerate into an open euthanasia and will threatened the weak and vulnerable with what will become a duty to die.
Please I urge you to reconsider this policy. Furthermore if any physician refuses to be a killer he should be allowed to do so.
At the age of seventy my biggest fear is that I will not be able to CHOOSE how my life ends; I am a big supporter of “Dying with Dignity” and unless organizations such as yours, especially yours, step up to the plate and support people like me, my only choice when the time comes will be suicide.
I watched both my parents suffer incredibly with terminal cancer; to use a cliche, none of us would allow our pet dog to suffer like that. My biggest fear is dementia or Alzheimer’s and if I were to get that diagnosis in the coming years suicide early on would be my only choice. I am more concerned with quality of life rather than length of life. I have no desire to end up in lock-down in diapers with no quality of life eating up health care dollars that would be better spent on research.
My current doctor, though a competent man, has bluntly told me he would not ever consider assisted dying because he is a fundamentalist Christian. I believe that unless the idea of this being a criminal act is dispensed with, few doctors will feel differently. In the meantime I am looking for a different doctor.
Progress is being made in Quebec thanks to the doctors there. It is now your turn to stop dithering and step forward and support CHOICE just as you once did for abortion.
This is an URGENT matter as it is under consideration with the Supreme Court NOW.
Please do the right thing for the many Canadians who feel as I do. With increasing longevity and a huge financial drain on the health care system the time has come to offer everyone CHOICE.
Please respect the right of each person to act according to his or her conscience
with regard to the RIGHT to refuse to participate in any form of Euthanasia.
I do not believe that a governing body should tell a doctor that he or she must do as the patient asks in this regard. It seems that we are all trying to be God, or maybe just appease persons who lobby for this.
Why would you want to place a GUILT TRIP on one whose conscience tells him or her this act
is against his or her thinking and belief?
PLEASE be wise and act in a sensible way.
I am writing to express my views concerning the proposed “Planning for and Providing Quality End of Life Care” policy document.
I am not in favour of allowing physicians to end patients’ lives by assisted suicide / euthanasia. I would feel very uncomfortable visiting a doctor who on a regular basis participates in assisted suicide. I would always have at the back of my mind the question whether my physician really has my best interests in mind, should he or she be approving of this new CPSO policy.
Please allow physicians in Ontario the basic right of freedom of conscience on matters such as assisted suicide and abortion.
As Professor Theo Boer from the Netherlands so succinctly puts it: “I used to be a supporter of legislation. But now, with twelve years of experience, I take a different view.” He also says, “We were wrong – terribly wrong, in fact.” Professor Boer mentions that each year, since the implementation of the Netherlands’ official support of assisted suicide, there has been a 15% increase in assisted suicides. He states that “Euthanasia is on the rise to become the ‘default’ mode of dying for cancer patients.”
Please don’t let the genie out of the bottle – let’s not put our physicians in the role of deciding when to terminate people’s lives, or making the means so easily available for people to end their lives who are already in a fragile state of mind.
I am very concerned to hear that College of Physicians and Surgeons of Ontario is considering removing conscience rights from medical personnel. It is a most basic human right for one to be able to refrain from a practice that is against one’s conscience. I certainly hope that end-of-life policy does not change to allow for assisted suicide which goes against the principle of protecting life, but, if it does become legal, physicians should maintain their conscience rights to refuse to participate.
As an honours graduate of Health Sciences and as the spouse of an individual in the medical profession, I wish to share some feedback regarding the draft policy on end-of-life care as written by the CPSO.
First of all, I believe that physicians need to uphold their promise to “Do No Harm”; a promise which is contradicted through participation in the direct killing of an individual through euthanasia.
Secondly, should euthanasia or assisted suicide become legalized in our country, there MUST be an allowance for physicians/nurses to maintain their right of conscience to refuse to participate in any way.
Lastly, I would personally not feel safe if my physician participated in euthanasia or assisted suicide. Furthermore, as the sibling of an individual with special needs, I fear that euthanasia/assisted suicide will bring about a culture in which the lives of those with disabilities are completely disregarded and seen as disposable. I fear that people like my sister would be in danger of being euthanized because of others regarding them as a “burden” on society. The CPSO needs to affirm the value of the lives of those with disabilities and speak strongly against proposals to euthanize those individuals.
Rather than focusing on legalizing euthanasia and assisted-suicide, I believe that the CPSO should focus more on advocating for superb palliative care and working to increase the access to palliative care across the province.
As a senior and a Christian, I feel it is essential that doctors not be required to end the life of any patient. I would be afraid to have a doctor who was willing to kill me if I had a bad day and requested it. I am the widow of a doctor and the mother of a doctor. They went into the medical profession to save lives, not to kill.
I believe that physicians need to uphold their promise to “Do No Harm.”
I believe that a physician must maintain their right to refuse to participate in any way with life ending procedures like euthanasia, assisted suicide or abortion.
I would not feel safe if my physician participates in euthanasia or assisted suicide.
Some of the proposals in the draft policy seem to be the antithesis of the subject. It seems to me that unquestionably and in recognition of the Hippocratic Oath, all medical professionals should focus their efforts and resources on providing care for their patients, not aiding and abetting in their death in any circumstance. Physicians need to uphold their promise to “Do no harm”. To even suggest that a physician should make judgements on a patient’s quality of life as a consideration for killing the patient, is beyond conscionable.
Even if euthanasia or assisted suicide is legalised, and any such judgement would be based on social ideology and utilitarianism no matter the source, physicians must retain the right of conscience to refuse to participate in any way, for such is the essence of freedom – and fidelity to the Hippocratic oath.
I myself would change my physician if I knew he participated in euthanasia or assisted suicide. I certainly would not trust him.
I wish you God’s guidance in your deliberations. Of our many professions, I, as a citizen, look up to physicians to hold noble standards and principles and, as Aristotle has argued, nobility is synonymous with virtue.
I am writing to express my concern about the CPSO`s recent draft legislation.
Freedom of conscience, like the other fundamental freedoms enshrined in the Canadian Charter of Rights and Freedoms, is a fundamental pillar of democracy. This being the case, how can breaching this right be required by professional practice and human rights legislation? It shouldn`t be, nevertheless this is where the CPSO’s recent draft legislation is taking us.
As a Canadian citizen, I don`t want to be cared by a physician who would be willing to give me a lethal injection with the intention of killing me or who would help others to commit suicide. How would “my rights” to the kind of doctor I wish to have be respected if this draft were to go through? Medical care would be eroded if physicians couldn`t be allowed to use their own best judgement to practice the medicine that they feel is best for their patients. To reduce physicians to “yes men” who merely do whatever a patient may request places them in an absurd position. To force them to refer for procedures that they themselves would not perform is equally dangerous.
There may be rare circumstances where physicians exercising their right of conscientious objection would jeopardize a patient’s life or create a serious risk to their health and there are no reasonable alternatives. The ethical and legal validity of physicians’ refusals in such a situation would need to be determined on a case by case basis, not through steamrollering and destroying physicians’ freedom of conscience.
Consideration should be given to creating a public list of physicians who register as having conscientious objection to providing a specified medical procedure. This would allow people who want to be treated by a physician with such values to identify those physicians, at the same time allowing those who want such procedures to avoid those physicians. Reasonable steps would also need to be taken to ensure sufficient numbers of physicians were available on either side to honour Canadians’ choices. Upholding important values, such as respect for freedom of conscience, is not cost-free and we should be prepared to pay what is necessary to do so.
Forcing physicians to act against their conscience, to do something they believe is deeply wrong against their will, not only harms them. This coercive violation of their freedom of conscience also harms society and the values that inform its culture. Killing the consciences of our medical doctors will lead to inestimable harm to the people of Canada and society as a whole.
Physicians need to uphold their promise to “Do no Harm”. I would feel unsafe if my physician participated in euthanasia or assisted suicide in any way, including providing referals for these acts. Patients have the right to feel safe with their physician.
As a Canadian citizen I am asking you to reject the CPSO draft legislation and protect the conscience rights of doctors.
Thank you for the opportunity to comment on the draft document: Planning for and Providing Quality End-of-Life Care.
In light of the recent Supreme Court of Canada decision on the constitutionality of our existing laws prohibiting euthanasia, it appears that some form of physician assisted suicide is inevitable in our country. With this in mind, I wish to comment on Lines 350-351 of the draft where it states:
“Offer referral to another professional with expertise in the relevant area and facilitate obtaining a second opinion, as appropriate;”
This statement is troublesome, and will put some physicians in an ethical and moral dilemma. A physician who is opposed to “assisted suicide” should be allowed to inform a patient that he is not only unwilling to fulfill the patient’s request to end the patient’s life, but the physician should be under no obligation to assist the patient in finding a physician who will end the patient’s life. The finding of a physician who is willing to assist a patient in ending his life is a process that should be left to the College, who should maintain lists of physicians who will assist in ending people’s lives.
In a similar way, a patient may wish to see a physician who does not perform such end of life “treatments” because some patients, particularly the elderly and more vulnerable, will take some comfort in knowing that their primary care physician will not attempt to coerce them, however unintentionally, to end their life. Again, a list of physicians who will not perform assisted suicides should be maintained by the College for patients to access as required. This approach will acknowledge that we all have our own bias and view of life, and that this bias does and will affect a physician’s interaction with a patient in end of life discussions, both positively and negatively.
I submit that the above statement in the draft document should be struck from the draft, and in its place the College should include a statement that it will maintain lists of physicians who are willing, and those who are unwilling, to assist in a patient’s suicide so that patients may access the physician of their choice.
I agree that a physician who chooses to not participate in physician-assisted death should not be obliged to provide a referral for physician-assisted death.
The list idea is good.
It would be remiss of us not to thank the Rasouli family for refusing to give up on a loved one, thereby promoting necessary change. The new draft proposals have much to be pleased about. However, the critical issues facing the College must be dealt with and written in stone. Of extreme importance is who has the sole unconditional right to establish “Do Not Attempt Resuscitation” on a patient’s chart. The patient or the patient’s caregiver (power of attorney) is the only acceptable answer. We are dealing with life or death and must disqualify anyone else from being the decision maker. A doctor may wish to discuss this with the family and the family may respectfully listen. However, in the final analysis only the patient or the caregiver should make this critical decision.
Life saving and life sustaining treatment must also be a personal or caregiver decision as it is an extreme adjunct of DNAR.
Currently we are bombarded with an inordinate amount of “Right to Die” discussion in the media. The “Right to Die” is a personal choice and those who choose to do this should be provided with the means to do so. No doctor must ever physically participate in a suicide, period. We cannot help but wonder if the scarcity of health care dollars is the driving force here.
Palliative care is the compassionate part of dying. Our hospice, and we expect all other hospices, radiate more love, compassion and care with the wonderful volunteers they have. Hospitals and doctors should work to heal and make people well and they should do that better than they did for our family, otherwise, re-writing a new policy will simply be an exercise in futility in our opinion.
In our experience, our hospice is far superior to our hospital. The draft policy endorses the College’s policy “to protect the public”. We admit this sounds nice and comforting. For us, it was sadly a miserable failure. But, every cloud has a silver lining. For our family the silver lining was two doctors who obviously do protect the public. The attending coroner following the death of our matriarch, called us to explain her duties. She said she would phone us later in the day and did. She called for an autopsy and made a suggestion to the Chief Coroner for Ontario that the ‘Patient Safety Review Committee’ examine this death. The Chief Coroner, who was the other doctor who wanted “to protect the public”, did exactly that. Our family cannot understand how this preventable death could happen in the ICU in our hospital. We were told many times that our matriarch had suffered a stroke.
The coroner was compassionate, truthful and an excellent coroner, as the Chief Coroner of Ontario said to us. One additional comment made to us from the coroner was a powerful incentive to follow her lead. She told us of her decision regarding the autopsy and about discussing changes that needed to be made “to prevent another family going through what we had gone through”. Nothing would fill the huge loss we had endured, but we determined to try with unbridled determination to follow her lead, to prevent another family going through what we have.
I am writing to urge you to support physician assisted dying. I speak from personal experience.
My husband ended his own life. He was 76 years old and suffered from ALS.
If physician assisted dying had been legal at the time of his death, we would have enjoyed the following priceless benefits:
1. He would have lived longer. He was fully engaged with life and his mind was clear and active. However, he knew that he had to act while he still had the capacity to do everything himself.
2. He would not have had to make decision and take action entirely on his own. He was acutely aware of the possibility of criminal prosecution for any assistance.
3. Professional medical expertise would have been present at his death. The thought of his death was daunting. The thought of his failed death was unbearable.
4. There would have been no police interrogation. We knew ahead of time that this was the law and we accepted this. The policy investigation began a few minutes after his death and lasted almost four hours. A normal leave-taking was therefore impossible.
For these reasons I feel strongly that the present law should be changed and your College should add its voice to the growing support for assisted dying.
I understand that you are looking at end-of-life policies, and are interested in feedback. For ten years, I work as a hospital chaplain, for the most part in long-term and palliative care. I was called to the oncology unit at a hospital to support a family in distress. The scene was truly disturbing. Several relatives were attempting to hold down a lung cancer patient, who kept trying to sit up to get the breath denied to him by his damaged lungs. Other members of the family watched in horror.
This man had been diagnosed several months earlier, and I had met him and his wife after they had received the terminal diagnosis. He was a brace man and spoke of going home to try and get the most out the time he had left.
Disturbingly, at the time I describe he was still hooked up to a chemo line, even though his condition was beyond any hope.
I asked the family if they had ever been offered the option of palliative care, and they had not, not did they know what it was. They were eager to hear about this option, long overdue in their case, unfortunately.
The doctor was called, and when they arrived, they agreed to remove the patient from the chemo line and administer enough morphine to relieve his pain. He died soon afterwards, but not in the earlier misery which had extended to his entire family.
My point is that education among doctors about palliative care, and education among their patients would contribute much more to healing than any other measures. While I worked, it seemed to me that many physicians resisted this model of care, but it is a good model, which not only supports a dying patient but helps his whole family to grieve in a healthier way later. In your professions, I am sure you are aware of the many somatic and psychological symptoms that are caused by a difficult grieving process. Grief follow-up is part of the responsibilities of a palliative care team, and can be extremely beneficial.
I will get right to the point. I pray that someday it will be possible, if I desire, to have an understanding physician assist me in having my death with dignity. I have made this decision, after serious research, thoughtful deliberation and after experiencing the following.
My mother, at age 98 was mentally very sharp, was rushed to the hospital in severe pain with a twisted bowel. I was with her when a very kind Doctor informed us that, if he operated, because of her age she may wake up with impaired mental capacity. If he did not operate then she would surely die. It took her 2 seconds to make a decision that there would be no operation but asked that the end be as fast as possible.
It took my mother days to die. She was holding on the bars of her bed and her face was not at peace! I spoke to the head of Palliative Care at the Hospital and she kept telling me my Mother was not suffering. I know my Mother and I know she was not at peace.
Palliative Care Doctor told me she could do no more because she would be committing a crime. To me the crime was watching my Mother die suffering. When I asked this Doctor did she know for sure that my Mother was not experiencing horrific nightmares due to the drugs she admitted she could not know for sure if this was happening?
My Mother’s mouth and lips were dry and filled with cuts and ulcers no matter how many times I swabbed her mouth and lips with water and oils!
I watched my Sister die of cancer under Palliative Care and listened to my Step-Father in his 90’s living in a Nursing Home, cry because he wanted to die but it was the above that made me research my options.
Just think of the suffering and distress both mentally and physically, for the person and their entire family that could have been eliminated if a person had the choice to make their own end of life choice.
I make the following suggestion with thoughtful and serious considerations. Maybe we should look at our Doctors of Veterinary Medicine. Our amazing family member, a mixed breed dog, became very ill and could not function anymore. Our wonderful, thoughtful, kind Veterinary Doctor came over to our home, gave our dog anesthetic and when she was peacefully asleep gave her a final injection. She died in peace with the entire family who lover her right beside her holding her paws and stroking her back.
Our Federal Government has to change our laws so that the Criminal Code does NOT prohibit the practices of euthanasia and physician-assisted suicide in Canada. I have been told that the law as it stands exists to protect all Canadians, including the most vulnerable members of society, such as those who are sick or elderly and persons with disabilities. These ARE the people that, if they desire,…..need to be protected from…..a death of suffering mental and physical pain and distress during their last hours on earth. EVERYONE should have the right to die with dignity without any pain or distress.
I understand the Province of Quebec is taking a progressive stance in this issue. I also understand that there is a 15 day waiting period and as you can see from my experience, this is not going to help this situation.
We trust our Doctors with our lives all during our life so why can’t the Government take the word of our Doctors when they know a person is going to die? Why put a time limit on waiting for the peace of dying pain free, by choice, with dignity.
Thank you for your time and thoughtful considerations.
With sincere appreciation for the invitation to provide feedback on the Planning for and Providing Quality End-of-Life Care draft policy, presented by the College of Physicians and Surgeons of Ontario (CPSO), I wish to respectfully provide the following comments for your organization:
- As one of a growing number of Ontarians in support the legalization of assisted dying, I am very much aware and dependent upon strong leadership coming from the CPSO to develop a regulatory framework which supports patients choice and guards against abuse,
- With that in mind, while the draft document in many ways clearly presenting the values of “compassion, service, altruism and trustworthiness” as articulated in the “College’s Guide”, I find Section 7 of the document “Wishes and requests to hasten death” lacking some human depth
- My opinion is based on a variety of personal experiences: the first one being my 10 year volunteer involvement in a Hospice Care setting (after my retirement from a 20 year career in Social Work). In my contacts with the residents in the Hospice setting, I began to recognize a theme which they shared. This theme consisted of the fact that they expressed not so much being afraid of death itself, but of their fear of what would happen between the “now “ and their upcoming death – the real anxiety being the unknowns related to pain and discomfort and the time this process of dying would entail.
- Another experience is my close connection with my country of birth, the Netherlands – one of the countries in which euthanasia and physician assisted death is permitted by law. When a close relative of mine was dying of cancer and experienced significant anxiety about the dying process, he spoke with his physician about the end-of-life options available to him. The moment his physician explained to him that in his circumstances medically assisted dying was an option and that his physician could begin taking the various steps required for this, the patient’s anxiety receded and he died a few weeks later in a relaxed state, without need the planned medical assistance.
- The call for Advance Care Planning, so clearly articulated in the document, becomes more meaningful for all of us if we can openly include and discuss with our physician circumstances in which we wish for assisted dying.
- The opportunity to travel to those jurisdictions where euthanasia or physician assisted suicide are permitted by law is more limited than assumed. In the Netherlands, for instance, one of the requirements is that the patient has an ongoing relationship with his or her physician at the time assisted dying is chosen. In Switzerland there appears to be more flexibility in this area. However, the question remains, what is the impact of this direction on the patient and his or her loved ones. I, personally, wish to die in my home here in Canada with my family present during this time.
- Furthermore, to select travel to another jurisdiction (especially if it would man travel overseas) tends to require the patient to take the step to die with medical assistance earlier than necessary.
- A strong advocacy voice is called for to ensure that, as is the case in the province of Quebec, medically assisted dying is to be included as a apart of the elements that comprise Quality Care at the end of life. I see the College of Physicians and Surgeons of Ontario, with its close connection to End-of-Life Care, playing a most important role in helping this matter become law.
Dear College of Physicians and Surgeons of Ontario,
Physicians must uphold their promise to “Do No Harm”. If euthanasia or assisted suicide is legalized, physicians must maintain their right of conscience to refuse to participate in any way. I would not feel safe if my physician participates in euthanasia or assisted suicide. Please reconsider this decision. Thank you.
Physicians' Alliance Against EuthanasiaResponse in PDF format.
In light of the recent Supreme Court of Canada decision supporting ‘physician-assisted’ suicide, I find it fascinating that our own self-governing body fails to recognize how far behind we are when it comes to end-of-life care in hospital – particularly the ICU. As a profession, our obligation is above all to ‘do no harm’ – however, by providing or allowing a provision to provide treatments to individuals that lie outside the standard of care, we are doing exactly the opposite. In essence, we are allowing the public to decide what is ‘medically suitable’ – This undermines the integrity and value of the profession, relegating specialist physicians in critical care medicine who have trained for years to be able to provide the highest quality of care to the sickest patients in our society, to simply acquiescent service men and women. It’s about time we speak up for our specialty, advocate for our patients, and lead Ontario in setting the standard of care…
Consent for DNR is the biggest issue in this document. In scenarios where death is inevitable, performing CPR or multiple attempts at CPR is clearly futile and should not offered as treatment option.
line 221, “not obliged to provide life sustaining therapies” will fly in face of the previous statement as well.
Rest of the document is good and acceptable
I am writing concerning your draft policy entitled “Planning for and Providing Quality End-of-Life Care”.
It is my believe that physicians need to uphold their promise “DO NO HARM”.
Now that the Supreme Court has legalized euthanasia, I still believe that physicians must maintain their right of conscience to refuse to participate in any way.
I also wish to emphasize that I would not feel safe if my physician participated in any way in euthanasia or assisted suicide.
Thank you for reading my concerns.
I am an intensivist and would support previous comments that the CPSO must provide further clarity to the following conflicting statements in the draft policy.
line 221 “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.”
line 240 “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.”
Without further clarification, the policy will provide neither protection of the public nor guidance to physicians in navigating crucial end-of-life discussions with patients and families.
The CPSO policy seemingly acknowledges in line 221 that there is no ethical or legal obligation for physicians to offer non-beneficial treatments. If so, how are we to interpret line 240? Does it mean only that physicians require consent to write a DNR order in a patient’s chart, but still have the discretion to withhold CPR at the bedside when a patient is dying? Does it mean that physicians should inform patients, surrogates and the interprofessional team that he/she will not provide CPR for a dying patient because it falls outside the standard of care, but not document this as an order? Does it mean that line 221 is rendered meaningless when there is a conflict between physicians and patients/surrogates?
What I think it means is that the CPSO needs to respond clearly to the legitimate concerns expressed in this forum and further engage the critical care community before finalizing its policy.
I have read the document from my colleagues. I feel it is a thorough assessment of the issues. I agree with their concerns and trust that the CPSO will take them seriously.
As an Intensivist who will practice within the confines of this policy everyday, I submit to you that Intensivists with formal research expertise in end of life decision making be included on your advisory panel. We are fortunate in Ontario to have world leaders in this area of medicine, at both U of T and McMaster University, and to not formally include them in the drafting of this policy is a gross oversight. In its current iteration, it’s apparent that the council of Intensivists was not sought. This needs to be rectified for the policy to reflect the realities of clinical practice.
Thank you for inviting input and feedback for the draft document “Planning for and Providing Quality End-of-Life Care”. The draft of Section 7.2 “Euthanasia and Physician Assisted Death” requires adjustment in light of the Supreme Court of Canada ruling on February 6, 2015.
The use of physician-assisted death to relieve suffering of competent adults with grievous and irremediable medical conditions (see SCC ruling) addresses a legitimate concern with an inappropriate solution. The acceptance of any form of euthanasia in the medical profession will compromise trust between doctor and patient and will give subtle approval to the broad premise that suffering justifies killing. The CPSO must uphold the value “to do no harm” within the medical profession.
There are two very different motivations represented in public opinion for the support of euthanasia. One is compassionate killing at near end-of-life and the other is a right to control one’s death. The desire for physician-assisted death for the purpose of compassionate killing can be overcome through palliative care. The desire for physician-assisted death for the purpose of controlling one’s death can spiral into many different scenarios as seen in euthanasia-friendly countries.
If the public clamours for euthanasia for the purpose of controlling one’s death like B.C. blogger deadatnoon.com, let the public access it through a means other than the CPSO membership. It is imperative to maintain the integrity of the medical profession and its inherent characteristic to do no harm. The social and legal complications of euthanasia are enormous and have far-reaching social implications which should not be camouflaged under the auspices of the medical profession.
If the CPSO accepts physician-assisted death as part of its mandate, it would have a hard time maintaining control and restricting its application once vocal members of the public criticize the criteria for eligibility and erode restrictions using arguments based on the Canadian Charter of Rights and Freedoms. Will CPSO acquiesce to patient-driven demands for broader application of physician-assisted death? What has more pertinence regarding the mandate of CPSO (today and in the future): the professional opinion of highly trained physicians or rights of patients as declared in the Canadian Charter of Rights and Freedoms which favors individual’s rights?
The CPSO is a self-regulating body and has a strong power of influence in many areas. I encourage you to apply pressure on our law makers to find an alternate solution to the Supreme Court of Canada ruling that posed physician-assisted death as the solution for the case Carter v. Canada on February 6, 2015. Excerpts from paragraph  of the ruling include: “What follows is in the hands of the physicians’ colleges, Parliament, and the provincial legislatures”, and “Rather, we underline that the Charter rights of patients and physicians will need to be reconciled”.
I also encourage you to employ your efforts to educate the public on the benefits of palliative care. Encourage public support for a provincial plan to improve the availability of palliative care across Ontario, a national plan for palliative care across Canada, and continued improvements in the field of palliative care.
Important that recognise no physician should be obliged to offer futile treatment.
Physicians are guided by rules and regulations that define the boundaries of what they can and cannot do. With changes to such policies and the Supreme Court Decision, physicians will now be told what they ‘will and will not do’. All Canadians are entitled to safety, security and protection. Physicians and hospitals must continue to fulfill this role and doctors and medical practitioners must not be forced into a role contrary to their conscience.
If physicians are subjected to make decisions contrary to their conscience, #1 they won’t stay in Canada and #2 what kind of people will be attracted to the field of medicine? What will future doctors be like if they are the next generation who will have already been indoctrinated into a field of indifference, acknowledging suicide and euthanasia as a matter of fact? Palliative care will no longer be an option because the aged will be considered dispensable. Doctors will simply be enforcing the necessary requirements for a ‘disposable society’.
Canada already has a shortage of doctors which will leave Canadians who are fearful of euthanasia and assisted suicide at a disadvantage to find another doctor if their current doctor happens to be in favour of euthanasia and assisted suicide. Imagine if all doctors will be ‘required’ to be in favour of hastening death. As the Supreme Court Decision affects all of Canada, Canadians have nowhere to go, nowhere to move to avoid being subjected to the new ruling if our laws are changed.
Canadians are being pressured by organizations in favour of assisted suicide and euthanasia who are aggressively marketing their ideology through the mainstream media. The general public knows only what they hear and see on television and newspapers and, as a result, are reacting to this subject with indifference or ignorance of the details and consequences involved.
If, as the media states, most Canadians are in favour of assisted suicide, then why aren’t there more organ donors? Signed organ donors are the lowest in Canada. As stated in the Globe and Mail (July 15/14) the “CEO of Trillium Gift of Life Network said her organization regularly hears worries from potential donors that medical staff will not work as hard to save their lives if they have registered to donate”. This fear of hospitals and doctors will only escalate if doctors are required to act against their conscience.
Changes to such a policy as this and the Supreme Court decision have caused nothing but confusion and fear throughout Canada. Families will be faced with opposing positions on the care for family members along with motives for aging parents. Single people, young and old, will be the most vulnerable. If (Line 241-244) the patient is single and has no family, substitute decision maker or Power of Attorney, who makes the decision that he/she receives life sustaining treatment? Nor is the subject of food and hydration addressed in this policy. Who will speak for the solitary 80 year old woman with no family?
Palliative care must take on a greater role in end of life care and become a standard practice. Our healthcare system requires allocating the necessary resources to develop and increase accessibility to palliative care and facilities. Knowledge of such care must be communicated to the public to better understand their options.
As stated in comment #28, this will have “catastrophic consequences for the entire healthcare system”, and unfortunately, the only people who will benefit from this entire issue will be lawyers.
I have been practicing as a critical care physicians for 10 years mainly in large academic teaching hospitals. I practice only critical care medicine. Despite the obvious desire to improve the communication around, planning and management of death of patients, I believe that this draft document would immediately, severely and negatively change the management of dying patients in intensive care units (ICUs) across Ontario. There is much to be lauded in the production of this document but I will focus my comments on the serious flaws which absolutely require clarification and revision prior to its ratification. I also believe that there is some confusion regarding the interpretation of the ‘Rasouli’ Supreme Court of Canada ruling, as well as the weighing of the recent (I believe non-binding) HPARB ruling.
(Line 221) “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.”
The Rasouli SCC decision requires us to provide such care if these treatments are already in place, until such time as consent for an alternative treatment plan is obtained from the SDM or CCB. This wording should be changed to “Physicians are not obliged to propose or INITIATE life-saving or life-sustaining treatments that are not within the standard of care.”
The SCC did not address the standard of care. Furthermore regardless of medical benefit, treatments that have a ‘health related purpose’ (such as vasopressors and mechanical ventilation in a patient dying of multiple organ failure) are required to be continued until such time as informed consent is obtained for an alternative treatment plan by the SDM of the CCB.
240 “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.”
This statement seems to be in direct contradiction to Line 221 – UNLESS the CPSO intended to suggest that IF such therapies were within the medical standard of care then they should be offered, and a ‘Do Not Resuscitate Order’, as part of a medically reasonable care plan, would require the physician obtain consent. In cases where ‘life saving interventions’ are clearly medically futile, expose patients to the risks of treatment without any hope of benefit and thus fall outside the medical standard of care, they should not be offered (as stipulated in Line 221) and no consent is required.
As an extension of Line 240, would the discontinuation of CPR also require consent? Are physicians and healthcare teams required to continue chest compressions until consent is obtained to cease and proceed with the declaration of death? Could a doctor face disciplinary action or litigation if they are seen to stop CPR, declare death and then be accused of causing the death they just declared? Surely this is not what the Supreme Court intended in Rasouli (they restricted the reach of their ruling as such in para. 70), nor the CPSO in this draft document.
The notion that consent is required to NOT offer a potential treatment in a future specific context which may never happen (accepting the inevitability of death) seems incredulous. As another extension of this would physicians be required to provide every patient who was ever listed on a transplant list an organ regardless of their suitability and ultimate candidacy? Again, I do not believe this was the intent CPSO draft, but as it currently stands without clarification this would be the possible interpretation and execution of this policy.
228 “… substitute decision makers may assess the proposed treatment options differently than the physician as they may consider, for example, whether the treatment prolongs life even if there is no clinical benefit.”
This is a VERY POOR example, and many readers could see it as contradictory to Line 221. If there is no clinical benefit why has such treatment been proposed? Did the authors wish to address the idea that patients and SDMs may weigh the values and ‘benefits’ of treatments differently than the treating physicians? Although a key consideration in the development of treatment plans, it does not itself override the fundamental principles in medical decision making by the physician: the determination of potential benefit and the risks of harm. Patients and their SDMs may accept high risks, but it is both malpractice, unethical and an abrogation of our duty to patients to offer treatments that have not benefits and only carry risks.
If I am correct in my assumptions regarding the true intent of this phrase, I would suggest that it be changed to something similar to: “Physicians are advised that patients and substitute decision-makers may assess the value of various treatment outcomes differently (e.g. prolongation of life over consciousness), and should consequently take a very wide view of potential outcomes when weighing the decision of whether therapy has any potential benefit to the patient at hand, and whether it falls within the medical standard of care.”
This document requires revision and correction of these three sections with input from critical care physicians, in addition to further consideration from the writing group. As it stands currently the document will create much confusion among intensivists, and result in a dramatic change of practice that would distract from, rather than benefit, the care of dying and critically-ill patients and their substitute decision makers in ICUs across Ontario.
Finally, as has been clear in the existing comments in the discussion, the recent SCC ruling regarding physician assisted death requires some careful mention in this document, as to not provide physicians with more support and guidance in this matter would seriously undermine the face validity of this policy.
I am very concerned about the idea of physician assisted suicide. Where does it end? How many elderly and disabled people will die when they should not because they are a financial drain on the health care system or emotional drain on their families and caregivers. As a retired supervisor of a total care group home it was my experience that some physicians were more than willing to withhold care for our clients because they “didn’t have much of a life anyway” This was said to me by a physician when I took one of our much loved clients in to emergency for a severely bleeding ulcer. After surgery to repair it he went on to live quite happily for 3 more years before he passed away quietly in his sleep. At 33 he exceeded his life expectancy by about 15 years. I understand there are many people who do not believe in God but I do very strongly and how many physicians who also believe in the Almighty are being put in the position of having to assist their patients in dying. How is it fair to put that burden on them? They must be allowed to do their jobs and to fulfill the oath they took when they became doctors to do no harm. If this means not performing CPR etc. when it is not useful but allowing nature to take it’s course then I am fine with that. I won’t tell you how to live or end your life as long as it does not create harm to those are left behind.
I concur with the Canadian Critical Care Society position on this document.
Very important topic, congratulations to the College committee that assembled it. Likewise to members of the profession and of the public for providing their perspectives. That said, a physician must retain the right to refrain from acts against his or her conscience. Specifically, non-abetting of assisted suicide and non-abetting of noncritical abortion. This means that the College takes responsibility of acting as a referral source for these services. Any form of coercion will create a schism within the profession and represents a form of one-sided “contract renegotiation” which will open the door to Human Rights complaints against the College by its own members. Could the writers of this policy please clarify their grounds for interference with physicians’ conscience and/or religious values? Agree with many commentators regarding the desirability of reducing the suffering involved with dying. Agree that palliative care needs support and development within the health care system. Palliative care needs to be discussed at length in this policy. Our health care system is unable to remove all sources of suffering but we can work to do better.Feedback and complaints from families regarding ‘bad deaths’ need to be taken seriously, learned from, and improvements need to be made so that others do not suffer through similar experiences. Agree with many commentators from ICU physicians regarding a need to defend professional autonomy around withholding futile treatments. Clarification of withdrawal of care versus withholding care is needed. Am very convinced by reports from Netherlands, Belgium, Switzerland, Oregon regarding impossibility of adequately safeguarding any form of legalized assisted suicide. Our society holds extremely stringent criteria to sentence murderers to life imprisonment. The concept is that not a single miscarriage of justice can occur – that our lives are too precious to wrongly accuse and imprison even one person. And yet for assisted suicide and euthanasia, no jurisdiction exhibits a standard of oversight and care anywhere close to that afforded by the criminal justice system. We will kill the wrong people with any system of legalized assisted suicide. Perhaps 1%, perhaps 5%. As a society, are we prepared to ease the suffering of a few at the cost of killing one person wrongly? Thank you
I am an intensivist writing in response to the CPSO proposed policy entitled ‘Planning for and Providing Quality End-of-Life Care’; my comments pertain to the section on consent for a no CPR order.
1) Considering that many, if not most, conflicts around end of life care occur in the intensive care unit, as were the 2 cases referred to in point 2 below, I find it surprising and concerning that no intensivist was involved in the creation of this section of the policy. (I am assuming this to be the case based on your response to commentator 1.)
2) Lines 218-20: Suggest revising to ‘offer’ palliative care, rather than ‘provide’, since palliation must be consented to by the patient/SDM along with any other treatment.
3) The requirement for physicians to obtain consent for a no CPR order (line 240) contradicts the obligation to not propose or provide treatments that are not within the standard of care (lines 221-2). Line 240 appears to follow from a flawed interpretation of the Rasouli decision, and from a decision by HPARB (EGJW v MGC, 2014 CanLII 49888 (ON HPARB)). Arguments for why the Rasouli decision does not apply to a no CPR order are reviewed in CMAJ 2014;186:E622. The latter decision was written by only 2 of the 3 members on the panel hearing the case and has not been subject to judicial review. It is unclear why a decision written by 2 members of an administrative tribunal should form the basis for a major revision of CPSO policy.
4) It is completely unclear to me why no CPR orders are subject to the requirement for consent, even if providing CPR would not within the standard of care for a particular patient (for example, a comatose mechanically ventilated patient with septic shock, on very high and escalating doses of vasopressors and renal replacement therapy after several days of life support) at the same time that other treatments are not subject to the same requirements. For example, why are the following procedures not obligated to be provided unless the patient or SDM declines: drainage of an massive intracranial bleed in a patient with a GCS of 3 and fixed pupils; intravenous chemotherapy for a bed-bound patient with widely metastatic cancer and poor performance status; coronary artery bypass grafting in a patient in STEMI and cardiogenic shock with a fresh stroke. In each of these cases, including non-beneficial CPR, providing treatments that are outside the standard of care violates professional standards going back to the Hippocratic oath.
5) Lines 228-30 are unclear. If a treatment is offered, capable patients provide or decline consent, or their SDMs do the same in accordance with the HCCA. If a patient or SDM desires a treatment in the absence of a clinical benefit, is the physician obligated to provide it?
6) There are numerous instances in this policy where the CPSO should provide practical guidance for physicians rather than waiting for a complaints process or disciplinary hearing to clarify expectations. The alternative would be for the CPSO physicians’ advisory service to provide a rapid response to these sorts of questions in real time, but I suspect that is highly unlikely to occur.
a. What process should physicians follow when CPR has been in progress for 30 minutes, has not succeeded in restoring spontaneous circulation, and the standard of care would call for it to be stopped, but the family declines consent?
b. What process should physicians follow when a patient is receiving mechanical ventilation but has been declared brain dead and the SDM declines consent for both organ retrieval and for discontinuation of mechanical ventilation?
c. If a physician offered CPR to an incapable patient and the SDM accepts, but also demands extracorporeal life support as part of resuscitation (should cardiopulmonary arrest occur), is the physician obligated to institute that even if doing so is not within the standard of care?
d. How should physicians go about transferring a patient to another hospital if a conflict cannot be resolved? Are we obligated to telephone every hospital in the province? The country?
I fully support the CCCS response to the end of life guidelines. They cannot be passed in their current form.
It is with extreme concern and sadness that I must write to the College of Physicians today with regard to the end of life policy. Physicians have through time been a body of honour and distinction to protect life and not destroy it. We all know this has gone by the wayside in so many areas. Now this body is attempting to destroy not only their own policy to care for life but to destroy the very morale of your own members.
If a doctor can not act out of conscience, they can not act at all nor should they have to be complicit in arranging for someone else to perform this act, compounding the destruction of their own conscience. In compelling physicians to refer, not only are you taking away their moral obligation, you are limiting their right to conscientious objection.
To take away Freedom of Conscience is to take away a basic foundation of a free supposedly democratic society. To do this you expose not only your members but all of society to an increased death sentence based on lack of trust and create a society of increased fear because not only are our very lives increasingly at stake but you are opening a cascade of further removal of rights and destroying the whole morality of our province.
Please, please, please, rethink these sections and enable our doctors to retain their freedom of conscience.
People who are dying need good palliative care, not a lethal injection. Allowing natural death is the best for all concerned: patient, doctor, family, friends. Mother Nature is always the best way.
Allow doctors to step aside when a patient requests a treatment or procedure that is in conflict with a doctor’s moral or religious beliefs. Why force doctors to refer? This is a trampling of physicians’ human rights. To remove this right is a fundamental assault on on their personal integrity. We need physicians who have integrity and convictions.
Most people would prefer their doctor to be a person of conscience, even if that conscience leads them to a conclusion that differs from the societal opinion of the day.
The policy entitled “professional obligations and human rights” must be amended.
Freedom of conscience is a foundational principle in our society and we all have a duty to defend it wherever it is imperilled.
In my opinion, there should be no directives.
Any physician should hydrate and try his best to save the life of the patient.
There should be no Drugs for Sedation. Such as Morphine, etc. Do no harm.
The present DNR directive is the most illegal and unprofessional document I have ever seen.
It should not be verbal. It should not be asked by a physician.
It should be a legal document, printed on paper, with a line for the signature of the patient. And a line for signature of a witness. A copy should be given to the patient and a copy should be filed in an office. Patients should be allowed to change their minds.
The DNR is one question in one sentence. Some call it CPR because that is what is used to resuscitate the patient. But it is DNR as follows:
“In the event of cardiac arrest, do you wish to be resuscitated or not resuscitated?”
I am surprised that the CPSO is so far behind in this matter.
I believe that doctors should be able to provide quality health care that does’nt jeopardize their conscience rights.
Physicians need to “Do No Harm”. The fact that legalized euthanasia or assisted suicide is now permitted, we believe that physicians must maintain their rights to refuse to participate in any way.
We would not feel safe for end of life care if our physicians participated in euthanasia or assisted suicide.
Dear Sir or Madam,
As a senior, I am very concerned about end-of-life care not only for myself but also for that of my loved ones.I feel that physicians need to uphold their promise to “DO NO HARM”.
If euthanasia & assisted suicide are legalized, physicians must maintain their right of conscience to refuse to participate in any way. I would not feel safe for myself or my loved ones if our physicians participate in euthanasia & assisted suicide.
Under no circumstances should doctors have the right to lethally inject people to terminate their lives!
Doctors need to preserve life and to at least offer resources to make the lives of those that are suffering more bearable by providing pain relief.
In the case of a fatal disease the patient can choose not to be kept alive artificially by machines but under no circumstances should the doctors be administering drugs to terminate a life.
Please ensure that:
- physicians need to uphold their promise to “Do no harm”!
- if euthanasia or assisted suicide is legalized (I sincerely hope not), then physicians must maintain their right of conscience to refuse to participate in any way
- I would not feel safe if my physician participates in euthanasia or assisted suicide
Dear Sir or Madam:
I have read the draft policy that is being proposed concerning End-of-Life Care.
I wish to express my strong opinion that I do not agree that physician-assisted suicide and/or euthanasia be legalized. I think that measures should be taken to improve access to suitable palliative care for patients who are suffering.
If the legislation does go ahead and become law for physicians to assist in suicide or perform euthanasia, then I strongly believe that physicians should not be required to perform this and that they be allowed to opt out on the basis of personal beliefs. In addition, they should not be required to refer the patient to another physician who would perform it.
Thanks for asking for input from the public on this matter and for considering my opinion.
I am writing to express my concern regarding the decision by Canada’s Supreme Court go against its own prevoius rulings,. the will of Parliament and the expressed wishes of a majority of Canadian citizens and allow doctors to assist patients to end their lives by commiting suicide.
Canada’s law against assisted suicide has come before the Court a number times and has always been upheld. Does not the law oblige the Court to uphold its own previous decisions?
This decision by the court is troubling and will cause people to lose confidence in our courts as well as the medical profession.
Suffering people must be given the best of care and comforting and this will not be achieved by giving doctors a license to kill.
I strongly oppose this decision.
To the Ontario College of Physicians and Surgeons:
Allow me to say that I believe that physicians should dedicate their time and resources to caring for people who are sick, depressed or suffering from mental or physical illness – not assist in killing them.
Once we embrace the idea of suicide, not as a tragedy we should seek to prevent, but a right we are obliged to uphold; once the taking of life is converted from a crime into a service — “physician-assisted death” — to be performed at public expense; once we have crossed these sorts of philosophical and legal divides, how is it to be imagined that we could stop there? I would not feel safe if my physician participated in assisted suicide.
I am afraid that the interpretation of the law will become a slippery slope leading to future challenges to assist young children with terminal illness to die, to end the life of the mentally incompetent and eventually to kill anyone who is simply tired of living without any particular illness.
Please do not force doctors to act against their own conscience, rather allow them the right to refuse to participate in assisted suicide.
I would suggest that the OCPS work closely with the province to expand resources into the areas of palliative care, home care and mental health services in this province. That is the just, loving and compassionate solution to living with dignity.
I ask that you stand for the following:
l. Uphold your promise to “Do No Harm”.
2. State that if euthanasia or assisted suicide if legalized, that you maintain your right of conscience to refuse to participate in any way.
3. I will not feel safe if my physician participates in euthanasia or assisted suicide.
Thank you for inviting input and feedback for the draft document “Planning for and Providing Quality End-of-Life Care”. I am a member of the public. The draft of Section 7.2 “Euthanasia and Physician Assisted Death” requires adjustment in light of the Supreme Court of Canada ruling on February 6, 2015.
It is true that we do not need to take extreme measures to prolong life. Patient may suffer severe pain through the period of the trial time. Superficially, the Supreme Court of Canada decision allowing assisted suicide is a right thing to do ending a life in a painless manner. Currently the CPSO is proposing that us physicians who refuse to perform procedure to which we morally object must refer the patient to someone else to get it done. I urge the CPSO not to go thru with this unjust policy. We are compelled to become accomplices. It is an assault on freedom of conscience on us physicians. Life is precious. We should use each present moment to prepare for the time of our death by living well. We physicians should try to provide with the best medical assistance we can offer, e.g. Palliative Care for those at the end of life. Please do not force us to lose our moral compass. Give us a slight room for freedom of conscience. Physicians are known to be for healing and not agents of death. Let the patient, not the physician, search someone else who believes in performing the procedure.
I AGREE with you completely . As physician we should help patient to live and not to take part to kill our patient.
Dear Sir or Madam,
In response to your request for feedback on the draft policy on end-of-life-care, titled “Planning for and Providing Quality End-of-Life-Care”, please may I state my deep concerns regarding a physician’s right to conscience when he or she opposes patient killing.
It is my strong belief that physicians need to uphold their promise to “Do No Harm”. Also, that in the terrible event euthanasia or assisted suicide were legalized, physicians must maintain their right to refuse to participate in any way. I personally would not feel safe if my physician were to participate in euthanasia or assisted suicide.
I once again urge you to please protect a physician’s right to conscience.
In response to your request for feedback on the draft policy on end-of-life-care, titled “Planning for and Providing Quality End-of-Life-Care”, please may I state my deep concerns regarding a physician’s right to conscience when he or she opposes patient killing.
• I see a risk that assisted suicide become a substitute for effective palliative care, a pretext not to improve it;
• Physicians need to uphold their promise to “Do No Harm.” I see a real risk that physicians get exposed to creeping pressures from institutions such as nursing homes, or family members, to circumvent safeguards and engage in active euthanasia (i.e. without the consent of mentally fully fit patients);
• If I learned my physician had engaged in this type of practices, I would not feel safe and would loose trust in him;
• Furthermore, in case “assisted suicide” were authorized nevertheless, in no way should physicians loose the right to refuse in conscience to participate in such practices.
I urge you to protect the conscience rights of all health care providers in Ontario.To leave our health care in the hands of people who have been forced to abandon their deeply held beliefs about health care is not in our best interests. There is no need to mandate all health care workers to follow the same set of beliefs. If a patient is dissatisfied with his or her health care provider,the choice to go elsewhere exists with no difficulty.
I think it is crucial that the College members and MPPs visit Ontario Palliative and complex continuing care hospitals to see that living with terminal illnesses does not have to be a misery. Proper care and support for family should be a obligation for health care providers, not assisted suicide which is against the nature. I bet that some practicing physicians don’t have enough knowledge about palliative care. I think College as a regulating body should provide education workshops for those physicians prior to make any drafts or policy.
I have practiced as a health care ethicist in Ontario for 25 years.
There are some key provisions of this draft policy that need revision. It is absurd to require physicians to gain consent to a DNR. (Line 240)This is the only case I can think of where physicians would be required to gain consent to not do something that cannot work. Not only would this require physicians to perform pointless and indeed harmful resuscitation attempts, but it also places a completely unnecessary burden on patients or families as they refuse a proffered intervention. In my opinion the HPARB decision referenced here does not force that conclusion but only the conclusion that the patient/family would need to be informed.
The requirement that physicians offer treatments that are somehow “within the standard of care” even if they do not bring a clinical benefit is incoherent. (Lines 231-240) How could a treatment be within the standard of care for a particular patient and yet not offer a clinical benefit? And even if such a treatment existed it is not clear why it should be offered. If a treatment is offered, and accepted, it must be provided. Again, this would force physicians to provide treatments they believe to be either futile or positively harmful.
Given the Supreme Court of Canada decision in the Carter case it makes sense to withdraw this policy to address those issues. (Section 7)
Some commentators have pointed out that the elephant in the room in the Rasouli decision is the issue of health care costs. Rasouli gives the authority to families to require continuation of life-sustaining therapies even in those cases where there is no realistic prospect of a meaningful recovery. The cost of maintaining a person in an ICU has been estimated to be close to $1 000 000 per year. That is not an abstract sum but rather represents other goods for others foregone. The Supreme Court of Canada expressly said that it was not in a position to address cost issues — but someone must. Who? Does the CPSO have a role to play in these discussions? The provisions of this draft policy have significant cost implications if the authority to demand futile or pointless interventions is granted to patients and or families.
Finally, the CPSO has a draft policy for consultation on professionalism and human rights. As law and policy change on physician assisted death the obligation of a physician to refer a patient seeking such assistance may well become a contested topic.
I’m a Critical Care physician in Manitoba who works with these issues on an absolutely routine basis. I think there are many issues that are problematic in your proposed guidelines. I believe that the Canadian Critical Care Society may be commenting on your statement and i fully agree with the planned response which you should have soon.
Having said that, the obvious problem i see with your statement is the requirement that consent be obtained for a DNR order. That is patently ridiculous! CPR is clearly a medical therapy with specific indications. If it is a medical therapy, then it can only be offered in the context of providing some utility. Too many people seem to think that CPR is what you see on TV. it was designed for sudden cardiac arrest due to cardiac arrythmias. Basically the person is in pretty reasonable shape apart from a sudden cardiac event. In that circumstance, there is some hope of effectiveness. But in the case of someone who is known to be ill and arrests despite therapy, there is virtually no hope for benefit. Most intensivists would suggest it would tantamount to malpractice to intentionally offer it in that circumstance since the only real possibility is prolonged pain and discomfort. Most families can see that but some for emotional reasons simply cannot.
I would not under any circumstances perform CPR on someone who i believe cannot benefit particularly those whose course of illness inevitably will lead to cardiac arrest. These cases do occur. We occasionally have people who are in severe shock and arrest despite best efforts with their families pleading to “do everything” including CPR. Sometimes some physicians do it only for the for the sake of the family. In most cases, the “CPR” is perfunctory or worse ie for show and not at all serious. This kind of deception degrades our profession. Much better, i believe, to compassionately but firmly indicate that death has occurred and that CPR has no role here.
Requiring consent for DNR will be freighted with serious issues and is not at all a standard of care anywhere in Canada.
I welcome such open dialogue and discussion on this important topic with the CPSO and the members of the public.
To date, critical care physicians have been largely abandoned – left to deal with these issues on a case-by-case basis on their own.
We need support from our regulatory and legislative bodies regarding these challenging and value laden issues. We expect that they will become a common feature of ICU practice in the near future as the baby boomer cohort ages.
I support palliative care measures and not euthanasia.
Although I do not practice in ON, I support the CCCS position with respect to this policy. It will have implication country wide.
As a practicing critical care and emergency medicine physician and as a director of a critical care residency program, i have significant concerns about the draft policy.
My most significant concern is the requirement that physicians obtain consent for a DNR order, even in situations in which CPR is not medically indicated. This requirement would essentially force physicians to offer and initiate treatment despite it being futile or inappropriate in the context of a patient’s illness. This is inappropriate, and in my opinion, unethical.
I agree that communication with patients and SDMs to explain why treatments are not offered is essential. However, there is no legal justification to require consent for a DNR order when CPR is not a reasonable therapy or within the standard of care. It is akin to requiring surgeons to offer surgery even when there is no evidence of benefit to surgical intervention.
CPR should be considered like any other medical treatment, and be offered to patients when medically indicated and likely to be successful, and not offered when it falls outside the standard of care. While recent legal decisions have identified that physicians cannot withdraw established therapy without consent, there is no legal requirement that physicians offer treatment they deem futile or outside of the standard of care.
I share the concerns of the Canadian Critical Care Society as articulated in its response to the draft policy.
I am very opposed to this policy from CPSO. It completely misses the spirit of the Supreme Court decision and appears to be written by a small select group with a personal agenda. As an Ontario physician, I will not support it.
The Supreme Court of Canada deliberated that physician-assisted death would be a solution to Carter v. Canada. Then they gave a year for physicians’ colleges, Parliament, and the provincial legislatures to figure out how to handle physician-assisted death before it becomes legal.
I suggest CPSO respond that physician-assisted death would grossly alter the nature of the relationship between physician and patient and compromise physicians’ responsibility to the profession of medicine to do no harm, and therefore, will not be accepted as a practice of CPSO.
Physician-assisted death would become a possible but rejected solution. The Supreme Court of Canada would have to find a different solution to Carter v. Canada. There must be a better solution than physician-assisted death.
that freedom of conscience still matters and cannot be eliminated through policy
I strongly believe that physicians need to uphold their promise to “Do No Harm.” Physicians should not be involved in any way in assisting suicide.
Fundamentally, physicians must maintain their right to refuse to participate in any life ending procedures like euthanasia, assisted suicide or abortion based on religious or moral conflict.
I would not feel safe if my physician participates in euthanasia or assisted suicide, especially if compelled to participate in these activities without the ability to refuse.
I am a retired RN who has worked in palliative care in the community. The patients that I attended were always given whatever amount or type of medication or support required to alleviate their suffering.
There are physicians and nurses who according to their moral conscience would not want to participate in the death of an unborn child (abortion), or in the death of their patient by physician assisted suicide. If a colleague is not to be found who would be willing to do this, can a physician lose his or her license to practice medicine by following their moral conscience?
I fully support the feedback you have received from the Canadian Critical Care Society. As a member of the board for the society I have had the opportunity to contribute to that. I would emphasize what is detailed in that document.
1) Requiring “consent” for a DNR order is the wrong approach. We don’t get consent to not do other treatments particularly when they are not indicated. (eg. liver transplant)
2)There must be better clarity around the process of conflict resolution.
3)There should be better guidance for the provision of aggressive symptom management.
commenting as an intensivist
Section 7.2 Euthanasia and Physician Assisted Death will require a complete overhaul in light of the recent Canadian Supreme Court ruling striking down the applicable provisions in the Criminal Code of Canada
Section 5.2 Life-Saving and Life-Sustaining Treatment is problematic. Line 240 proposes “The College requires physicians to obtain consent for a “Do Not Resuscitate” order. This would suggest the requirement is mandatory irrespective of context. The American Heart Association’s most recent guidelines for CPR (Circulation 122: 5665-5675, 2010) clearly state that CPR is justifibly withheld in circumstances of clear futility such as with obvious signs of irreversible death (i.e. dependant lividity) or extreme prematurity (gestational age < 23 wks or birth wt < 400 gm), anencephaly, or some major chromosomal abnormalities in newborn infants. The policy should be revised to indicate the acceptability of a "Do Not Attempt Resuscitation" order in cases of widely accepted futility.
Quality end-of-life-care means choice. And that choice must include medically assisted dying. Your section on this issue is sparse in the extreme and smacks of head in the sand attitude. Considering that over 80% of Canadians are in favor, legalization has been a strong possibility for some time, so your draft policy is long overdue. It is also missing crucial elements. and this is one.
On a positive note I am glad to see you are addressing the importance of preparation of patient and SDM through advance care planning, and the necessity for physicians to engage in this planning process. Dying With Dignity Canada is a strong advocate of education on this issue, and offers advance care planning kits for free download from their website or by mail. This organization also offers workshops on advance care planning. With better preparation and a clearer understanding of both the risks and benefits of medical procedures there is less possibility of conflict situations arising over treatment.
I am a critical care physician.
I believe it is advisable to inform families when ACLS maneuvers will not be initiated, for instance when a patient is imminently and irretrievably dying. Whether this constitutes assent or consent on behalf of the SDM is debatable, however with few exceptions (the exceptions tend to provide religious reasons to continue) SDMs accept this.
Like with many guidelines much is implied and little is stipulated. For instance, should there be a DNR consent form signed and present on every chart when appropriate? More broadly, what therapies would DNR preclude?
Another question posed by this policy surrounds the standard of care. Critical care medicine is evolving rather quickly and involves ever-more sophisticated therapies. For instance, could ECMO at some point be interpreted as the standard of care for refractory respiratory failure, including for individuals with terminal lung disease who are not transplant candidates? It seems outlandish however it is not inconceivable that someone could make that argument. Would it be practicable to offer every well-established therapy (as is ECMO) to every patient in whom it could be applied?
I am an Intensivist in Hamilton. I appreciate this discussion being re-opened and fully agree that patients/SDMs must be involved in the end-of-life treatment and decision making process at all levels. However, I am concerned about the following in the draft:
Section 5.2: “Life-Saving and Life-Sustaining treatment” represents a major change from the existing policy created in 2006.
Lines 221-222 state: “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.”
Line 240 then states: “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.”
Lines 221-222 are consistent with existing policy, whereas Line 240 seems to me to be a misinterpretation of recent legal cases.
These statements are inherently contradictory. There are cases where preforming CPR is not within the standard of care. However, in that circumstance, the patient/SDM may not necessarily consent to a “Do No Resuscitate” order.
Implementation of this policy will place intensivists and our patients in unfortunate scenarios whereby the physician may be:
1. Obliged to provide CPR in situations where providing this treatment is harmful and outside the standard of care.
2. Uncertain as to when he/she can stop CPR once initiated i.e. does one need SDM consent to stop CPR (withdraw a treatment) if there is no consent for DNR?
3. Unclear what to do for patients who will arrest without pre-emptive intubation, but in whom intubation falls outside the standard of care. Does one not offer intubation, yet provide CPR once the patient has expired if the patient/SDM does not consent to DNR?
As well, do we extend this to chemotherapy when it “might’ help a patient but the proposed regimen is not covered by Cancer Care Ontario guidelines? What about for dialysis where it may prolong life but prolong suffering as well if there is multi-organ failure that will clearly result in death. There are numerous other examples of potential “life-sustaining” treatments that no one would typically get consent to “not offer”. CPR and any other form of life support should be considered in the same light.
I believe we do have a long way to go re engaging patients in EOL decision making and that this will hopefully occur long before the ICU. However, it is inevitable that many patients will not have these discussions with their SDMs prior to a critical illness. It would seem to me to be rather crude to single out only one specific aspect that requires explicit consent vs others that would seem not to.
I hope that the critical care community might be engaged further in better defining these sections prior to proceeding with the final policy.
Thank you for considering
I am a paraplegic, having been disabled as a result of MS. I do not believe in assisted suicide. I believe it is morally wrong.
I have an active life and enjoy it to the fullest. When my end-of-life time comes, I would like there to be palliative care choices, such as more hospices, places where I can be kept comfortable. I do not want to be on life support or have extra measures taken to preserve my life.
I am, however, concerned for doctors, especially family doctors, who do not want to provide end-of-life medications to their patients. And, because of their beliefs, do not want to refer their patients to anyone else either.
I do not believe in abortion, however, if a woman wants to have an abortion, she goes to an abortion clinic. If a person wants assisted suicide, then there should be doctors who are willing to provide that service to go to.
I believe doctors should remain true to their Hippocratic Oath “to do no harm”. They should not be made to do something that their conscience dictates as wrong and against everything a doctor stands for.
Greetings: As a lay person, I have read your policy draft with interest and am left with unanswered questions and concerns. It does not appear to me that there is any protection in your policy for physicians whose conscience is opposed to killing their patient upon his/her request; or assisting a patient to kill him/her self. The Introduction states: “Planning for end of life ensures that the care provided to patients aligns with their wishes, values and beliefs. Physicians provide quality end-of-life care by meeting the standard of care and by addressing and managing the physical, psychological, social, and spiritual needs of patients, while being sensitive to their personal, cultural and religious values, goals, and beliefs….
..it is important that physicians assist patients in identifying meaningful and realistic goals of care that are compassionate, respectful and that seek to incorporate patient wishes, values and beliefs”
My question is, what about the physician’s wishes, values and beliefs, if/when they contradict that of the patient. Will the government or the College of Physicians and Surgeons on Ontario dictate that he/she violate his/her own conscience. If a physician embraces the Commandment “Thou Shalt Not Kill” is he/she compelled to break God’s Command if it is the patient’s wish that he/she do so?? Surely, such a demand upon a gifted physician could put a wedge between him/her and the vocation he/she has embraced! Therefore, I believe it is imperative that NO physician is forced to act in any way that is contrary to his/her own convictions!!
I can also see, as a patient, that one could feel vulnerable when placing one’s trust in a physician whose conscience dictates that he/she kills some of his/her patients or assists them in killing themselves. One would question how hard such a physician would strive to sustain the life of his/her other patients.
Would the patient who has lost the ability to speak for him/her self not be at the mercy of a family member who may have ulterior motives for their demise?
What protection could there possible be for those vulnerable patients who for whatever reason are experiencing a temporary but deep depression? They may wish their life was over, but with love, support and adequate medical care that person may emerge from the depression and be grateful that life has not ended for them?
There is also a huge danger that someone else may determine that one’s life is not worth living; whereas, the patient may not share that view. I can also imagine that there would be instances where elderly people would be made to feel they are a burden on their families and so should opt to end their lives.
It is my strong opinion that the decision recently made the the Supreme Court is a death sentence for many innocent patients. We need only look at the situation and abuses in other Countries where Euthanasia and Doctor assisted suicide have been legalized.
I hope that my feedback is considered as bearing some value.
I am a resident of Ontario, and would like to provide the following remarks in response to the CPSO’s request for feedback on end-of-life care. I am doing so on my own initiative, as a member of the public concerned over the direction that end-of-life care in Ontario may take, particularly in light of the recent Supreme Court Decision.
- I support palliative care and believe it should be made a standard part of physician education, as well as made widely available as an integral part of health care across Ontario (if I am correct in understanding that neither if these are currently in place).
- There should be specialists in palliative care and they should be the lead physicians when such care is being administered (to avoid some of the problems with the Liverpool Care Pathway), but the concept is something that all physicians should understand and be prepared to refer to when a patient’s circumstances make it an advisable option to consider.
- It is very important that palliative care not simply become a vehicle for euthanasia, particularly through misapplied terminal sedation hastening death when it is not actually imminent (as I believe happened to a relative of mine; one moment she was an aggressive dementia patient, tearing down curtains and biting people and certainly not dying: the next moment she was being heavily sedated because “something had to be done” and three days later she was dead).
- I agree that physicians should engage with patients who express a with or request to hasten death, in order to understand the motivation for the request and to address any “treatable” issues, but this should always be done with life-saving intent.
- The intentions of any substitute decision-maker should also be clearly in the interests of the patient, and not sullied by any other motive up to and including their own psychological distress, and especially by any financial motivation with regards to the patient’s estate or any other conflicts of interest. Their eligibility for this position should depend on not having any such conflicts of interest – this does not seem to be defined here.
- Communicating effectively and often may build trust and confidence, but the latter will depend more on the contents of the communications than the frequency. If there is pressure to choose euthanasia I cannot see how any trust or confidence will be built, in fact it may be undermined with greater frequency of communication.
- Given the imbalance in power and authority between the physician and the patient or substitute decision-maker, I would expect that consent should also be obtained without undue pressure, to be valid.
- There should always be a bias in favour of life, and physicians’ first principle should remain “first, do no harm.” I cannot see how the legalization of euthanasia, even if attempts are made to put limits around its application, will not result in widespread distrust of doctors who are willing to practice it. I myself would not trust a doctor willing to do so.
- In light of the recent Supreme Court decision, with which I disagree, Canadian physicians must maintain their right to freedom of conscience to refuse to participate in any way with a decision to recommend or refer for euthanasia.
- I would expect that they are also entitled, and in fact expected, to provide their best medical advice, when it is to counsel against euthanasia, and to seek alternatives to address patient’s suffering.
- I believe that the use of euthanasia in Canada in an attempt to reduce suffering actually runs the risk of ceasing to make advances in the art of doing so, and likely in retarding or even stopping medical advances generally by Canadian physicians in any and all areas leading to requests for euthanasia (depression etc.), if the solution to managing pain becomes the easy option of killing the patient.
I believe it would be extremely harmful, in fact entirely destructive, to physician-patient relations in Ontario and to the professional value of trustworthiness for the CPSO to in any way facilitate or embrace the practice of euthanasia for patients.
Thank you for considering my views.
To the College of Physicians and Surgeons:
As a member of the general public and the wife of a man suffering with ALS, I am writing to you with my concerns regarding your draft policy: “Planning for and Providing Quality End-of-Life-Care”. I am particularly concerned with the element in the policy which compels a physician, who objects to a particular procedure as a matter of conscience, to help a patient find a colleague who will perform that procedure. In light of the recent Supreme Court decision to legalize assisted suicide, I feel it is essential that physicians maintain their right of conscience to refuse to participate in any way. I know, as a patient, as a wife and a mother, I would not feel comfortable knowing my doctor participated in assisting others with suicide and would actively seek out a physician for my family who did not participate in or abet this “procedure”.
As physicians you take an oath to “Do No Harm”. I would suggest to you that injecting a patient with a lethal substance with the intention to kill that patient is, in fact, “Doing Harm”. I would hope that, as a College, you would, at the very least, protect your members from discipline if they rightly find this act abhorrent and refuse to participate in it.
I hope you will seriously consider my concerns.
To the College of Physicians and Surgeons of Ontario:
In response to the draft policy on Planning for and Providing Quality End-of-Life Care, I am concerned about how sections 7.1 and 7.2 might be interpreted and applied in future. Physicians need to uphold their promise to “do No Harm”. If euthanasia is legalized, physicians must maintain their right of conscience to refuse to participate in any way.
I would not feel safe if my physician were to participate in euthanasia or assisted suicide.
I completed the survey on this policy and am following up to expand on my thoughts. I do so as a former nurse and someone who worked organizations providing senior services and long term care. I also have several personal experiences that shape my perspective.
Too often I have seen people whose final weeks and months are undignified and full of pain and suffering. Some of this reality might have been lessened with better and more appropriate medical care. In some case, despite excellent physician support, the suffering could not be relieved and even though the patients wanted death hastened, death could not be assisted.
I have seen physician care that has been very compassionate and effective to the extent allowable under the law. These physicians have often expressed their significant frustration with being unable to do more to relieve the suffering or to assist the patient to die when the person desperately calls for an end. I also have witnessed physicians who are less effective or not being available to address the need of patients at the end of life. Some doctors also do not seem to respect the individual’s right to make decisions as long as the individual is capable. This especially the case with seniors.
Therefore, leadership by the CPSO is critical. Physicians need to understand the importance of the role they play at the end of life. With the recent Supreme Court decision, the CPSO must now be part of the development of a clear and effective legal and regulatory framework for assisted dying in Ontario. Like with Quebec, this does not have to wait for action by the federal government. The CPSO could be instrumental in working with the Ontario government to craft a new Ontario law the would ensconce palliative care rights and also allow Ontarians to choose medically assisted dying within clear and strict criteria. The current draft policy, while a good start, will need to be expanded.
This Email is to inform you of concerns I have, being a Canadian citizen, in light of the new decision by the Supreme Court of Canada to legalize assisted suicide and euthanasia.
How sad it must be for you doctors, who once were the guardians of life, to be asked to be instead the conveyers of death. I am especially concerned with those people who for whatever reason are in a low state of mind: homeless people, teenagers, those with mental illness,the elderly or disabled, who might find the offered help to end their own lives a great temptation. I can think of times in my own life when, under disturbing circumstances beyond my control, I might have seen suicide as an easy way out. Thank God that possibility was not given to me, for I am glad that things eventually got better, and I have been able to enjoy the rest of my life.
I hope and pray that you physicians and surgeons who are of such benefit to our society for you healing skills will fight with all your might against this promotion of assisted suicide and euthanasia.
This policy refers to the provision or withdrawal of therapy including withholding treatment essential to the life of the patient.
We would remind the authours that Neurologists are called upon in the determination of brain death. Upon a finding of complete and irreversible absence of brain function, in accordance with this policy, physicians are obliged to obtain consent to withdraw life sustaining treatment.
Lacking a working definition of life the utility of the policy is problematic.
After a determination of brain death and a substitute decision maker’s objection to withdrawal of life supporting therapy, the CPSO policy should be explicit. Does this result in application to the Consent and Capacity Board?
Second, the definitive determination of substitute decision maker is implied in the policy. In the policy, absent a power of attorney for medical care, determination of the substitute decison maker should be explicit in the policy. The Trillium Gift of Life Network Act (R.S.O. 1990, CHAPTER H.20 Section PART II.1 NOTICE AND CONSENT) might be suitably abridged for this purpose.
To whom it may concern ,
I am writing to express my concern regarding the legalization of assisted suicide and doctors’ rights .
1.I feel that the physicians should uphold their oath/promise to “Do no Harm “. Since assisted suicide directly results in the death of a person , this action can certainly be said to “do harm ” to the person .
2.I feel that physicians must be free to maintain their right of conscience in refusing to participate in any way , if assisted suicide or euthanasia is legalized .
3.Personally , I would not feel safe if my physician participates in euthanasia or assisted suicide.
Lastly , I do not agree with legalization of either assisted suicide or euthanasia. These practices are not medical care . Increasing availability and improving palliative care are the proper and morally acceptable “end-of -life care”
As you know as of February the 6th Canada now has a law to legalize assisted suicide by physicians. I believe this is a grave error for the Canadian populace or any nation.
As physicians , doctors have been trained to not only respect the gift of life but to do everything possible to save life . By this law medical physicians are now ending life or assisting in putting people to death.
Our country needs to assist people in dying with excellent palliative care showing we care for their lives . The medical profession needs to let the Canadian population know that it is a profession that gives people hope in their value as human beings.
Assisted physician suicide negates the culture of life!
Taking away a physician’s right of conscience could place a doctor in a position where they are essentially being expected to participate in what they believe to be murder. I believe that physicians must be allowed to have the right to refuse to participate in euthanasia. The fact that eliminating this right is even being discussed is unconscionable – the Hippocratic Oath itself states that a physician will do no harm! I, for one, would not feel safe if my doctor participated in assisted suicide, and would seek a new doctor.
Forcing doctors to take part in assisted suicide would be a major force in driving us towards a culture of death, where human life is not valued the way it should be. Doctors, who ought to be helping to preserve life and not end it, would become life-enders, not life-protectors. Please do not take away the conscience rights of physicians, as the impact on society would be profoundly negative.
I am writing with great concern about challenging the conscience rights of physicians. Although I do not live in Ontario, it is a definite concern, as it will seep across Canada, province by province.
Physicians need to be able to uphold their promise to “do no harm”.
If euthanasia and assited suicide are made legal in this country, physicians must maintain their right of conscience to refuse to participate in any way. No good can come from forcing a doctor to practise medicine in a way he/she finds morally reprehensible.
I would not feel safe if my doctor was forced to participate in any way in hastened death of this sort.
I am writing to express my serious concern regarding the Policy on End of Life Care entitled “Planning for and Providing Quality of End of Life Care”.
My concern is that physicians will have to betray their consciences in order to assist a patient who is requesting euthanasia or assisted suicide. In my opinion, physicians should not be providing these services to anyone. Doctors have made an oath to heal and save lives, not to harm, and definitely not to end lives. They should instead be referring these patients to counselling and therapy.
If conscience rights are going to be taken away from doctors, therefore, forcing doctors to provide euthanasia, assisted suicide and abortion to a patient, then the role of the doctor takes on a whole new meaning whereas he will no longer be healing and saving lives, but harming and ending lives. I, along with many other citizens, would not feel safe if a physician is willing and/or forced to provide these life-ending procedures.
I encourage that changes be made in this policy where the conscience rights of doctors will be respected and where they will not be forced to provide a life-ending procedure that they would never provide themselves.
I am hoping these changes will be reflected in this policy.
Because the Supreme Court has now decriminalized physician assisted suicide, I believe the CPSO policy on End of Life Care should include the following:
1. physicians need to be able to uphold their promise to do no harm.
2. physicians must maintain the right of conscience to refuse to participate in any way in assisted suicide, including right to refuse to refer patients to providers of assisted suicide.
3. I would not feel safe if my physician or any consultant physician were to participate in physician assisted suicide.
Please give serious consideration to these concerns.
I have read the draft policy that is being proposed concerning End-of-Life Care by the Ontario College of Physicians and Surgeons. I also have been distressed by the recent ruling by the Supreme Court of Canada on this issue.
Thank you for the opportunity to respond to the draft policy of the College on Planning for and Providing Quality End-Of-Life Care. I see evidence of thoughtful commentary.
I am concerned that Canadians are beginning to contemplate legalizing Practitioner Assisted Death (PAD) and that the CPSO is going even further to deny the right of physicians to dissent if PAD becomes accepted practice.
The CPSO policy implies that disagreeing with PAD and refusing to participate in it or referring to practitioners who would perform it represents kind of regressive attitudes and practice.
Do we want our physicians to deny their consciences on so crucial an issue?
I can accept that if a patient with whom a physician already has an established physician-patient relationship approaches that physician with a request for PAD, the physician has a duty to the patient and perhaps the family members to have a serious and substantial discussion with them about their request. If after having such a discussion the patient still desires assistance with dying, I feel the physician should retain the right to respectfully disagree with the patient and decline to be involved with providing that particular service.
Whether the physician is objecting to PAD according to conscience or simply exercising clinical judgment, does not mean that there is dereliction of care and caring.
Whether legislation makes it legal to seek PAD or not, patients still have the right to have copies of their medical records forwarded to other service providers and to seek out their services.
Such service providers might include practitioners called Euthanologists.
Determining deemed incurability and mental competence to seek termination of life may require medical training and supervision but I do not see the need for medical training to be a necessary
qualification to be a Euthanologist, just as jurisdictions that practice capital punishment have judicial executioners who are mandated to terminate life according to regulations.
As a psychiatrist, I have seen many patients who were ambivalent about continuing to live.
The majority of them changed their minds about the desirability of suicide through treatment and the passage of time.
Furthermore, there may be patients that would feel compelled to hasten toward PAD when there could be still be meaning and enjoyment in their lives.
I am told that PAD started in the Netherlands 30 years ago and has expanded to include patients who have not had the opportunity for sufficient treatment and who have not given full and informed consent for PAD.
Physicians have shouldered the burden of caring for patients to sometimes heal and always to comfort.
To accomplish these goals requires us to cultivate a special mindset that involves a rigorous mixture of caring and therapeutic optimism.
I am concerned that requiring physicians to “switch gears” and assist with a patients choosing termination would do damage to professional morale, and also to our reputation among those who seek our help in our traditional roles – helping to lessen suffering of patients and dealing with threats to the length and quality of their lives.
The argument that physicians need to be coerced into providing PAD turns on the concept of patients’ rights to access services.
However, conscripting our profession as a whole to meet the proclaimed rights of those seeking termination would significantly harm the rights of the greater number of patients and potential patients who seek our help.
Being seen as sometime terminators as well as sometime healers, I believe, would harm our attempts to build trusting therapeutic relationships with the majority of those who come to us for help.
Thus I would ask that the College take the stand that physicians retain the right to refuse to participate in Practitioner Assisted Death.
Once again, thank you for your work and the work of the committee in this important area.
I am pleased to see that the College plans on revising the current policy – Decision-making for the End of Life. As a self-regulating body, the College should have been out front, taking the lead, not waiting to be told by HPARB and the Courts that an updated policy is urgently needed.
Doctors are expected to meet the standard of care and act in accordance with all relevant and applicable legal and professional obligations.
Following Ontario Consent and Capacity Legislation, 1996 is not an option.
Most people will die in hospital. Communication is paramount. End of life wishes, that are applicable to the circumstances need to be discussed as early as possible.The conversation needs to be ongoing, updated regularly and all questions need an answer.
Institutional end of life wishes do not follow the patient when they are transferred to hospital. This is the case even if the patient has an advance care plan, as advance care plans do not preclude a capable patient from making a different decision at the time of care and are not directions to a health care provider. All patients admitted to hospital for care are Full Code/CPR – this is the default position.
Physicians need to understand their patient’s wishes, values and beliefs not just there medical situation.
First, the physician needs to assess and chart if the patient capable.
If the physician determines that the patient is not capable, Ontario law provides that decisions respecting medical treatment for incapable persons are to be made by a substitute decison-maker (SDM) pursuant to the Health Care Consent Act, 1996.(HCCA)
For an incapable patient, the physician must identify the SDM that will be making treatment decisions for the patient. The name and contact information for the SDM must be charted. This information must be available to all members of the health-care team.
The Consent and Capacity Board (CCB) is responsible for resolving disputes that arise between physicians and substitute decision-makers.
The HCCA puts the onus on doctors to object if they consider that the decisions of the SDM are not in the best interests of the patient.
Doctors are not permitted to make unilateral treatment decisions and write DNR orders without consent.
The HCCA governs consent to medical treatment and establishes a dispute resolution mechanism that must be used for patients who lack capacity to make their own decisions.
The HCCA governs the question of consent regardless of physician’s assessment of the benefits that medical procedures may provide.
It is essential that the revised CPSO policy will provide Ontario doctors with a clearly written policy which will conform to Ontario Consent and Capacity Legislation.
Physician are required to obtain consent for a Do Not Resuscitate (DNR) order.
This will be clearly written into the revised policy – as it should be.
The requirements for consent to treatment at the end of life are the same as the requirements for consent to treatment in other health care situations.
Please clearly address….
If there is a disagreement between the physician and the SDM of the incapable patient, does the physician still provide Full Code/CPR to the patient if they require life-saving/life sustaining treatment prior to a CCB decision? If the physician has not received consent for DNR order, I would say – Yes?
Please allow a physician to have the option of conscientious refusal in this matter.
Doctors one and All:
Assisted Suicide is simply a euphemism for murder. One of the ten commandments says ‘Thou shalt NOT kill.
Aren’t doctors to heal not to hurt or hinder wellness in any human being? If one doctor’s conscience keeps him /
her from assisting an individual in committing suicide, why should he be compelled to direct that person to someone
else with less scruples? At the end of the road when we stand before God to give an account of the deeds done while
in the body do we want to have to say ” I helped Mary or George take their life.” Not me! Live by the Hippocratic Oath.
This is not a country under Hitler. Let’s keep Canada a safe, healthy place to live, raise children and enjoy life till God
College of Physicians and Surgeons of SaskatchewanThis draft policy is well written. It covers all aspects well and will be useful guidance to practicing physicians. We particularly liked the break down to the ten sections. The detail provided about ensuring patients understand what is meant by palliative care is helpful, as is the section on managing conflict.
I am writing to comment on the Planning for and Providing Quality of End-of -Life Care. Physicians need to uphold their promise to protect life and to “Do no Harm”. If Euthanasia is legalized, Physicians must maintain their right of conscience to refuse to participate in any way. I would not feel safe if my physician was participating in euthanasia or assisted suicide. If this becomes legal, it can be a very slippery slope. I can just imagine….It would save the government huge amounts on the cost of caring for the dying….possibly resulting in the government putting less money towards palliative care and care of the vulnerable and the disabled…. As a result I can just imagine that people who want to die naturally, may not have the resources needed to die in a comfortable way. And because of the decreased need, this area may be neglected by the government. I also fear that patients may be encouraged by loved ones and medical personnel to be euthanized……these patients may feel like they are a burden to their families and to their caregivers and internally may feel a pressure to say yes to euthanasia, against their wishes….this would be a sad state of affairs.
When physician assisted death was legalized in the Netherlands in 2001, in the first year 1882 died that way. That annual rate was quite stable the first few years. Last July Dutch ethics Prof Theo Boer, reported to the British Parliament on his study of almost 4000 cases over the nine years he served on a regional Euthanasia Review Committee, “Beginning in 2008, the numbers of these deaths show an increase of 15% annually, year after year. The annual report of the committees for 2012 recorded 4,188 cases in 2012 (compared with 1,882 in 2002). 2013 saw a continuation of this trend and I expect the 6,000 line to be crossed this year or the next. Euthanasia is on the way to become a ‘default’ mode of dying for cancer patients.”
CNN reported Oct 14, 2014: “Available data suggests that pain is rarely the reason why people choose assisted suicide. Instead, most people do so because they fear burdening their families or becoming disabled or dependent.”
Our “dying with dignity” lobby, and now our activist Supreme Court, do not heed such data.
Legalizing doctor assisted suicide would allow one human being to kill another human being, this is appalling.I think it will be a sad time in Canadian history if we expect our doctors to kill people instead of being sustainers of life. In Belgium where doctor assisted suicide is legal suicide rates have increased drastically. WHY? Because those who suffer lose hope. When death is promoted people who suffer, those with disabilities, cancer, accident rehab, CF, arthritis, mental illness and many other reasons of suffering,… the will to go on is stomped on! Pain management and palliative care are the areas we should be fighting for, let us please keep murder out of the equation
It seems that those who are in favour of physician assisted suicide prefer for their own benefit, taking an individual rights perspective as opposed to a broader collective rights approach to the dilemma of end of life. I am opposed to giving people the right to have someone else – a trusted physician end peoples lives. Not only are we trying to obligate doctors to play god and help decide when to end a life, we are making it far more difficult for them in the future to take a moral stance in favour of life. While it may seem like I am in favour of prolonging life through any and all heroic means available I am not. There is a place to end life prolonging treatments if it is seems as having no efficacy and/or it is worthwhile to support people who choose not to undergo heroic means. This is a real misreading of the opposition to the movement called dying with dignity.
The devaluation of people with disabilities and those who are elderly is apparent everywhere and especially in this debate where they are viewed as a peripheral consideration. Society at large believes that people with disabilities would be “better off dead”. This legislation that socializes people into thinking about disabling conditions as intolerable or worse than dying puts them and seniors at further risk. Simply put. They will be at far greater risk than those who are not considered an economic burden. Our unwillingness as a culture to offer humane conditions and support at end of life is very telling. Palliative and hospice are grossly underfunded because it costs to help people have a “good death”. In a culture where there is so much fear about death it is clear why euthanasia is seen as a viable “treatment” option. There will be no real safeguard for people with disabilities as we move headlong as a nation to legitimize the taking of another’s life in the name of humane treatment.
A culture that fears becoming disabled and dependent more than death has a lot to learn about the gift of “frailty and vulnerability”.
This is my hope that we would walk with each other into this debate aware of each others vulnerability aware that this ruling may worsen or deepen some peoples vulnerability unintentionally.
Toujour Vivant-Not Dead YetResponse in PDF format.
Hamilton Health Sciences Medical Advisory CommitteeResponse in PDF format.
Canadian Critical Care Society, the Canadian Society of Palliative Care Physicians, and the Canadian Hospice and Palliative Care AssociationResponse in PDF format.
Ontario Hospital AssociationResponse in PDF format.
Information and Privacy Commissioner of OntarioResponse in PDF format.
Ontario Medical AssociationResponse in PDF format.
Medico-Legal Society of TorontoResponse in PDF format.
College of Physicians & Surgeons of AlbertaResponse in PDF format.
Response in PDF format.
ARCH Disability Law CentreResponse in PDF format.
Dying With Dignity - Physician Advisory Council (Ontario)Response in PDF format.
Thank you for this opportunity to respond. I found it difficult to answer some of the survey questions given the new Supreme Court of Canada (SCC) decision. But I will submit additional comments on the policy and site two personal experiences which have influenced my views on this subject.
There is no current or existing policy to compare the draft proposed policy to. This policy could have been written in two parts: one for family GPs and one for emergency physicians.
The proposed policy has created a few Catch 22’s for physicians.
1. A) This policy is asking doctors to obtain DNR consent from patients, which frees doctors of EOL responsibilities for that patient. Yet, the policy (and now the new SCC decision) wants doctors to participate, act against their conscience and respect the patient’s wishes to prematurely end their lives by providing that assistance.
B) SCC has pretty much dictated that all doctors will HAVE to have something on file from their patients showing their wishes. If the doctor is not in agreement to providing assistance to premature/assisted suicides, nor is prepared to participate by referring their patient to someone who will participate in an assisted suicide, they risk losing the patient/client/customer. Which means their livelihood is affected. Therefore, if they act in accordance with their conscience they lose business and if they agree to do what the patient wants, they have to act against their conscience.
C) The lawyers on the Supreme Court have now dictated what doctors will be required to do and how doctors will act with end of life issues, eg. assisted suicide, etc. The policy, established by the College of Physicians and Surgeons will be in submission to the Supreme Court. Therefore, does the College have the legal right to establish practices to be followed by physicians or do only the lawyers have that right?
2) My Father was diagnosed with an, at that time, unknown condition of Papilledema. He agreed to undergo extensive and invasive medical testing to determine why and what his life threatening condition was and how to treat it. Doctors were called in from North America to observe his case and he underwent many painful and exhaustive tests. He agreed to these tests to help someone else who might have or will develop what he had. He died in hospital. His case was entered into the medical books, at that time. As I was then working for Ophthalmologists, I actually witnessed another case like his in our office and because of what they had learned from my father’s case, they were able to save this 18 year old girl. He chose as noble as possible means of dying, a death made to be worth something.
3) My Mother was admitted to hospital with multiple complications from primary biliary cirrhosis (unknown then what her illness was). Within the first 2-3 days, the young doctor proposed we remove her from all forms of life sustaining support. Up to that point we had not even known this was an option nor was it something we would have even considered. This option introduced confusion and doubt. It was a time of grief, fear, confusion, exhaustion and distress. We made the decision to do as the doctor had suggested. She died two days later. We were young, the doctor was young, but the question here was, did that doctor impose his own values on us by presenting this ‘option’ as something, as he put it, .. “[he] would do if it were his mother”. This was not a subject the general public discussed in those days, nor were we privy to the information on the subject as we are today and though the doctor did what [we have to suppose] he thought was right, we did what we thought was ‘the right thing to do’, and that was to let nature take its course. The subject of food and hydration was not addressed in your policy and despite all the information available to us now and the evidence, yet debate on the subject of food and hydration, our decision at that time was based on the information provided us then. However, at times like this, and all doctors know what I mean, when in doubt, ‘don’t take it out’. We have struggled with our decision for over 35 years.
4) I have sited these experiences to demonstrate that not only are family members, and those who have power over the end of life for themselves and others, confused on this issue and in a state of confusion during this period of facing death, doctors may be imposing further confusion and doubt by having to introduce these options as they will be required to do so by your policy and now the SCC decision.
We therefore return to the Catch 22 situation: this subject will have to be a mandatory exercise for GPs to discuss with patients prior to reaching any medical emergency, if the doctor doesn’t agree to participate, he loses the patient, if he agrees he acts against his professional, moral and personal conscience. Furthermore, if the doctor is pro-assisted suicide, the patient loses trust in the doctor and is possibly vulnerable to his values, especially if they cannot change doctors or will develop a fear of hospitals with doctors who might participate. Doctors are at a premium and it is by no means easy to find a new doctor (in this case GPs) in Ontario.
Like us, who have struggled with the decision for our Mother, doctors are only human. If they are forced by this policy to act against their conscience, how many doctors will leave the profession? We do not live in a time like Nazi Germany, but we’re getting closer to it.
Thank you for this opportunity. I trust the College will make the right decision and protect not only the patients but the men and women who have dedicated their lives to saving people.
Regional Bioethics GroupResponse in PDF format.
Advocacy Centre for the ElderlyResponse in PDF format.
Dear Policy Committee College of Physicians and Surgeons of Ontario,
We are writing regarding the “Planning for and Providing Quality End of Life Care” draft policy currently being circulated for feedback. We believe the policy provides a comprehensive and thoughtful account of many of the important considerations arising in end-of-life care. However, we have serious reservations about including the statement: “The College requires physicians to obtain consent for a “Do Not Resuscitate” order.” (pg.9, line 240)
We believe including line 240 in its current iteration runs the risk of causing serious harm to patients for whom CPR offers no likely benefit. Specifically, we are concerned about situations arising in which physicians unable to obtain consent for a DNR order will be obligated to provide cardiopulmonary resuscitation (CPR) in cases where CPR has no hope of benefit and is burdensome or harmful to the patient.
From an ethics perspective we affirm line 221 that physicians should not be obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care. However line 221 is inconsistent with line 240 and the proposed College requirement for physicians to obtain consent for a “Do Not Resuscitate” order. The requirement to obtain consent for a treatment that is outside the standard of care may have unintended consequences. This requirement may set a precedent in medicine where patients and substitute decision-makers (SDMs) have the right to treatment in an “a la carte” style resulting in numerous requests for treatments that are outside the standard of care and may be harmful. Moreover, line 240 now makes it unclear whether requiring consent for a DNR order implies that consent must now be obtained to stop (withdraw) CPR once initiated if requested to do so by an SDM.
Lastly, we suggest that line 240 is more prescriptive than it needs to be. The Health Care Consent Act (1996) defines a plan of treatment as providing “for the administration to the person of various treatments or courses of treatment and may, in addition, provide for the withholding or withdrawal of treatment in light of the person’s current health condition.” The word “may” suggests that not all instances of withholding or withdrawal of treatment fall under the definition of treatment and therefore, consent may not be required in all instances.
We recognize that the College may find it necessary to include line 240 in light of the recent HPARB decision. In this case, we suggest reframing line 240. Instead of stipulating that physicians must obtain consent for DNR order, the policy could suggest that physicians have a duty to disclose to a patient or SDM when they believe CPR falls outside the standard of care. In the event that patients or SDMs disagree and request that CPR be provided, then the “Conflict Management” process is followed. If the last step is reached and a physician is found who is willing to provide CPR, transfer of care could occur; otherwise the physician would not be obligated to provide a treatment that was outside the standard of care. This approach has the merit of honoring the spirit of the HPARB decision while placing equal emphasis on some of the important features arising in the provision of quality end-of-life care: open and honest communication, the weighing of benefit and burdens, and honoring patient autonomy in end-of-life decision making.
Unnamed Catholic Hospital - Working GroupResponse in PDF format.
Sunnybrook Health Sciences CentreResponse in PDF format.
Trillium Gift of Life NetworkResponse in PDF format.
To the CPSO:
Sincere thanks for attempting the daunting task aiming to clarify the physician roles and responsibilities while providing quality end of life care. I am responding to the CPSO’s request for comments on the draft policy.
Unfortunately, I believe it would be very challenging, if not impossible, for physicians’ to navigate this policy while providing end of life care in Ontario.
My concerns start in the opening paragraph, which describe a far-reaching ‘standard of care’ for palliative care.
Physicians provide quality end-of-life care by meeting the standard of care and by addressing and managing the physical, psychological, social, and spiritual needs of patients, while being sensitive to their personal, cultural and religious values, goals, and beliefs. Quality end-of-life care aims to reduce suffering, respect the wishes and needs of patients, and lessen conflict and distress.
This standard of care is dependent on physicians practicing within a fully functioning multi-disciplinary palliative health care system available 24hours a day, 7 days a week. As well, the patient/family must have the desired response to symptom management, which may or may not occur even when they receive care based on best-evidence.
The document goes on to state that physicians are required to follow ‘all relevant and applicable legal’ obligations, yet, the implications of the numerous recent End of Life (EOL) legal court cases are not readily available for the physician to navigate and the cases seem to have resulted in contradictory demands.
Demonstrating professional competence, which includes meeting the standard of care and acting in accordance with all relevant and applicable legal and professional obligations; I wonder if the CPSO policy writers were attempting to be all-inclusive in this document, and in doing so, were confronted with the EOL contradictions in practice and law and this seems to be reflected in the document. Please see contradictions within the document listed in Appendix 1. These contradictions make the document challenging if not impossible to follow.
Hospice Palliative Care advocates tirelessly attempting to improve the health system for patients and this will continue. However, at present Ontario has a disjointed patchwork of palliative care services. There is limited access to a palliative system of care and many of the services, if they exist, are typically available during the average working day, five days a week.
I suspect it would be of benefit to the CPSO and physicians striving to follow CPSO policy to have a document that clearly identifies the roles/responsibilities/duties of the individual physician providing care within the context of limited, unpredictable, inequitable palliative resources in Ontario. When Ontario has an adequately resourced functional palliative health care system, it would be an excellent time for the CPSO to revisit the role of the physician within that functioning system.
At the present this document requires that physician practice in an ideal palliative health system that does not exist in Ontario. I am concerned this document may position the CPSO and their physicians in a vulnerable position.
Thank you for the opportunity to respond to your draft policy document.
First and foremost, well done! This draft revision is a formidable task…and your consultation process is an extraordinary one…enviable in its breadth and inclusion.
Next, I would ask that you consider attempting to frame the document much more explicitly in terms of ‘goals of care’. I feel strongly, based on my experience in the last five years working with many clients at the end of life and the committed professionals supporting them through it, that approaching the lamentable but necessary discussions through this goals lens makes an undeniable difference to the quality of communication and satisfaction with the outcomes of the dying process for professional sand family.
In addition, as you know, it is now a different legal landscape in Canada with respect to assisted dying. As an occupational therapist of some 20+ years, I have been involved in supporting individuals who dread and others who welcome this change. It will be a complex and nuanced route ahead for many of us seeking to craft a framework for choices at end-of-life that include assisted dying. If the CPSO should wish any support that I might offer on that task, please do not hesitate to contact me.
Lastly, with respect to the consultation at hand, please don’t overestimate the impact of your decision to include the requirement for consent where CPR is in question. This position is a profound relief to many of us in the field of healthcare ethics practice. That said, it will by no means be greeted with enthusiasm by all healthcare ethicists. Many of my colleagues argue against this requirement. I offer here my reflections, thoughts and attempt at an argument in favour of its inclusion.
In a nutshell, CPR is special. I think this is regrettable, but also undeniable. No other healthcare intervention carries such prominence in the mind of the average person. No other healthcare intervention is taught to members of the public by the thousands every year. No other healthcare intervention carries the notion of a universal duty to attempt it. No other healthcare intervention has an entire in hospital emergency response built around it. No other healthcare intervention is reflexively initiated by default, in hospital or beyond it. [The Heimlich manoeuvre may be the only other exception - but even it does not have an equivalent array of machinations maintained to ensure its provision to all.] No other healthcare intervention is as close to being de facto standard of care.
Shifting to ‘no CPR’ status is a change in the treatment plan from that which is collectively understood as ‘the default plan’ to a different one that carries with it a clear indication that there is very limited hope for a person to live through a cardiac arrest. It is regrettable that there are circumstances in which people find it so profoundly difficult to accept the limitations of modern medicine that they would wish such harm for the miniscule prospect of hope. It is regrettable that professionals are asked to engage in activities that will bring them intense moral distress. However, a policy that does not require consent for this change of plan potentially creates an environment of searing mistrust and poor communication.
Yes, many members of the public misunderstand CPR’s prospects for saving lives. Yes, many people will insist on full resuscitation status based on such a misunderstanding. Yes, providing CPR will be a lamentable, often harmful, damaging intervention to some dying and unwell people. Yes, performing CPR will induce significant moral distress for many healthcare practitioners in these particular cases.
In many ways, the healthcare professions and industry are responsible for these misunderstandings… with respect to CPR and other healthcare interventions. Hospital foundations, in particular, have promoted the ‘everything humanly possible’, ‘miracle networks’, ‘conquer cancer in our lifetime’ and ‘I believe’ notions of all powerful modern medicine . It ought not be surprising then when families feel they can hope for miracles .
More commonly, these end-of-life situations cut to the deepest values of the individuals – which means the emotions and anxieties associated with these decisions involve our very identities. Navigating such complex territory must be done with extraordinary sensitivities. Recent high profile cases have demonstrated that a few physicians are willing to make these navigations in a manner that is perceived, and arguably is, riding roughshod over values and beliefs, and it seems, the law. Thus it is not surprising that some will go to great lengths to attempt to have their values-based wishes respected .
But correcting these misunderstandings of the usefulness of CPR and attempting to avoid its potential harms is a huge endeavour that extends light years beyond any CPSO policy statement. This limitation must be acknowledged and policies developed for the real world where emotion can still influence some decision making far more than statistics can.
Raising awareness of the true usefulness of CPR will be a task for decades and generations to come. Evolving popular values takes time. And immense energies. The CPSO can work to both ends simultaneously – supporting its members and their colleagues to work within the law and within the fundamental principles of respect and trust, while also engaging in efforts to educate the general public about CPR most appropriate uses.
To craft a policy that relies on a subtle interpretation of individual words – such as ‘may’ – in the related legislation would not seem to be the most effective approach to framing medical practice. This will not address the core issue of communicating about and resolving conflicts between individual values.
It would seem most appropriate for the CPSO to expect more from its members. It may be that this issue touches on other political and power dynamics between the CPSO, the media and the public and HPARB.
HPARB may not be an entity with the same legal standing as a court, but it is in many ways a ‘people’s court’. It is the avenue open to the public to appeal the actions of self-regulated professions. That privilege of self-regulation must not be wielded in a manner that suggests arrogance or insensitivity. To create a policy that does not take into account its recommendations or requirements is to adopt a stance of antagonist and adversary to the agent of the public.
There is nothing other than a complex way through the current context of healthcare practice and popular perceptions of some aspects of it. Ultimately, I would argue that the greater good lies in taking an approach that always aims to foster those values of professionalism – compassion, service, altruism and trustworthiness – through the highest quality practice which I would suggest involves communication, respecting autonomy as the way to acting in best interests, demonstrating both professional competence and humility, and collaborating by recognizing both unique roles and contributions, but also unique values and goals of care.
Dear Sirs and Madams,
I wish to express my strong concern regarding the draft policy, Planning for and Providing Quality End-of-Life Care. I believe that this policy is very wrong and should be discarded. Physicians and Surgeons must continue under their oath to do no harm which would seem contrary to taking a life intentionally. No governing body should be allowed to compel any health care practitioner to end a human life. I would feel quite less than secure and very unable to trust any physician or surgeon who included in his or her practice the taking of human life.
Please stand strong against this profound threat to the values so many hold dear and continue to hold Ontario as a province where life is cherished.
Citizens with Disabilities OntarioResponse in PDF format.
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