Organization
[September 07, 2022 3:02 PM]
Ontario Palliative Care Network Secretariat, Ontario Health
 
Dear CPSO,
 
We apologize for the delay in getting you this feedback. Thank you for the opportunity to review your guidance. We are in overall support of the work and are appreciative of the CPSO's focus on this important topic. We particularly liked that the document talks about working with a variety of healthcare professionals to support families and that it reinforces the concepts of Advance Care Planning (ACP) and Goals of Care (GOC), and key principles of the decision-making process. Here are links to the 3 documents that OPCN has developed on the same topic: (Person-Centred Decision Making; Making Decisions About Your Care; Approaches to Goals of Care Discussions)
 
We only have a few suggestions for your consideration in the ACP and GOC section:
 
Please consider the following edits:
 
1. In the first statement: we suggest adding “and especially when palliative care needs are identified” to help clarify the first statement.
 
2. In the first statement: The suggestion “raising end of life care issues” could be interpreted as being only expected one time. It should be emphasized that the process of raising end of life care issues is dynamic and not one-time. 3.
 
Overall: we suggest using the language “patients with palliative care needs” to replace your current language: “Patients who are palliative” and those “receiving non-curative treatment”
 
4. Overall: suggest your document further emphasize that goals of care discussions are iterative
Organization
[August 30, 2022 3:20 PM]
Ethics Quality Improvement Lab, William Osler Health System
Response in PDF format.
Organization
[August 26, 2022 1:09 PM]
Canadian Critical Care Society (CCCS)
Response in PDF format.
Organization
[August 26, 2022 12:19 PM]
Ontario Medical Association (OMA)
Response in PDF format.
Organization
[August 22, 2022 3:06 PM]
Euthanasia Prevention Coalition
 
Concerns about the Draft Decision-Making for End-of-Life Care policy.
The Euthanasia Prevention Coalition has more than 5000 members and has been directly involved with issues related to End-of-Life Care policy since 1999.
 
In February 2004, the Euthanasia Prevention Coalition intervened in the Scardoni v. Hawryluck, [2004] O.T.C. 128 (SC) case at the Ontario Superior Court of Justice.
 
The case concerned a woman who was 81 years old and living with Alzheimer's. The woman developed aspiration pneumonia and was admitted to hospital, where she was periodically placed on a ventilator. The patient's doctor believed that the use of the ventilator would take a terrible toll on the patient, and that the intravenous tubing required for the administration of other drugs would cause additional discomfort. The patient's medical team became convinced that the benefits to the patient of the treatment she would receive in the intensive care unit were outweighed by the burdens it would impose on her, and of what they considered to be the lack of any enduring beneficial effects. The doctor proposed that the treatments being administered in intensive care should be dispensed with in the future to the patient's daughters, the appellants; instead, every effort should be made to treat the patient's infections in the internal medical ward and to keep her as comfortable as possible with painkillers and sedatives.
 
The daughters disagreed with the treatment plan, as outlined by the doctor. The case was heard by the Consent and Capacity Board who agreed with the doctor and ordered that treatment plan be followed.
 
The family appealed the decision to the Ontario Superior Court of Justice who decided that the Consent and Capacity Board failed in their interpretation of the act.
 
Justice Cullity stated in the decision [1]:
The appellants, who were appointed by the patient as her attorneys under a power of attorney for personal care executed by the patient before she knew that she had Alzheimer's disease, told the Board that the patient had always expressed a belief in prolonging life and not taking it. The Board correctly found that the provision of a power of attorney that authorizes a person to give, or refuse, consent to treatment to which the Act applies is not, without more, the expression of "a wish applicable to the circumstances" within the meaning of s. 21(1)1. However, it did not follow that the existence of a power of attorney for personal care had no relevance. The existence of the patient's power of attorney, which referred expressly to consent to treatment to which the Act applied, formed part of the context insofar as it indicated that she contemplated that, for one reason or another, she might, in the future, lack capacity to make decisions with respect to treatment.
 
Justice Cullity further stated in the decision:
The Board also discounted the patient's maxim, "Where there's life, there's hope" on the basis that there was little hope in the circumstances of this case. In so doing, the Board ignored the consideration that it is the fact, and not the correctness, of the patient's belief to which weight and significance are to be attributed for the purposes of s. 21(2).
 
There are a few more issues related to this case, but essentially Justice Cullity was affirming the role of the SDM to uphold the wishes of the person who they were legally appointed to represent.
 
I bring up this precedent-setting court case based on our concerns related to Sections 7 and 9 of the draft policy [2].
 
Section 7 states:
7. When a physician determines that providing resuscitative measures to a patient would be medically futile, the physician can write a DNR order in the patient’s medical record but must, at the earliest opportunity (and, if possible, before the DNR order is written):
a. Inform the patient and/or SDM that an order will be or has been written;
b. Explain to the patient and/or SDM why resuscitative measures are not appropriate; and
c. Provide details regarding all other clinically appropriate care or treatment(s) they propose to provide.
 
By stating that the physician can write a DNR order in the patient’s medical record but must, at the earliest opportunity (and, if possible, before the DNR order is written), the policy undermines the role of the SDM to provide consent to treatment. Writing a DNR order is a treatment plan, and treatment plans require the consent of the SDM.
 
DNR orders must not be written without the consent of the SDM.
 
Similar to Scardoni v. Hawryluck, [2004] O.T.C. 128 (SC), it may have been preferable to follow the medical direction as stated by the medical team for Joyce Holland, but it contravened the wishes that Joyce Holland expressed when she was competent. The SDM in her case was only carrying out her wishes.
 
Imposing a DNR and then, at the earliest opportunity, gaining consent from the SDM is not legally correct. Therefore, Section 7 must state as follows: “The physician will consult the SDM at the earliest opportunity concerning a DNR order and only write a DNR order after obtaining consent.”
 
Section 9 states:
9. When a physician determines that the risks of providing resuscitative measures would outweigh the potential benefits, the physician can write a DNR order in the patient’s medical record but must, before writing the order:
a. Inform the patient and/or SDM that the order will be written;
b. Explain to the patient and/or SDM why resuscitative measures are not appropriate, including the risks of providing those interventions and the likely clinical outcomes if the patient is resuscitated; and
c. Provide details regarding all other clinically appropriate care or treatment(s) they propose to provide. In Section 9, by stating that the physician can write a DNR order in the patient’s medical record but must, before writing the order…, the policy undermines the role of the SDM to provide consent to treatment. Writing a DNR order is a treatment plan and treatment plans require the consent of the SDM. DNR orders must not be written without the consent of the SDM.
 
Why is this so important?
Consent is fundamental to the medical system. When physicians assume a right to consent or deny consent for patients, they are undermining the trust relationship and they are denying patients the right to be treated, as the law states, based on their known values and beliefs.
 
These issues go further: if doctors make decisions on behalf of patients without the consent of the SDM, it will create a divide between patients and doctors, and possible future court cases. Trust will be lost, and the public will become more guarded upon entering hospitals due to concerns that their rights will be undermined.
 
Consent to treatment is wider than the concept of needing permission to do something to a person’s body, which could be construed as battery. Refusing or denying care can also be viewed as discriminatory, whether that be a person with a disability, a person from a certain religious or ethnic community, or a person who is elderly (ageism).
 
People have the right to give or deny consent to treatment and treatment plans, and undermining that right will undermine the trust in our medical system.
 
There are further concerns.
If a physician has the right to write a DNR order (treatment plan) without the consent of the patient or SDM, then what else does a physician have the right to do?
 
If Scardoni v. Hawryluck, [2004] O.T.C. 128 (SC) decision does not help with changing the draft policy, then maybe consulting the Supreme Court of Canada’s Cuthbertson v. Rasouli [3] decision will provided added insight.
 
The Euthanasia Prevention Coalition is concerned that life and death decisions would be made without patient and SDM consent. The draft policy must be instituted, since it is not legal. Consent to treatment must remain as a fundamental principle, and if not, it will lead to more disputes, legal challenges, and a loss of trust between patients, family, and medical professionals.
 
Organization
[August 22, 2022 10:44 AM]
Department of Critical Care Medicine, the Hospital for Sick Children (SickKids)
Response in PDF format.
Member of the public
[August 22, 2022 9:46 AM]
I would like to see reporting to the Regulatory College of 'controlled acts' (Regulated Health Professions Act Section 27) undertaken which do not assess the physical or mental condition of an individual (having been born alive) or do not diagnose, treat or prevent any disease, disorder or dysfunction (Medicine Act Section 3), with an explanation of why the act was performed.
Organization
[August 22, 2022 9:00 AM]
Regional Ethics Program, Trillium Health Partners
Response in PDF format.
Organization
[August 18, 2022 12:42 PM]
Professional Association of Residents of Ontario (PARO)
Dear CPSO Policy Department:
 
Thank you for the invitation to provide feedback on the CPSO Decision-Making for End-of-Life Care draft.
 
We have reviewed the document and overall find it to provide clear and thorough guidance.
 
In this draft, there is language about care withdrawal, but we did not find that inclusion of the process of MAID. Given it is still relatively new and we believe is a somewhat complicated process, we suggest that the MAID Policy should be referred to or referenced in this EOL policy.
 
We once again appreciate being included in the CPSO's consultative process.
Physician (including retired)
[August 05, 2022 9:20 AM]
1. The differences between the 2 situations where a physician may write a DNR order must be clarified. I.e. what is the difference between "futility" and "harms outweigh benefits". Concrete examples must be used, since the protocol (s7 vs s9) is slightly different. 2. There must be clarity on what a "DNR" order means. The policy clearly gives physicians the power to decide that CPR is not in a patient's best interest or futile (agree with others that this is a dated term and "non-beneficial treatment" may be more appropriate), BUT what of intubation/ mechanical ventilation? I think much more harm is done to patients who are inappropriately intubation/ ventilated than those who undergo inappropriate CPR. 3. Overall I think this is an important policy and a step in the right direction. It further empowers physicians to do what we are trained to do, which is make a decision about the appropriateness of a treatment (here, CPR) and offer it if it is likely to benefit the patient.
Organization
[July 27, 2022 9:09 AM]
Canadian Medical Protective Association (CMPA)
Response in PDF format.
Physician (including retired)
[July 24, 2022 7:58 PM]
Intrigued about the language "physician with a sustained physician=patient relationship MUST determine whether it is appropriate to have an ACD ...."; how/when would this occur? how will you know whether this is occurring? As a senior respirologist who has had many conversations with patients about this issue, am amazed at how few acknowledged EVER having a conversation with their primary care physician. Given current culture, it seems that this issue almost always arises at a crisis point; entry to hospital, entry to assisted living, entry to nursing home....but not at a time of clinical stability, when it would seem most natural and un-threatening....
Physician (including retired)
[July 24, 2022 8:47 AM]
The initial components of this policy are a step in the right direction of encouraging GOC discussions in more appropriate situations ie not when we are acutely admitting patients in the ER. The majority of the time when I have these discussions admitting as a hospitalist patients or SDMs have never thought of these issues despite very obviously having life limiting conditions whether advanced heart failure, renal failure, cancer, dementia etc. It is inappropriate for those in ongoing relationships with these patients to avoid these discussions leaving it to admitting hospitalists seeing patients for the first time under stressful, acute times. It has the downstream effect of taking up enormous time in these acute settings reducing consultation throughout, lengthening LOS in ER before being seen, which is connected to adverse outcomes.

These discussions take time. The CPSO should support the creation of a dedicated fee code specifically for these discussions as exists in Medicare in the US.
Physician (including retired)
[July 23, 2022 7:13 AM]
L26 - add the idea that key family members should be included, such as “when possible, key family members”

L93 - strengthen the level of commitment to intervene in patient suffering from “reasonable” to “making ongoing, substantial efforts to support the patient’s physical comfort….”
Physician (including retired)
[July 22, 2022 1:28 PM]
Section D, "taking reasonable steps to transfer care of the patient to another facility or health-care provider, if possible and requested by the patient and/or SDM", should be removed, especially in an ICU setting. If CPR has already been determined to be futile, why would the physician be compelled to embark on an doubly futile, and significantly taxing job, of finding an accepting physician and arranging transfer? Some other alternatives include getting a second opinion from within the same institution (this obligation can at least be reliably fulfilled, and doesn't impose an impossible workload), and not refusing a transfer to another accepting physician is found (but the responsibility does not fall on the ICU physician). Inter-ICU transfers are resource intensive, valuable, and already difficult for life-saving care... why would we impose this significant burden for futile care?
Other health care professional (including retired)
[July 13, 2022 10:28 AM]
There are some important improvements over the previous version of the policy but there are some significant issues here.

1) There is no value in adopting the language of 'futility'. It is a colloquial term that is not an accepted part of the clinical lexicon, and is not referenced in any key legal decisions. I would strongly suggest using the language from the Wawrzyniak decision and refer to CPR that lies outside the standard of care.

2) This draft actually goes too far in giving physicians discretion to withhold CPR by introducing a second category, when the physician determines that the risks of CPR outweigh the potential benefits. CPR lies within the standard of care in such situations, so there is no legal basis for allowing physicians to unilaterally withhold CPR. From an ethical perspective, the issue is that benefit can only be defined by the patient (or with reference to the patient's values and beliefs). Therefore, the appropriate approach in such cases is one of shared decision-making, in which the physician and patient/SDM (through a goals of care discussion) establish what the patient would consider beneficial and what risks the patient would be willing to accept to pursue that benefit. The draft policy gives physicians the authority to make this determination and only requires the physician to "consider" the patient's wishes and beliefs.

3) There is some confusion regarding the role of goals of care discussions and decisions about withholding CPR. Step 2 of the policy states that physicians must initiate a timely goals of care discussion with any patient who is palliative, receiving non-curative treatment, or is at risk of clinical deterioration. However, a goals of care discussion should not be required in cases where CPR lies outside the standard of care. While it may be appropriate to communicate such a determination in a broader goals of care discussion, decisions about CPR when it lies outside the standard of care should not themselves require a goals of care discussion.

4) Relatively minor point, but the final step of the "Providing Support" section requires taking reasonable steps to transfer a patient to another facility or health care provider. I would argue that such a transfer should not be required in cases where CPR lies outside the standard of care. If CPR truly lies outside the standard of care, then no physician should be willing to provide it and it would send a mixed message to the patient/SDM to offer a transfer in such cases.
Other health care professional (including retired)
[July 03, 2022 5:34 PM]
I do not believe the HCCA hierarchy of decision makers is culturally safe for many people including Indigenous, racialized people, people with cultural traditions other than white male European up on which the laws are based. The way we have taught and integrated the HCCA into practice can exclude from decision making elders, knowledge keepers etc from involvement in care. I have also seen this with patients from Africa who may defer decision making to "Chiefs" and we need to find a way to accommodate that. Also our approach to the hierarchy of decision makers has denied access to hospitals of trained workers or people who know how best to communicate with a person who has a disability. Staff have said "you are not on the hierarchy" and deny admission. This only creates more work later. Again we need to nuance how we approach the HCCA. I do appreciate B.C.'s equivalent to our HCCA. They have a section that includes the need to bridge communication barriers. It is very practical and reasonable. However I think we have been entrenched in maintaining our HCCA without critically questioning whether it is culturally safe or safe.
Physician (including retired)
[June 28, 2022 9:02 PM]
I think this policy is a step in the right direction but it still adds provisos that leave physicians facing similar challenges as before.

1. I do think it is important to consider patient's wishes, values and beliefs when making decisions in regards to whether to offer CPR / intubation. However, those wishes, values and beliefs need to be reasonable and not unrealistic. For example, if a patient believes that they will beat incurable cancer, or a SDM believes that their loved one with live forever, or that they must not die without resuscitation (because they feel they have failed them otherwise or that it is in their religion). These are unrealistic wishes, values and beliefs. Their needs to be some language that reflects that the patient or SDMs wishes, values, and beliefs must be realistic.

2. The expectation that a step for resolving disagreement would be that the physician must take steps to transfer a patient to another facility is not acceptable. First, this is often logistically impossible for several reasons: 1. Patients are ill and cannot be transferred in that state; 2. ICUs are very full everywhere and often not able to accept transfers. Additionally, one cannot expect a consulting physician from another facility to provide a reasonable assessment of the patient from a phone call from the referring physician and may set up unrealistic expectations for the patient / SDM. Furthermore, attempting to arrange transfer is a very time-consuming and cumbersome task. How many attempts should be made at transferring the patient if the potential receiving facility either says no they do not have space or they are not willing to take the patient? Saying that CPR / intubation is not appropriate, and then stating that another facility may be willing to offer it sets up unrealistic expectations and creates a mindset that what we initially stated is potentially not standard of care but rather just our opinion. This expectation needs to be removed from the policy.
Physician (including retired)
[June 26, 2022 10:16 PM]
I think this document is hoping to support a change from the behaviour you have described.
Physician (including retired)
[June 22, 2022 6:58 PM]
I find it quite unreasonable that a physician can deem ANY medical therapy futile and therefore not medically indicated... with the single notable exception of CPR. A surgeon is not compelled to offer a futile surgery and a medical oncologist is not compelled to offer futile chemotherapy. However, all of Ontario's physicians are expected to offer CPR in clearly futile situations when unreasonable patients and/or families cannot be reasoned with. This leads to an enormous amount of care-giver burnout (across all disciplines) and the CPSO needs to support physicians as medical experts making expert recommendations and decisions for their patients. CPR is a medical intervention and it should not be something that a patient and family can demand in a clearly futile situation!
Physician (including retired)
[June 22, 2022 9:57 AM]
In the section "Advance Care Planning and Goals of Care Discussions", section 2., the phrase "patients who are palliative" should be replaced with the phrase "patients who have opted for a palliative approach to care". A patient is never "palliative". The CARE provided is palliative. The original wording would be akin to saying "patients who are supportive" or "patients who are intensive".