Physician (including retired)
[May 14, 2021 3:18 PM]
Dear Committee Firstly, I thank the committee for their efforts to improve the care of patients at end of life. This is an important issue and the CPSO is to be commended for tackling it. However, there are some key points that, in my perception, the guidance either gets wrong or fails to take advantage of the clarity offered by recent legal precedents. There is a very clear court decision made in the Wawrzyniak case where "The Court concluded that the writing of a no-CPR order and withholding of CPR do not fall within the meaning of “treatment” in the Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A. As such, consent is not required prior to withholding CPR and physicians are only obliged to provide CPR in accordance with the standard of care". This is clear legal precedence and yet, on all but the most detailed analysis of this guidance there is apparent and effective contradiction to the legal precedent (vide infra). The reason I state that the guidance “apparently and effectively contradict this guidance” is that conflicting statements made in the guidance are confusing on the issues of both no CPR orders and consent for no CPR. For instance, the guidance states (underlines my own)- "Question- Does the College require that consent be obtained before writing a no-CPR order? Answer- No, the College does not require that consent be obtained prior to writing a no-CPR order". "The policy also does not require that physicians propose a no-CPR order be written” “Only if the patient or substitute decision-maker disagrees upon learning that the order will be written must physicians engage in a conflict resolution process to try and find consensus”. “During this time, physicians must not write a no-CPR order”. “However, if the patient’s condition deteriorates and they experience a cardiac or respiratory event while conflict resolution is underway, physicians are permitted to make a bedside determination about which resuscitative efforts, including CPR, to provide and are only required to provide those that are within the standard of care”. Points for analysis- a. No hospital or clinical team can safely enact a no-CPR order policy without these decisions being documented in writing in the patient’s chart. Failing to do so would risk harm to our patients. b. The statement that clinicians can “make a bedside determination about which resuscitative efforts, including CPR, to provide….” is no actionable. The only clinician that can in any practical way make such a decision, is an Attending Staff Physician. This is especially so in the presence of conflict with a patient or their SDM. Staff Physicians spend only a fraction of the day at a patient’s bedside or within easy reach of any individual patient’s bed to be able to make such an immediate decision. This decision does indeed need to be immediate as it has to be made within seconds of the cardiac arrest event. There is never time to phone a senior physician to seek clarity before starting CPR in such a situation and the clinical team would have to default to performing CPR in line with good practice, hospital policies and College of Nursing guidance in face of such a delay. c. The above statements suffer from a significant lack of clarity about the requirement for consent. I do not believe the committee can state “the College does not require that consent be obtained prior to writing a no-CPR order” and the statement that “Only if the patient or substitute decision-maker disagrees upon learning that the order will be written must physicians engage in a conflict resolution process to try and find consensus”. There is either a requirement for consent or these is not, and the legal precedent says there is not! Allowing no CPR order to be withdrawn (even if temporarily so) make it a matter for the consent process. These statements, in effect, actually say to our physicians “you should get consent for CPR because you are at risk of challenge if you don’t” (vide infra). d. If the CPSO feels that the patient or their SDM has a right to appeal this decision, then it should be through legal routes (remembering the clear legal precedent) and the no-CPR order should stay in place unless an injunction is granted through the courts (this can be achieved in hours to safe guard the patient’s interests if appropriate). e. If the CPSO feels strongly that the CCB needs to be part of this pathway then again, the no-CPR order should stay in place whilst their opinion is sought. f. It must be identified that the statement “Only if the patient or substitute decision-maker disagrees upon learning that the order will be written must physicians engage in a conflict resolution process to try and find consensus” will not lead to a CCB referral in most cases but will lead to physicians acquiescing and leaving the no CPR off the chart to avoid complaints, the CCB processes or legal action (I have seen this in action many times as physicians are understandably avoidant of such unpleasant legal situations (vide infra)). g. I fear the committee thinks that a referral to the Consent and Capacity Board is a relatively easy way through these challenges, but, in fact, it is not so! The CCB has become increasingly time consuming, combative and “legalised”, and its decisions are not legally binding. When these decisions are appealed (which has become standard), such appeals simply fall to the courts and their timelines for such appeals is many months to years for appeals. h. CPR cannot have a different status to all other treatments and procedures offered in medicine. Legal precedent now agrees with this and identifies CPR as not being a treatment (under the Health Care Consent Act of Ontario) which surely gives us even greater clarity on its place and the need for consent / agreement. i. The statement “…including CPR, to provide and are only required to provide those that are within the standard of care” seems to somewhat rapidly pass the decision back to the physician in emergency situations while conflict resolution is underway. If this decision can be made using standard of care arguments at that time why not in the cold light of day when decision making is done best and with the most input from the patient, the SDM and the inter-professional team? j. CPR is never benign, apart from the many physical injuries that can occur, the loss of dignity at the time of death is considerable (and sadly death is the most common outcome by far for CPR in hospitals). Physicians only place such orders in the most dire situations where the success of CPR is measured in fractions of one percentage point; so following on from this, this policy will lead to the delivery of significant amounts of futile CPR. k. From personal experience, I wonder if the committee can see the unintended consequences of their recent and current CPSO guidance on these matters. Critical Care Clinicians are exhausted and under direct fire (including from numerous College complaints) from their SDMs (N.B. it is rarely from patients), who are demanding treatments that are inappropriate and not part of the standard of care. The controversy is causing harm to the professionals trying to offer excellent care whilst dealing with these crucial matters.
Organization
[May 14, 2021 2:03 PM]
Medico-Legal Society of Toronto
Response in PDF format.
Organization
[May 13, 2021 5:08 PM]
Hamilton Health Sciences, Department of Critical Care
Response in PDF format.
Organization
[May 13, 2021 11:38 AM]
Ontario Medical Association (OMA)
Response in PDF format.
Physician (including retired)
[April 30, 2021 4:54 PM]
I agree with the detailed analysis posted on 5 Feb 2021 and will only add / reiterate a few points. 1] The CPSO does not seem to appreciate the implications of the Wawrzyniak v. Livingstone, 2019 ONSC 4900 decision, which held that consent is not required prior to withholding CPR and physicians are only obliged to provide CPR in accordance with the standard of care. By the current policy, CPSO appears to want to change the standard of care so that a no-CPR order cannot be written while a conflict resolution process is under way. However, such an order is required to direct other HCWs - eg nurses - on the course of action to take in the event of an arrest. 2] The CCB is completely impractical as a body to mediate these conflicts (not available 24/7; decisions take weeks), and more importantly does not have jurisdiction when a treatment such as CPR is not being proposed. Judge Cavanagh made the point that 'no CPR' is not a treatment under HCCA in lines 248-52 of his judgment.
Organization
[April 30, 2021 1:44 PM]
Ontario College of Family Physicians (OCFP)
Response in PDF format.
Member of the public
[April 29, 2021 1:28 AM]
Ironic that BioMed Central is based in the UK where doctors in 2018 commanded that Alfie Evans not be allowed medical care in Italy but instead be removed from his ventilator and die. UK is also where doctors in 2021 commanded that RS not be allowed medical care in Poland but instead be denied food and water. The doctors and lawyers said that they were concerned about Alfie Evan's and RS's "best interests," and we are supposed to believe that these professionals knew Alfie's best interests better than his parents did. RS's wife sided with the doctors over his best interests, but RS was a devout Roman Catholic (against suicide) and his mother, two sisters, and niece all opposed the doctor's intentional dehydration of RS. No, in a world gone MAD (Murder Arranged by Doctors), I don't think we want doctors to decide what is in our best interests more than they do already. "Distributive justice" seems to be just as bad or worse.
Physician (including retired)
[April 16, 2021 8:59 AM]
As a critical care physician who was completing subspeciality training when the initial CPSO policy on end-of-life care was released, I am concerned that the policy has had unintended consequences that have resulted in patient harm. Beyond the obvious harm of broken ribs, pain, and loss of dignity from inappropriate chest compressions, the wording of the policy has also contributed to the institution of mechanical ventilation in patients who could not recover, and condemned those whose substitute decision-makers could not assent to palliation to prolonged, noncontributory, and profoundly unpleasant care in the ICU prior to their death. While I am strongly supportive of the Policy’s emphasis on communication and patient autonomy, I would like to suggest changes that would mitigate the harms I have listed, and better serve both physicians and the public. As the current pandemic has unfortunately emphasized, the decision to institute mechanical ventilation is always fraught with uncertainty regarding outcome; recovery after prolonged mechanical ventilation is decidedly mixed, with age and duration of mechanical ventilation both predictive of a reduced quality of life amongst ICU survivors. The decision to undergo intubation despite an uncertain outcome should be based on the patient’s values. There are many situations, however, where a plurality of physicians would concur that there is no chance of meaningful recovery: for instance, a patient with incipient respiratory failure from metastatic malignancy, deemed to have no further treatment options by Oncology, will not recover once intubated. Obviously these difficult realities need to be discussed, in a timely and sensitive manner, with the patient. Once this discussion has taken place, however, physicians should be empowered to write a ‘Do Not Intubate’ order in the patient’s chart, in order to protect the patient from a medicalized death and allow the institution of appropriate palliative measures. The current wording of the Policy, by mandating ‘good faith’ CPR in situations of disagreement, abnegates our ability to avoid ICU admission in situations where invasive physiologic support cannot be of benefit. Given that the patient, in such a situation, remains ‘Full Code’, and that Advanced Cardiac Life Support protocols usually include endotracheal intubation, the ICU physician must either choose to watch and wait until the patient suffers respiratory arrest, at which point they will be intubated and brought to the ICU (should they survive), or ‘bite the bullet’ and intubate them pre-emptively, recognizing that they cannot recover, in the hope of achieving a plan for palliation with their family and saving them the pain of CPR. Faced with this miserable dilemma, in my experience, physicians choose the latter option as the lesser evil. Rather than saving lives, this changes the way in which these patients die – their deaths are prolonged, medicalized, and undignified, and their families endure significant and unnecessary distress. Revisions to this Policy must establish a patient-centered process by which a physician (or group of physicians) might establish that a patient cannot meaningfully benefit from mechanical ventilation, and place orders in the chart such that palliation, rather than invasive physiologic support, be offered in such circumstances. Such difficult situations typically arise when physicians and substitute decision-makers cannot agree on a plan of care. (In my experience it is rare that patients themselves insist on a treatment once it is explained that it cannot be of benefit in their case). By requiring consent for a ‘no CPR’ order, the Policy aims to empower substitute decision-makers – in many cases, however, I believe that this requirement causes harm. In my experience many substitute decision-makers, despite a complete and sophisticated understanding of their loved one’s situation and prognosis, are unable to assent to any change in the plan of care that is perceived as ‘giving up’. Whether this is due to religious precepts or emotional distress is immaterial – many people feel that we are asking them to ‘sign off’ on their loved one’s death. They too are suffering – perhaps living the worst days of their lives – and for some, this is simply not possible. Many people in this situation appreciate the guidance of a physician, and, given the Rasouli decision, it is vitally important that noncontributory therapies not be initiated in this context. I would suggest that the revised Policy mandate that physicians, after discussing the range of therapies that are possible, state which they recommend as treatment options, and which therapies cannot be of benefit and will not be considered. The CPSO should support physicians in making these patient-centred judgements prior to the institution of treatment, leaving the cumbersome and prolonged process of the CCB to handle conflicts that arise regarding treatment cessation. Ultimately, patient autonomy must mean the ability to choose from an array of indicated and appropriate treatment plans, not the ability to compel painful and nonbeneficial treatment – all the more so when it is the substitute decision-maker, rather than the suffering patient, who is making choices. In closing, I would like to note that the existing Policy, by virtue of the problems I have outlined, continues to contribute to the moral distress of ICU personnel. While this may seem like a secondary consideration, the pandemic has demonstrated the reliance of the healthcare system as a whole on the functioning of our Intensive Care Units. ICU physicians face significant barriers to migration, but the same is not true of our nursing and allied health colleagues. We are all moral agents, and we need to know that the pain and discomfort we inflict on our patients are in service of a meaningful recovery. By supporting physicians in instituting appropriate care, and avoiding ICU admission in situations where it cannot be of benefit, a revised Policy will have a salutary effect on the retention of personnel in ICUs across the Province, with beneficial impacts on the health of all Ontarians. Thank-you for the opportunity to contribute to this consultation.
Physician (including retired)
[April 03, 2021 10:49 AM]
To Whom It May Concern: I appreciate the opportunity to provide suggestions for the revised CPSO Policy on Planning for and Providing Quality End of Life Care. I will start by highlighting the fact that there are sections of the policy that require no changes, including section 2, which emphasizes an obligation to communicate effectively and compassionately with patients/SDMs. This is one of the cornerstones of good medical practice for patients nearing the end of life. I will focus my suggestions on Sections 13, 15 and 17, to address issues that we encounter frequently in clinical practice. In each section, I will explain the issues that arise with that section as it is currently worded, and conclude with language to address these issues. 1. Section 15 Section 15 is no longer consistent with the HCCA as it was interpreted by the Ontario Superior Court in Wawrzyniak v. Livingstone [ONSC 4900 (2019)]. In his decision, Justice Cavanagh found physicians do not need consent for “the medical decision not to offer CPR as a treatment option…and writing and acting on the DNR order.” Applying Rasouli, Justice Cavanagh ruled physicians do not require consent to withhold medically inappropriate CPR under the HCCA because, among other things, not offering or providing CPR does not involve medical interventions or physical interference with the body. Choosing not to offer CPR was not a treatment decision, but rather “the physicians’ professional assessment of whether CPR would or would not be of medical benefit to Mr. DeGuerre.”[199] Justice Cavanagh emphasized that under the HCCA, treatments must be proposed before patients or substitute decision-makers can consent to them, noting, “[t]he HCCA does not provide that a physician is required to propose every conceivable treatment to a patient and allow the patient to choose which treatment or treatments to receive.” Whether a physician is required to offer a treatment depends on “the physician’s professional assessment of whether the treatment offers a medical benefit ... a contextual assessment of the patient’s circumstances, including the patient’s condition and prognosis, the expected result of treatment for that patient, and any risks of treatment for that patient.”[194] Justice Cavanagh further ruled that proposing a treatment does not mean that physicians are forever bound to provide it. Even if patients or substitute decision makers had previously consented to a “full code” order, this would not compel physicians to provide CPR if they determined, due to a change in circumstances or context, it would no longer be beneficial [223-6]. He rejected the plaintiff’s argument that previous authorities were unclear and ruled that substitute decision makers cannot insist on treatments that are medically inappropriate [264], even if they consented to them at an earlier point when that treatment was offered. This reflects a longstanding legal principle, recognized in a number of Anglo-American jurisdictions, that autonomy is a negative right; while patients can refuse treatment or insist that it be withdrawn, there is no right to demand it1. Section 15 still indicates that “Physicians must not unilaterally make a decision regarding a no-CPR order”, and directs physicians to engage in a process of conflict resolution when the patient or substitute decision-maker insists that CPR be provided. Notably, while that conflict resolution process is underway, “physicians must provide all resuscitative efforts required by the standard of care, which may include CPR” [emphasis added]. Essentially, physicians are still obliged to respond to a cardiac arrest, but that response does not have to include CPR that would be outside the standard of care. Unfortunately, because many cardiac arrests occur outside of daytime hours, there is a good chance that the person leading the resuscitation will not be familiar with the patient, and would only be able to make a clinical judgment about the effectiveness of CPR after the CPR has already been initiated. Physicians have a professional responsibility to communicate (or make reasonable efforts to communicate) their concerns about performing CPR in cases where they do not feel that it is medically appropriate, and be honest when they feel that CPR would be outside the standard of care. Wawrzyniak changes nothing in this regard, and the revised CPSO policy (like many other end-of-life policies) should continue to emphasize the importance of honest and supportive communication, and the obligation for physicians to present alternatives to aggressive treatment (as represented in Section 2). Suggested Changes to Section 15 (original language included, but with changes reflecting language from the Wawrzyniak decision): “Physicians must not unilaterally make a decision regarding a no-CPR order, unless the physician feels that CPR would offer no medical benefit based on a contextual assessment of the patient’s circumstances, including the patient’s condition and prognosis, and the expected result of CPR for that patient. • When writing a no-CPR order in the patient’s record, physicians must inform the patient and/or substitute decision-maker that the order will be written and the reasons why. • If the patient or substitute decision-maker disagrees and insists that CPR be provided, physicians must engage in the conflict resolution process as outlined in this policy. • If the patient experiences cardiac or respiratory arrest while conflict resolution is underway regarding the writing of a no-CPR order, physicians must provide all resuscitative efforts required by the standard of care, but this need not include CPR if CPR is felt to be outside the standard of care. • If the patient and/or substitute decision-maker previously gave consent to a plan of care that included CPR, this does not oblige other physicians to offer or provide CPR that they feel is inappropriate. However, physicians must inform the patient and/or substitute decision-maker about their decision not to offer CPR and the reasons why, and this must be documented.” 2. Section 13. Section 13 is very helpful because there are many situations of genuine prognostic uncertainty and trials of life-sustaining treatments may be helpful for resolving these. However, according to the HCCA as interpreted by the Supreme Court of Canada in Rasouli, physicians must obtain consent in order to withdraw life-sustaining treatment. This is potentially problematic in trials of life-sustaining treatments, if the patient and/or SDM does not provide consent to withdraw life-sustaining treatments in the event that the outcomes of a trial do not warrant continuation of the life-sustaining treatments. In other words, a physician could feel that life-sustaining treatments have little chance of success, but offer them as a time-limited trial to give the patient the benefit of the doubt. But if the trial fails and the physician proposes to withdraw life-sustaining therapies, the patient/SDM might refuse to consent, turning the trial into an open-ended course of life-sustaining treatments that are now causing discomfort for no potential benefit- an outcome that is arguably worse than having never initiated life-sustaining therapies in the first place. The potential for this scenario is a disincentive for physicians to offer trials of life-sustaining treatments. In order to remove this disincentive, and indeed encourage physicians to offer trials of life-sustaining treatments in cases of low but uncertain potential benefit, Section 13 should be clear that consent for a trial of life-sustaining treatments comes as a “package”. In other words, when consent is provided for a trial of life-sustaining treatments with clear outcomes, and those outcomes are not achieved, this includes consent for the withdrawal of life support. This is not to say that disputes will not arise about whether or not the trial’s objectives were achieved, and these may lead to the conflict-resolution process outlined in sections 25-7. But the idea of the trial as a package would preclude any separation of the initiation and the withdrawal of life-sustaining therapies, and ultimately reduce the hesitation physicians might have in offering this approach. Suggested changes to Section 13: “In instances where the outcomes of potentially life-saving and/or life-sustaining treatments are uncertain and physicians propose these treatments on a trial basis, physicians must be clear about the outcomes that would warrant the continuation of treatment and the outcomes that would warrant the discontinuation of treatment. • When consent is provided for a trial of life-sustaining treatments with clear outcomes, this includes consent for the withdrawal of life support in the event that those outcomes are not achieved. • If there is a dispute about whether or not the outcomes of the trial were achieved, physicians should follow the conflict-resolution process outlined in sections 25-7.” 3. Section 17. Section 17 is very helpful for emphasizing the obligation to treat symptoms. However, there are occasional circumstances (at least once per year) where an incapable patient is nearing the end of life and is in obvious discomfort (e.g. pain, dyspnea), and the patient’s substitute decision-maker is requesting that the care team not provide opioids or sedatives. Various justifications may be provided for this request: • A belief that these medications shorten life or are otherwise harmful • A belief that the patient is not actually experiencing discomfort • A belief that the patient would not have wanted to receive comfort medications (possibly based on a statement in a living will or advance directive document) End of life suffering in an incapable patient should be considered a medical emergency. Consistent with the HCCA’s approach to emergency treatment despite refusal (HCCA s.27), physicians may provide emergency treatment if they believe that the SDM is not compliant with s.21 of the HCCA (essentially, that there is no true Prior Applicable Capable Wish and this is not consistent with the patient’s best interests). Although a capable patient may refuse any treatment, or choose to experience discomfort for personal reasons rather than receive comfort medications, this is a very rare scenario. It hard to imagine that a blanket statement refusing all comfort medications, even when suffering at the end of life, would be an informed and capable decision when made months or years earlier in a state of good health. It is more likely related to a misconception (by either the patient or SDM) about the medications or failure to anticipate or recognize the suffering being experienced by the patient. In other words, if an SDM is refusing consent for comfort medications for a patient who is clearly suffering at the end of life, the physician should provide appropriate comfort medications unless there is a clear indication that this refusal is based on a well-documented, applicable and capable wish specific to this situation, or a demonstrable history of voluntarily accepting preventable suffering. The burden of proof for refusing comfort care on behalf of an incapable patient should be high. Suggested Changes to Section 17: “End of life suffering should be considered a medical emergency. Physicians must provide treatment in proportion to the pain and/or symptoms the patient is experiencing and closely follow any changes in the patient’s pain and/or symptoms to ensure that appropriate treatment is provided. • If an SDM is refusing consent for appropriate comfort medications for an incapable patient who is clearly suffering at the end of life, the physician should provide appropriate comfort medications unless there is a clear indication that this refusal is based on a well-documented, applicable and capable wish specific to this situation, or a demonstrable history of voluntarily accepting preventable suffering.” Thank you in advance for your consideration of these suggestions. References 1. Manning J. Q: Can a Court or Patient Demand Treatment? A: Yeah But No. J Law Med. 2018;25(3):626-633.
Physician (including retired)
[March 31, 2021 7:41 PM]
In regards to section 18 Dying at Home For those patients who choose to die at home there needs to be the ability to contact a physician or NP after hours. Often this is not the case and patients end up being transferred to emergency. If the patient's physician is unable or unwilling to arrange for this after hour coverage then transfer to a physician/NP willing to do this should be made. Otherwise it would be like someone practicing obstetrics only on weekdays 9-5 with no arrangements made for care for delivery at other times. Palliative care is becoming more of a specialized area of training and unfortunately not all family physicians have this skill set. Again transfer to another physician with this skill set may be required to provide appropriate end of life care.
Member of the public
[March 20, 2021 9:03 PM]
I appreciate the opportunity to participate in the preliminary consultations regarding the Planning for and Providing Quality End-of-Life Care Policy. I submitted comments through the CPSO survey tool on this consultation. The additional comments below focus on specific language. These comments are not designed to change the scope or meaning of the policy. Rather, they are designed to improve its clarity and effectiveness. 1. Definition of “palliative sedation.” It would be useful to clarify whether the referenced “intolerable suffering” includes not only physical but also existential suffering. 2. Section 2. A mandate to “communicate effectively” is appropriate. But the following language on “manner and tone” implies that this will be all oral communication. Substantial evidence shows that communication is materially enhanced by using educational tools like patient decision aids. Note that Section 30(b) advises use of “materials or resources” in the organ donation context. That is also useful in the treatment context. See, e.g., https://decisionaid.ohri.ca/ 3. Section 4(b). An advisory to help patients discuss ACP by “providing necessary medical information and opportunity for discussion” is appropriate. But ACP would be materially advanced by also providing well designed tools that guide and facilitate these discussions (whether patient with physician or patient with family). See, e.g., https://www.advancecareplanning.ca/resource/primary-care-toolkit/ 4. Section 6. The statement here is categorical. “Physicians must obtain valid consent before a treatment is provided.” But the emergency exception is noted in section 12. It would promote clarity and uniformity to add exception that here too. 5. Section 8. The advisory to “reassess capacity” is appropriate. But the caution here is in only one direction – to guard against erroneously presuming capacity. The opposite danger is equally real: wrongly determining the patient lacks capacity. Therefore, it would help to advise physicians undertake efforts to restore or support capacity in a patient who seemingly lacks it. 6. Section 13. Patients or SDMs may agree to a trial plan (e.g. “withdraw if no improvement after day x”). But they may later rescind that consent. Clarify the physician’s rights under the original agreement and obligations under the later-amended instructions. 7. Section 14. You write that physicians “must obtain consent” to withdraw life-sustaining treatment. Clarify whether that consent can be tacit. For example, with respect to no-CPR you advise that physicians can be “straightforward and directive.” Presumably, this means an announcement rather than a question (e.g. “We are writing a DNR for your mother”). Many contend that the absence of patient or SDM objection to such an announcement constitutes consent. 8. Section 14. There have been six recent tribunal cases in Ontario concerning brain death conflicts. There have been many more such conflicts at the bedside that have not escalated to tribunals. While mechanical ventilation is not technically “life-sustaining,” it would be useful to clarify whether clinicians may withdraw it after determination of death on neurological criteria. 9. Section 14(b). Since sections 14(b) and 15(b) are similar, they should have a more parallel construction. At the end of 14(b) add: “Physicians must not withdraw life-sustaining treatment while conflict resolution is underway.” 10. Sections 14 and 15. These sections use the same language “must not unilaterally make a decision.” But that is inaccurate for two reasons. First, it is not the “decision” that is problematic, but the writing or implementation of the order. Second, it is confusing to use the same language in both these sections, because while Section 14 requires consent, Section 15 does not. 11. Sections 14 and 15. These sections address withdrawing life-sustaining treatment and writing a no-CPR order. But they do not address withholding treatment other than CPR. I realize that the first situation was directly at issue in Rasouli and that the second situation was directly at issue in Wawrzyniak. But the CPSO can and should provide guidance even in the absence of direct judicial authority. 12. Section 22. Assume the physician has done what is mandated here and the patient really, truly wants to hasten her death. Physicians should discuss the available options. MAID is mentioned in Section 23. But what about VSED, palliative sedation? This is already an obligation under principles of informed consent but would be helpfully clarified here. 13. Section 25(a). A mandate to “communicate clearly” is appropriate. Substantial evidence shows that communication is materially enhanced by using educational tools like patient decision aids. See, e.g., https://decisionaid.ohri.ca/ 14. Section 26(a). Application to the CCB should be a last resort. Revise this section to advise an application to the CCB only after the conflict resolution processes in Section 25 have been tried and failed. The CCB has itself advised exhausting informal dispute resolution first. See, e.g., In re DP, 2010 CanLII 42949 (ON C.C.B.) 15. Footnote 12. In describing the Rasouli case, the term “life support” is used. But it would be clearer to use the terms from the definitions of this policy: “life-sustaining treatment.” 16. Footnote 13. You note that “patients may not be aware of the limitations of CPR.” This is a particularly good opportunity for patient decision aids to eliminate a lot of this misunderstanding. See, e.g., https://acpdecisions.org/
Organization
[March 18, 2021 2:48 PM]
Canadian Medical Protective Association (CMPA)
Response in PDF format.
Organization
[March 10, 2021 5:13 PM]
Canadian Critical Care Society (CCCS)
Note: some content has been edited in accordance with our posting guidelines. Response in PDF format.
Member of the public
[March 07, 2021 8:27 AM]
This seems like a well thought out and reasoned comment. I agree with the issues it raises. They should be thoroughly explored in any update to this important policy.
Organization
[February 17, 2021 2:04 PM]
Professional Association of Residents of Ontario (PARO)
Response in PDF format.
Physician (including retired)
[February 05, 2021 2:16 PM]
Note: some content has been edited in accordance with our posting guidelines. CPSO Feedback 1. Policy is unethical – the previous policy places too much weight on autonomy and neglects sounds ethical principles of distributive justice and non-maleficence. Please refer to [the following] article published in BMC Ethics. Ethical failings of CPSO policy and the health care consent act: case review. BMC Med Ethics. 2019 Mar 19;20(1):20 There are three justifications for withholding or withdrawing potentially life prolonging medical treatment: the patient validly refuses it (autonomy); the expected utility is too low to warrant the public resources necessary to provide it (distributive justice); or it is against the patient’s best interests (interests). Respect for patient autonomy is a central pillar of ethical medical practice. When discussing the rights of autonomous patients, [the article] acknowledge[s] two different types: positive and negative rights. A positive right would entitle the patient to, or allow them to demand, the provision of a treatment, and a negative right would enable the patient to be free from any unwanted treatment or interference. [The article] take[s] the common view that the negative right of a competent patient ought to be supported, but an absolute positive right to receive whatever treatment the patient demands should not exist. [The article] begin[s] from the starting point that evidence-informed medical opinion is necessary to constrain the options available to patients to ensure they receive ethically appropriate care that is supported by the best available medical evidence. In 2015, the CPSO revised its “Planning for and Providing Quality End-of-Life Care” policy to require that physicians provide CPR or life-sustaining therapy when requested unless they receive consent to withhold it, even if such provision is not medically indicated. This policy requires that physicians strictly comply with patient demands for life-sustaining therapies. The consequence and reality is that it leaves no room for the other relevant ethical considerations discussed above. The current CPSO policy regarding CPR provides patients and their SDM(s) with a positive right: the right to demand and receive an intervention. This is not ethically justifiable and contravenes both the HCCA and the process of informed consent. The former CPSO policy, Decision Making for the End-of-Life, stated that decisions regarding CPR and other potentially life-sustaining treatments should be made according to the likelihood of benefit to the patient and should take into account his or her goals, values, and beliefs. It also noted that Physicians are not obliged to provide treatments that will almost certainly not be of benefit to the patient. [The article] strongly suggest[s] that the CPSO revise its policy and allow physicians to use their professional judgement, based on the best available medical evidence, on when to offer and provide CPR and other forms of potentially life-sustaining therapy. A treatment should not be provided simply because an individual or their SDM demands it and it can be implemented. Rather, it should only be provided if there is some reasonable probability of benefit, if it is desired, and if it can be defended on grounds of distributive justice. [The article states] that if there is any reasonable doubt about whether a treatment will provide medical benefit to the patient, and [the] other considerations presented above are met, that it is better to err on providing therapy than not. Although “reasonable doubt” is itself subjective, some clarity and guideline(s) could become a topic of informed debate. In addition, in cases where questions or debate still exist, the CCB would continue to have an important role for adjudication. 2. No treatment is universal and no treatment can be demanded when not indicated – water, oxygen, and food seem like basic necessities of life but can also cross into the realm of a treatment and there are times when they are not indicated. Water cannot be given to someone with SIADH induced hyponatremia because it is not indicated. Oxygen can be limited in rare conditions and is titrated to a saturation. Food can be prescribed and artificial feeding is not recommended in advanced dementia (Choosing Wisely Canada and Canadian Geriatric Society guidelines). Surgery cannot be demanded by a patient when it is not indicated or is too risky. Then how can CPR be universally indicated in someone who has no further treatment options and is clearly at end of life? Just because it can be delivered by a bystander (water and food can be as well) does not mean it is indicated in every individual or must be provided if demanded. 3. Treatments all have side effects – There is no doubt CPR can save someone’s life. CPR is meant for individuals who are relatively young and are free of many diseases. As someone’s age increases and chronic health problems with it the probability of CPR being successful in terms of survival and quality of life diminish substantially. The subsequent initiation of life sustaining treatments such as intubation, dialysis, immobility, NG feeding, vasopressors, and other catheters cause pain and suffering. The longer they are in place the higher chance of complications. Months of vasopressors will result in the loss of digits, skin, and scalp. 4. Cost to system [...] Critical care is a costly and finite resource that provides the ability to manage patients with life-threatening illnesses in the most advanced forms available. However, not every condition benefits from critical care. There are unrecoverable health states in which it should not be used to perpetuate. Such situations are considered futile. The determination of medical futility remains controversial. [...] There is a significant economic cost of providing resource-intensive critical care to patients in which these treatments are considered futile. Clinicians should carefully consider the allocation of finite critical care resources in order to utilize them in a way that most benefits patients. 5. Burn out – there is no doubt this policy directly contributes to physician and nurse burnout. I’ve talked to many nurses who feel abandoned and distraught when having to look after patients they believe has no hope of recovery and more importantly is suffering. These same nurses have quit ICU. I have had many nurses tell me they have called in sick because they could not handle looking after a patient that they felt we were hurting. 6. CCB is flawed – The CPSO has appropriately suggested the use of CCB in their previous policy and I agree it serves a role but it is neither rapid nor does it consider all relevant information in their decision making process. It is not the fault of the CCB, it must follow an outdated HCCA. The CCB in its decision-making process are not to consider whether the treatment is medically indicated. There is no regard for evidence-based medicine, including expert or professional opinion and advocacy, and the current best interests of the patient are not considered unless there is no expressed wish or that wish is impossible to comply with. A “wish that is impossible to comply with” refers to whether the physical act of implementing the wish, such as CPR or organ transplant, can be done, and not to whether a medical intervention should be offered or implemented. In the absence of an explicit wish, the SDM is legally required to consider the incapable person’s best interests; the SDM must contemplate the values and beliefs they know the incapable person held when capable and believe he or she would still act on if capable. Of course, [the article recognizes] it [is] logical to require that SDMs consider the patient’s prior-expressed wishes when making treatment decisions on their behalf. What [the article] contest[s] is that there is not currently an effective mechanism or process to establish limits on what the patient or their SDM could demand and expect to be provided with in terms of medical intervention. [The article's] suggestion is to amend section 21 of the HCCA act to include considerations of distributive justice, of patients’ best interests not limited to cases in which patient wishes are not known, and of futility. In addition, [the article] also advocate[s] that the section contain references to evidence-based medicine and expert opinion; recommending that if the treatment is not indicated, it should not be offered. 7. CPSO policy and the healthcare law offer diverging requirements [...]. The present CPSO policy compels physicians to offer CPR even when there is no hope for recovery or for ongoing life. Specifically, the policy states that: A decision regarding a no-CPR order cannot be made unilaterally by the physician […]. If the patient or substitute decision-maker disagrees and insists that CPR be provided, physicians must engage in the conflict resolution process [….]. While the conflict resolution process is underway, […] if an event requiring CPR occurs, physicians must provide CPR unless the patient’s condition will prevent the intended physiologic goals of CPR from being achieved [1]. Consent legislation, on the other hand, does not provide for any treatment to be given by default [13]. In fact, previous rulings have said that providing CPR should be left to the discretion of physicians [14, 15], as informed by the medical evidence. The CPSO is no doubt aware the Ontario Superior Court of Justice recently determined that, under both Ontario’s health care consent legislation and common law, physicians do not require consent to withhold cardiopulmonary resuscitation (CPR) that they believe to be medically inappropriate. 8. Public is uninformed regarding CPR and life-sustaining treatments – previous studies have shown the general public bases their beliefs about CPR based on television shows. Please refer to this article in the NEJM Cardiopulmonary resuscitation on television. Miracles and misinformation. As an intensivist and internist who is responsible for the directing cardiac arrests in our hospital, I can absolutely guarantee that there are many situations in which CPR would never have the intended outcome. The mandate of the CPSO is to protect the public, I dare say that the CPSO needs to protect the public from themselves and unrealistic demands. I call on the CPSO to provide the public with information on outcomes and the potential consequences of CPR and life sustaining treatment. 9. The discussion with a patient about CPR or ICU must be done by an expert in those areas – all consent must be informed. The best person to discuss CPR or ICU would be an intensivist or someone with knowledge about CPR or ICU such as emergency physicians and internists to name a few. Consent for chemotherapy comes from an oncologist it does not come from an intensivist. Likewise, discussions about CPR and life sustaining treatments needs to come from informed experts in the area, this needs to be suggested in the next policy. Practically speaking this would be difficult but it is a start. The bigger issue is better educating the public and other physicians about CPR and ICU. 10. No CPR order – this is completely confusing and non-sensical. We don’t have to provide CPR according to the law but I can’t write a no CPR order if there is disagreement. If a patient disagrees that I will not prescribe antibiotics for a viral pneumonia I am allowed to write I will not give them antibiotics?? Can you not see the absurd nature of your policy?? This results in fear and uncertainty in these situations and will certainly result in intrusive CPR being done when it is not indicated. The ultimate decision to provide CPR rests with a capable physician experienced and trained with not only how to administer but when to administer CPR as well. I respect patient autonomy and their opinions but it is not the sole factor that decides what order or treatments are written.