End-of-life care
relationship, all physicians have the
Involving those close to the paresponsibility to discuss with their patient in discussions may be benefitients the importance and the benefits
cial as it can, for example, help the
of advance care planning and choospatient understand their diagnosis,
ing a substitute decision-maker. The
prognosis, medications, the tests
policy advises physicians that they may
that are required, and the decisions
need to initiate these discussions sensithey have to make about treatment
tively, over multiple occasions as patients
options.
may not always be ready to participate.
“Such involvement can also help the famDr. Carol Leet
“Patients are entitled to receive quality end-of-life
ily caregivers provide more effective care at home
care that allows them to live as well as possible until
and mitigate their own distress,” states the policy.
they die,” said Dr. Leet. “And I think this policy will
Dr. Leet also believes that conversations around death
help physicians as they plan for and provide quality
and dying should not just be reserved for palliative care
end-of-life care that aligns with a patient’s wishes, values
physicians and oncologists. In fact, the policy states that
and beliefs.”
as part of routine care in an ongoing physician-patient
Engage patients in discussion before writing no-CPR order
photo: D.W. Dorken
I
n early 2015, a draft version of the Planning
for and Providing Quality End-of-Life Care
policy was circulated for consultation feedback.
Through this consultation we heard a number of
objections to the proposed requirement that consent be
obtained for a no-CPR or Do Not Resuscitate Order
(DNR).
In response to this feedback and given that the law is
unclear regarding a consent requirement for a no-CPR
order, Dr. Leet and the Working Group articulated a
new requirement for physicians that places emphasis on
good and effective communication and a robust conflict
resolution process.
The policy states that physicians must engage patients
or substitute decision-makers in a discussion before
writing a no-CPR order and engage in conflict resolution if there is disagreement.
As the requirements regarding no-CPR orders were an
area of significant controversy in the consultation and
leading up to the Council meeting, these requirements
were the subject of intense discussion and deliberation
by Council members. In particular, one key issue Council debated was the requirement that physicians provide
CPR, should the patient arrest, while conflict resolution
regarding a no-CPR order is underway.
Members of Council recognized the difficulties this
requirement may put physicians in, but ultimately believed that the policy position was the best compromise
the College could achieve. Council members reflected
that:
• The policy requirements place an important emphasis
on early, good and thorough communication and education to avoid conflicts regarding no-CPR orders;
• The policy respects patient autonomy in decisionmaking regarding end-of-life care and is responsive to
the public’s expectation that they be involved in these
types of decisions;
• To allow physicians to not provide CPR during conflict
resolution regarding a no-CPR order would significantly undermine the conflict resolution process and the
public may wonder how genuine or sincere the conflict
resolution process is when physicians can make a decision at the bedside to just not provide CPR.
“We felt very strongly that the decision to write a noCPR order could not be made unilaterally by physicians
as this would not respect patient autonomy, and this
decision was supported by our public polling results. In
the end, we feel that the policy has struck the right balance,” said Dr. Leet.
The policy is inserted at page 19.
Issue 3, 2015 Dialogue
37