MESSAGE FROM THE PRESIDENT
and answering questions.
When a physician communicates effectively
and frequently with a patient or the patient’s
substitute decision-maker, it promotes trust
and confidence in the relationship. And, that
will go a long way to making future conversations easier, including difficult conversations
about when life-support should be withdrawn
or when a no-CPR order should be written.
One component of our policy development
process included public polling to ascertain
the public’s views, expectations and understanding around key concepts associated with
end-of-life care. This included the provision of
CPR, which was one of the most challenging
issues we dealt with in the course of developing
the new policy.
A couple of important themes emerged
through that public polling. In relation to CPR
specifically, we learned that Ontarians are generally not aware that CPR has a low likelihood
of success.
We took this to mean that there is work
to be done on our part as physicians to help
educate the public on CPR, what it really
involves, and that it needs careful consideration
of whether it will truly be in their best interest.
We must improve our communication with
our patients about CPR and work to remedy
the lack of understanding or misunderstanding
people have regarding CPR.
With respect to decision-making around
no-CPR orders, the polling results also demonstrated very clearly that the public wants to
and expects to be involved in this process. We
specifically asked whether decisions regarding
no-CPR orders are a medical decision and as
such, one that a doctor should make. Here the
public was unanimous in their disagreement –
in the view of the public, this is not a decision
for physicians to make alone and they expect
to be actively and meaningfully involved in
the decision as to whether a no-CPR order is
written.
The draft version of this policy did contain a proposed requirement that consent be
obtained for a Do Not Resuscitate (DNR) or
no-CPR order. During the consultation for the
draft policy, we heard a number of objections
to that requirement. Many argued that the law
does not require physicians to obtain consent for a no-CPR order. Others worried that
requiring consent to withhold CPR treats CPR
differently than any other treatment and would
oblige physicians to provide treatment against
their professional judgment and that would
not be in the best interests of the patient.
In the policy, we acknowledge that the legal
requirements regarding consent to a no-CPR
order are unclear. While we are aware of and
reviewed decisions of the Consent and Capacity Board, the Health Professions Appeal
and Review Board, and decisions of various
Ontario courts which relate to this question, in
our assessment of the legal landscape, it is not
currently clear whether there is a legal requirement for a physician to obtain consent prior to
writing a no-CPR order.
We came to believe by the end of the consultation that requiring consent (as defined
in the Health Care Consent Act) for a no-CPR
order when the legal requirements are unclear
may have negative outcomes for patients.
However, we also felt very strongly the need to
respect patient autonomy and we believe that
the decision to write a no-CPR order cannot
be made unilaterally by physicians; patients or
the substitute decision-makers of incapable patients must be involved in the decision-making
process in a meaningful way.
Given this lack of legal clarity and given the
feedback heard through our consultation, we
articulated a new requirement f