POLICY MATTERS
Court Decision
on Provision of
CPR Reflected in
CPSO Policy
A
significant Court decision has been released
that clarifies physicians’ obligations with
respect to the writing of no-CPR orders and
the provision of CPR. The College's policy
redesign initiative provided an opportunity to reflect the
court’s decision and update our policy addressing end of
life care.
In late August, the Ontario Superior Court released a
comprehensive decision, dismissing a civil suit against two
physicians. The decision specifically addressed the issue
of whether or not consent is required prior to writing a
no-CPR order and what physicians’ obligations are with
respect to providing CPR in general. Notably, the Court
specifically engaged with the Rasouli decision to determine
whether the analysis and conclusions presented in that case
apply in the context of withholding CPR as well.
Ultimately, the Court determined that the withhold-
ing of CPR, including the writing of a no-CPR order, is
different than the withdrawal of life-sustaining treatment.
In particular, it noted that while consent is required for
the latter, which was at issue in the Rasouli case, the
reasoning and conclusion of that case does not apply in
the context of withholding CPR. Therefore, consent is
not required.
Instead, the Court found that physicians are only obliged
to provide CPR when doing so is within the standard of
care. It determined that the writing of a no-CPR order is
effectively a process requirement (not a treatment) that is
needed in order to respond to a hospital policy that CPR
be provided as a default treatment option.
When the Planning for and Providing Quality
End-of-Life Care policy was originally developed, there
wasn’t legal clarity, which left the College trying to set
out a reasonable position. However, given that legal clar-
ity has now been provided by the Court, the policy has
been updated to remove any impression that the College
requires consent to be obtained prior to writing a no-
CPR order. It also makes clear that the College does not
require physicians to provide CPR in instances where
doing so is not in accordance with the standard of care.
Instead the policy states that before 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 why.
“The language has been simplified and revised to be
clear that the obligation is to inform, not to make a
recommendation or proposal. This addresses stakeholder
feedback we’ve recently received and aligns with the
Court’s determination that a no-CPR order is not being
proposed and consent is not required,” said Craig Rox-
borough, Manager of the College’s Policy Department.
Given that physicians are only obliged to provide CPR
in accordance with the standard of care, the policy has
been revised to state that should the patient experience
cardiac or respiratory arrest while conflict resolution is
underway, a bedside determination can be made regard-
ing the resuscitative measures that are warranted in ac-
cordance with the standard of care.
Importantly, certain aspects of the policy have been
preserved, such as the prohibition of the unilateral writ-
ing of a no-CPR order. Before 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 provid-
ed, physicians must engage in the conflict resolution pro-
cess as outlined in the policy. However, the amendment
allows physicians to make appropriate in-the-moment
treatment decisions.
The policy will be reviewed in its entirety in 2020.
MD
ISSUE 3, 2019 DIALOGUE
29