Dialogue Volume 15, Issue 3 2019 - Page 29

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