Discussing a patient’s goals of care (the level of intervention that they would want should they encounter serious illness) is a challenging component of each hospital admission. When I met Elizabeth*, I was apprehensive that her goals may not be in line with what was medically feasible. She was an elderly woman with advanced dementia – she was bed-bound, had lost her ability to speak and required a feeding tube as she could no longer swallow safely. She came to the hospital with pneumonia, and I feared that her difficulty breathing may not improve with medical therapy alone. When I proposed this possibility, her family clearly stated that their mother was “Full Code”, meaning she would have wanted every possible medical intervention to keep her alive, including CPR and intensive care if needed.
I have had the privilege of training within two medical systems. I spent medical school and an internship year in the United Kingdom, working as a junior doctor for the National Health Service (NHS). I am currently an internal medicine resident at the University of Toronto. Working within these two healthcare systems has given me the perspective to question some of our ritualized behaviours as health practitioners.
I often feel conflicted and question our approach to goals of care discussions here in Ontario. Because we are generally poor at engaging patients in advance care planning prior to a health crisis, goals of care discussions in hospital may not reflect a patient’s previously expressed wishes or it may be the first time that a patient was asked to think about their ‘healthcare goals.’ The practice that I have encountered in Canada has been to discuss all options with the patients upfront, namely:
- Is the focus to prolong your life at all costs? This would include CPR and aggressive interventions like intensive care, intubation and mechanical ventilation.
- Is the focus to prolong life up to a point? We would use medications to treat your illness, but avoid using intensive measures if the situation arose.
- Is the focus on making you comfortable over prolonging the quantity of your life?
All of this information can be overwhelming for a patient or substitute decision maker. Our (perhaps misguided) instinct as healthcare providers is to default to prolonging life at all costs. A recent ruling by the Ontario Superior Court of Justice has amended current policy for physicians to no longer require consent from patients or substitute decision makers when withholding CPR in medically inappropriate situations. This ruling has been echoed with revisions made to the College of Physicians and Surgeons of Ontario policy on end-of-life care. However, given the recency of these changes, there has yet to be a dramatic shift in clinical practice.
What I observed working in the UK was drastically different. Our ethics teaching throughout medical school was founded on the principle that any patient could decline treatment, but treatment could not be demanded. In cases similar to Elizabeth’s, according to General Medical Council policy, we would explain that CPR and intensive management measures would not be offered, and would be inappropriate based on the medical standard of care. These conversations were rarely antagonistic – in the midst of an excruciatingly stressful time for patients and their families, they welcomed clear guidance on their available care options. In cases where the patient or caregiver disagreed with whether CPR should be offered, a second opinion could be sought, but the ultimate decision lay with the physician and care team.
From a resource allocation perspective, I wonder if this ingrained drive to only offer treatment when medically appropriate is rooted in pride and protectionism for the NHS. Founded in 1948, the NHS delivers free point-of-care service to all citizens in need, no health card required. While the NHS has its challenges like any healthcare system, I frequently heard unsolicited praise for the NHS from patients and physicians alike. The NHS remains a bipartisan source of national pride, which may be a driving factor in UK physicians’ protection of medical resources to maintain fair and equal access. Throughout my training in Ontario, I have not encountered the same pride among patients or physicians for our universal health care system, established federally by Tommy Douglas in 1966.
The Choosing Wisely campaign was set up in Canada in 2014 to encourage physicians to reduce unnecessary test and treatment provision. Their policy advises early advance care planning conversations with patients and families, and we must urgently heed this advice. It is within the scope of every physician’s expertise to determine when treatment is medically appropriate and necessary.
Practicing in Ontario has challenged me ethically when offering CPR or aggressive medical intervention, espcially if my judgment is that this treatment is inappropriate and futile. If we as Ontarians took more pride in our medical system, would we be less likely to use our precious resources unnecessarily to help preserve equitable access for all? We need to change our attitude toward protecting our finite healthcare means and continually engage in goals of care discussions, as challenging as they may be.
* The patient described is a composite of several patients the author has encountered and does not represent one individual.
Mara Waters is an internal medicine resident at the University of Toronto. She is a strong advocate for the Speak Up campaign, encouraging patients and families to begin advance care planning.