A recent update to the end-of-life policy issued by the College of Physicians and Surgeons of Ontario (CPSO) poses serious ethical problems for practitioners and may cause unnecessary harm to patients and distress for families.
The CPSO policy was revised following the conclusion of a court case involving a Toronto hospital patient whose daughter expressed concern about a No CPR (cardiopulmonary resuscitation) order being placed on her father’s chart without her knowledge or consent. The patient’s physician believed the patient was dying, unlikely to benefit from CPR, and could indeed be harmed if CPR were initiated. In keeping with hospital policy, this assessment was confirmed by a second physician. The patient died shortly after the No CPR order was written.
In its recent ruling, the court supported the actions of the physicians. The ruling reaffirmed that physicians are not obligated to propose or provide treatments that they do not believe are medically appropriate.
Despite this ruling, the CPSO’s revised end-of-life policy stipulates that the writing of a unilateral No CPR order is not permitted and that a conflict resolution process is required if there is a disagreement between the physician and the patient or the legally authorized substitute decision-maker (the designate) if the patient is incapable. The policy does allow a physician who is at the bedside when cardiopulmonary arrest occurs to not initiate CPR if the physician believes doing so would be outside of the standard of care.
This policy is ethically problematic for a number of reasons.
First, and foremost, physicians may feel pressure to intervene even when it may cause significant harm without any corresponding likelihood of benefit. This is particularly problematic when it is the substitute decision-maker who disagrees – it may result in CPR being performed that is outside of the standard of care and could be contrary to substitute decision-making principles outlined in the Health Care Consent Act. Although the policy allows physicians to not initiate CPR if they are present when the arrest occurs, it is unlikely in most cases that a physician will be at the bedside and thus quite likely that nursing or other staff will begin CPR. When physicians arrive, they may not feel comfortable directing the team to stop CPR if they are not familiar with a patient’s circumstances.
Second, CPR requires human resources – physicians, respiratory therapists and nurses as well as material resources such as medications and intubation equipment. It is difficult to generate an ethical justification for resource use in circumstances where it is almost certain that a patient will not benefit from CPR. It is possible that resuscitation efforts could on occasion restart the heart; this would typically result in admission to a critical care unit. However, many of these patients may suffer a subsequent arrest within hours or days. In these cases, the use of scarce critical care resources is again difficult to ethically justify.
Third, the conflict resolution process feels disingenuous. Patients and/or their designates presumably enter into the conflict resolution process in good faith but if the patient suffers an arrest, a physician at the bedside can unilaterally withhold CPR, making the time and energy spent working through a conflict resolution process wasted. Such a decision is likely to cause considerable distress to the patient’s designate and family.
Fourth, rather than entering into a potentially time-consuming and antagonistic conflict resolution process, physicians may alternatively opt to provide CPR even if it is not standard of care, exacerbating problems one and two.
Lastly, as already mentioned, it is unlikely a physician will be present when a patient suffers a cardiopulmonary arrest. As a result, nurses and other healthcare providers will initiate CPR. Providing CPR to, for example, an elderly frail patient with metastatic cancer and multiple co-morbidities where the likelihood of CPR success is almost nil is a traumatic experience for everyone involved, particularly if it results in broken ribs, punctured lungs and other complications. Many healthcare providers will experience moral distress following such incidents since they may believe they have acted in ways contrary to what they think is right, harmed the patient physically, and treated the patient in an undignified manner.
It has been well established in law, ethics, and professional practice that healthcare providers are not required to propose or provide treatment that they do not believe is medically appropriate. It is unclear why CPR is treated differently; there should be no need for agreement from the patient or designate on a decision to not provide CPR when it is not the standard of care. However, as with any other treatment request, the patient or designate is entitled to seek a second opinion from another healthcare provider.
Revisions to the CPSO policy are needed to address these ethical problems.
*No conflicts of interest