Decision-Making for End-of-Life Care

Approved by Council: September 2002
Reviewed and Updated: February 2006, September 2015, May 2016, September 2019, March 2023

Companion Resource: Advice to the Profession, Guide for Patients and Caregivers

Definitions

Advance care planning discussions: Conversations that take place between health-care providers, patients, and/or substitute decision-makers to help identify the patient’s personal, cultural, and religious/spiritual values and beliefs, as well as their wishes, including which treatment(s) they may or may not want at the end of life. The aim of these discussions is to prepare patients and/or substitute decision-makers for future decision-making.

Goals of care discussions: Conversations that take place between health-care providers, patients, and/or substitute decision-makers, in the context of a significant illness or disease when there are treatment or care decisions that need to be made in the foreseeable future. The aim of these discussions is to educate patients and/or substitute decision-makers about available treatment options, and help define obtainable goals of care by identifying the patient’s personal, cultural, and religious/spiritual values and beliefs, as well as their wishes, if they can be ascertained.

Life-sustaining treatment: Any medical procedure or intervention which utilizes mechanical or other artificial means to sustain or replace a vital function essential to the life of the patient (e.g., mechanical ventilation, medically assisted nutrition and hydration, vasopressors and/or inotropes).

Resuscitative measures: A suite of medical interventions (e.g., chest compressions, artificial ventilation, intubation and/or defibrillation) that may be provided following cardiac or respiratory arrest in an attempt to restore or maintain cardiac, pulmonary, and circulatory function. Not all interventions in the suite will necessarily be provided or required in all cases.

Substitute decision-maker (SDM): A person, or persons, who may give or refuse consent to a treatment on behalf of an incapable person.¹

Policy

Advance Care Planning and Goals of Care Discussions

1. When a patient’s specific circumstances and health status make it appropriate, physicians who provide care as part of a sustained physician-patient relationship² must, where possible, initiate a discussion about advance care planning, which includes:
   1. raising end-of-life care issues with the patient; and
   2. encouraging the patient to discuss those issues with their SDM.
2. When patients have a significant illness or disease and are at risk of clinical deterioration (e.g., cardiac or respiratory arrest) in the foreseeable future, physicians must, where possible:
   1. initiate a timely goals of care discussion, which includes:
      1. describing the underlying illness or medical condition and prognosis;
      2. educating the patient and/or SDM about the available treatment options, which may include resuscitative measures, and explaining the outcomes that can and cannot be achieved; and
      3. defining the patient’s goals of care by helping the patient and/or SDM identify the patient’s wishes, values and beliefs, or if they cannot be ascertained, identifying what would be in the patient’s best interests;
   2. facilitate the goals of care discussion to help build understanding about the treatment decision(s) that need to be made; and
   3. review the goals of care discussion with the patient and/or SDM whenever it is appropriate to do so (e.g., when there is a significant change in the patient’s medical condition or when the patient and/or SDM indicate that the patient’s wishes, values, and/or beliefs have changed).

End-of-Life Care

3. Physicians must seek to balance medical expertise and patient wishes, values, and beliefs when making decisions about end-of-life care.

Withdrawing Life-Sustaining Treatment

4. Physicians must obtain consent from patients and/or SDMs before withdrawing life-sustaining treatment.³ As part of the consent process, physicians must:
   1. explain why they are proposing to withdraw life-sustaining treatment; and
   2. provide details regarding clinically appropriate care or treatment(s) they propose to provide.

Managing Disagreements

5. Where consent cannot be obtained and the physician is of the view that life-sustaining treatment should be withdrawn, the physician must try to resolve the disagreement with the patient and/or SDM in a timely manner by:
   1. communicating information regarding the patient’s diagnosis and/or prognosis, treatment options, and assessments of those options;
   2. identifying the basis for the disagreement, taking reasonable steps to clarify any misunderstandings, and answering questions;
   3. reassuring the patient and/or SDM that the patient will continue to receive clinically appropriate care or treatment(s);
   4. making reasonable efforts to support the patient’s physical comfort, as well as their emotional, psychological, and spiritual well-being, by offering supportive services (e.g., social work, spiritual care, palliative care) and consultation with the patient’s primary care provider, where appropriate and available;
   5. offering to make a referral to another health-care provider, where appropriate and available;
   6. facilitating an independent second opinion, where appropriate and available; and
   7. offering consultation with an ethicist or ethics committee, where appropriate and available.
6. Physicians must determine whether to apply to the Consent and Capacity Board when:⁴
   1. in relation to treatment decisions, disagreements arise with an SDM over an interpretation of a wish, or assessment of the applicability of a wish, or if no wish can be ascertained, what is in the best interests of the patient; or
   2. they are of the view that an SDM is not acting in accordance with their legislative requirements.⁵

Withholding Resuscitative Measures

A physician’s decision to withhold resuscitative measures is not “treatment” and therefore does not require the patient or SDM’s consent.⁶

Where the risk of harm associated with resuscitation outweighs the potential benefits, physicians may decide it is appropriate to withhold resuscitative measures and write an order to this effect in the patient’s medical record.

7. Before determining that resuscitative measures will not be provided because the risk of harm in providing those interventions would outweigh the potential benefits, the physician must consider the patient’s wishes, as well as their personal, cultural, and religious/spiritual values and beliefs, if they can be ascertained or the physician is aware of them.
8. When a physician determines that the risk of harm in providing resuscitative measures would outweigh the potential benefits, the physician can write an order to withhold resuscitative measures in the patient’s medical record but must, before writing the order:
   1. inform the patient and/or SDM that the order will be written;
   2. communicate information regarding the patient’s diagnosis and/or prognosis, and explain to the patient and/or SDM why resuscitative measures are not appropriate, including the risk of harm in providing those interventions and the likely clinical outcomes if the patient is resuscitated; and
   3. provide details to the patient and/or SDM regarding clinically appropriate care or treatment(s) they propose to provide.
9. When a patient’s condition is deteriorating rapidly and there is an imminent need for an order to be written (e.g., actual or impending cardiac or respiratory arrest), the physician can write an order to withhold resuscitative measures in the patient’s medical record but must comply with the expectations set out in provision 8 at the earliest opportunity (rather than before writing the order).

Providing Support if Disagreements Arise

10. If the patient and/or SDM disagree with the writing of an order to withhold resuscitative measures, the physician can write the order, but must, at the earliest opportunity after learning of the disagreement, make reasonable efforts to provide support to the patient and/or SDM by:
    1. identifying the basis for the disagreement, taking reasonable steps to clarify any misunderstandings, and answering questions;
    2. reassuring the patient and/or SDM that the patient will continue to receive clinically appropriate care or treatment(s);
    3. making reasonable efforts to support the patient’s physical comfort, as well as their emotional, psychological, and spiritual well-being, by offering supportive services (e.g., social work, spiritual care, palliative care) and consultation with the patient’s primary care provider, where appropriate and available;
    4. facilitating an independent second opinion, where appropriate and available; and
    5. offering consultation with an ethicist or ethics committee, where appropriate and available.

Endnotes

^1. For more information on SDMs, please see the College’s Consent to Treatment policy.

^2. A sustained physician-patient relationship is a physician-patient relationship where care is actively managed over multiple encounters.

^3. The Supreme Court of Canada determined in Cuthbertson v. Rasouli, 2013 SCC 53 (hereinafter Rasouli) that consent must be obtained prior to withdrawing life-sustaining treatment.

^4. In Rasouli, the Supreme Court of Canada determined that when SDMs refuse to provide consent to withdraw life-support that, in the physician’s opinion, is not in the patient’s best interests, physicians must apply to the Consent and Capacity Board for a determination of whether the SDM has met the substitute decision-making requirements of the Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A (hereinafter HCCA) and whether the refused consent is valid. See in particular paragraph 119 of Rasouli.

^5. Please see footnote 1.

^6. In Wawrzyniak v. Livingstone, 2019 ONSC 4900, the Court concluded that the writing of a Do Not Resuscitate (DNR) order and withholding of cardiopulmonary resuscitation (CPR) do not fall within the meaning of “treatment” in the HCCA. Accordingly, consent is not required prior to writing a DNR order and withholding resuscitative measures, such as CPR, and physicians are only required to provide resuscitative measures in accordance with the standard of care.