Best interests at end of life: an updated review of decisions made by the Consent and Capacity Board of Ontario

Sibbald, Robert; Chidwick, Paula

doi:10.1016/j.jcrc.2012.09.005

Cited by 19 publications

(4 citation statements)

References 6 publications

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“…Our results suggest that emphasizing a patient's prognosis may fail to address SDMs' cognitive distress and may only heighten tensions, since SDMs may choose to reject the medical team's assessments. Some physicians have appealed to the concept of "best interest" [32], but prior work has identified "best interest" as being subject to interpretation by each party involved and is unlikely to lead to consensus [33][34][35]. Additionally, even though "best interest" has been legally defined [32], our study demonstrated that the CCB tended to focus on the "well-being" component, which more closely aligned with concepts such as the experience of pain or suffering.…”

Section: Discussionmentioning

confidence: 99%

“Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board

et al. 2022

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Background In end-of-life situations, the phrase “do everything” is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase “do everything” in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician–patient conflicts in order to explore its potential meanings. Methods We systematically searched the CCB’s online public archive from its inception to 2018 for any references to “do everything” in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes. Results Of 598 cases in the archive, 41 referred to “do everything” in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related “doing everything” to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients’ quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to “do everything” legally but followed existing laws by deferring to patients’ prior wishes whenever known, or to concepts of “best interests” when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients’ “well-being” and “best interests.” Conclusions In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to “do everything” highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient’s death, whereas physicians identified moral distress related to the prolongation of patients’ suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients’ goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care. Trial Registration Not applicable.

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Section: Discussionmentioning

confidence: 99%

“Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board

et al. 2022

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“…In two studies, Huynh et al 15 16 showed that ‘futile care’ was common and associated with significant financial cost, but there is little evidence that physician-SDM disagreement drives these types of cases. Chidwick et al 17 reviewed physician-SDM EoL disputes brought to Ontario's Consent and Capacity Board. Since 1996, only 26 cases out of 1367 reviewed involved physician-SDM dispute about a patient's EoL treatment, although the incidence of these cases is growing.…”

Section: Discussionmentioning

confidence: 99%

The impact of the Rasouli decision: a Survey of Canadian intensivists

Cape

Fox‐Robichaud

Turgeon³

et al. 2015

J Med Ethics

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“…The literature has revealed that the CCB adjudication process can be cumbersome and take longer than portrayed in recent court rulings. [6][7][8] The condition of an acutely ill patient with end-stage disease may very well deteriorate before the CCB meets and/or before it rules. Moreover, CCB rulings can be appealed to the Superior Court and subsequently to the Court of Appeal, and these appeals make take months to schedule.…”

Section: Existing Dispute Resolution Processes Are Limitedmentioning

confidence: 99%

“Must do CPR??”: strategies to cope with the new College of Physicians and Surgeons of Ontario policy on end-of-life care

Hawryluck

Oczkowski

Handelman³

2016

Can J Anesth/J Can Anesth

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The College of Physicians and Surgeons of Ontario recently released a new policy, Planning for and Providing Quality End-of-Life Care. The revised policy is more accurate in its consideration of the legal framework in which physicians practice and more reflective of ethical issues that arise in end-of-life (EOL) care. It also recognizes valid instances for not offering cardiopulmonary resuscitation (CPR). Nevertheless, the policy poses a significant ethical and legal dilemma-i.e., if disputes over EOL care arise, then physicians must provide CPR even when resuscitation would fall outside this medical standard of care. While the policy applies in Ontario, it is likely to influence other physician colleges across Canada as they review their standards of practice. This paper explores the rationale for the mandated CPR, clarifies the policy's impact on the medical standard of care, and discusses strategies to improve EOL care within the policy. These strategies include understanding the helphurt line, changing the language used when discussing cardiac arrest, clarifying care plans during the perioperative period, engaging the intensive care unit team early in goals-of-care discussions, mentoring hospital staff to improve skills in goals-of-care discussions, avoiding use of the ''slow code'', and continuing to advocate for quality EOL care and a more responsive legal adjudication process.Résumé L'Ordre des médecins et chirurgiens de l'Ontario a récemment publié une nouvelle politique, Planifier et prodiguer des soins de fin de vie de qualité. La politique révisée est plus précise dans sa considération du cadre légal dans lequel pratiquent les médecins et reflète mieux les questions déontologiques qui surgissent en matière de soins de fin de vie. Elle reconnaît également des exemples valables dans lesquels il ne faut pas offrir de réanimation cardiorespiratoire (RCR). Toutefois, la politique pose un dilemme éthique et légal de taille : si des disputes concernant les soins de fin de vie surviennent, alors les médecins doivent fournir une RCR même lorsque la réanimation tomberait en dehors de cette norme de soins médicale. Bien que la politique ne s'applique qu'en Ontario, il est probable qu'elle aura un impact sur d'autres collèges de médecins au pays lorsqu'ils réviseront leurs normes de pratique. Cet article explore la justification d'une RCR obligatoire, clarifie l'impact de la politique sur la norme de soins médicale, et examine différentes stratégies pour améliorer les soins de fin de vie dans le cadre de la politique. Voici quelques-unes de ces stratégies: une compréhension de la ligne entre aider et blesser, la modification de la terminologie utilisée lorsqu'on parle d'arrêt cardiaque, la clarification des plans de soins pendant la période périopératoire, l'implication rapide de l'équipe de l'unité des soins intensifs dans les discussions concernant les objectifs de soins, la formation du personnel hospitalier afin d'améliorer ses compétences dans les discussions concernant les objectifs de soins, le fa...

show abstract

Best interests at end of life: an updated review of decisions made by the Consent and Capacity Board of Ontario

Cited by 19 publications

References 6 publications

“Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board

“Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board

The impact of the Rasouli decision: a Survey of Canadian intensivists

“Must do CPR??”: strategies to cope with the new College of Physicians and Surgeons of Ontario policy on end-of-life care

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