By Lucas Vivas and Travis Carpenter

The COVID-19 pandemic has shed a light on many of the strengths and weaknesses of the world’s public health systems. In Canada, where the national health care system was stretched even before the expected COVID-19 surge, a conversation has begun about the need to direct health care resources to where they will be most effective and away from where they will not help. In some cases, this is opening the door to a long-delayed public conversation about the provision of “futile” care in the setting of limited resources.

In recent years, Canadian jurisprudence and regulatory policies have given the impression of exalting patient and family desires over professional judgment and a just resource allocation. In some cases, these controversial developments have served to increase the provision of “futile”, costly, and potentially harmful care in intensive care units in Canada.

Medical regulators and governments have allowed the courts to lead on this issue and have mostly remained passive. With a pandemic upon us, however, the folly of neglecting a public debate on the appropriateness of this approach has become evident, as policy makers find their ability to manoeuvre around these challenging and emotionally charged issues constrained by a lack of public insight and input.

Ontario, Canada’s largest province, has been the recent epicentre of much of this debate and the topic has generally provoked an acrimonious relationship between health care providers and their medical regulator (the College of Physicians and Surgeons of Ontario, or CPSO). The CPSO’s policy responses to cases such as Cuthbertson v Rasouli or Wawrzyniak v. Livingston have been questioned – some even casting doubt on their fundamental ethical soundness.

The COVID crisis has now forced a more urgent consideration of the issue. The provincial government in Ontario has already outlined a framework for triaging resources in the event of a surge – necessarily subsuming patient or family desires regarding scope of treatment, and raising the spectre of “death panels” that choose who lives and who dies. Physicians have an important part to play in dispelling these fears, as they are the front-line caregivers charged with deciding what medically-appropriate treatments constitute the “standard of care” and what treatments are likely to be futile and even harmful. Unfortunately, the CPSO has issued only cursory guidance to physicians, giving hollow reassurance that “circumstances” will be taken into account when the College is adjudicating complaints resulting from clinical decisions made in this environment. Rather than using the pandemic as a useful catalyst for expediting the planned revision and refinement of its end-of-life care policy, it seems like the College has instead decided to “sit this one out”.

These trying times have the potential to bring out all that is greatest in humanity. Medical regulators have a duty to support the front-line clinicians in their important work of educating and accompanying patients even while difficult decisions must be made. Now is the time for both governments and medical regulators to lead the broader public discussion on appropriate care and medical futility. Canada’s provincial governments, Ontario’s in particular, have displayed courage in defining limits and criteria for the provision of publicly-funded care – a resource that belongs to us all.  It is time for the CPSO and other medical regulators to lead with the same alacrity.

Paper title: Meaningful futility: requests for resuscitation against medical recommendation

Authors: Lucas Vivas¹ and Travis Carpenter^2,3

Affiliations:

1. William Osler Health System, Brampton, Ontario, Canada
2. Unity Health Toronto, Toronto, Ontario, Canada
3. University of Toronto, Toronto, Ontario, Canada

Competing interests None declared.