Decision not to offer or perform CPR can be at the discretion of treating physicians

In August, the Ontario Superior Court of Justice dismissed a malpractice lawsuit filed against two physicians who refused to provide cardiopulmonary resuscitation (CPR) to an 88-year-old man with multiple comorbidities and multiorgan failure. This ruling may have important implications for physicians in Ontario and elsewhere, according to a commentary published in this week's CMAJ (Canadian Medical Association Journal).

Notably, the court determined that under both Ontario's health care consent legislation and common law physicians do not require consent to withhold CPR that they believe to be medically inappropriate, or to write an order that CPR should be withheld.

This ruling indicates that the decision not to offer or perform CPR can be at the discretion of the treating physician, based on their assessment that CPR would not benefit the patient. "Even if patients or substitute decision-makers had previously consented to a "full-code" order, this would not compel physicians to provide CPR if they determined, because of a change in circumstances or context, it would no longer be beneficial," writes Dr. James Downar, a critical care and palliative care specialist at The Ottawa Hospital and Bruyère Continuing Care, with coauthors.

However, communication with patients and families is paramount. "Physicians have a professional responsibility to communicate (or make reasonable efforts to communicate) their concerns about performing CPR in cases where they do not feel that it is medically appropriate and to be honest when they feel that CPR would be outside the standard of care," write the authors.

In light of the court's ruling, the College of Physicians and Surgeons of Ontario updated their end-of-life policy to no longer require consent to withhold CPR. However, the policy still requires physicians to obtain consent to write a "No CPR" order -- an apparent inconsistency that may be addressed when the policy is revised in 2020.