Assisted Death: The Risks and Benefits of Tribunal Approval.

Should every request for physician-assisted death require approval from some kind of independent tribunal? The benefits include consistent interpretation of statutory or judge-created guidelines from hospital to hospital, accurate reporting of assisted deaths, a process that protects vulnerable patients and health practitioners, and assurance to the public that the process has sufficient safeguards. On the other hand, such a process might cause delays for persons suffering intolerably. Accessibility might be a problem, and there is the risk that the patient's personal health information becomes fodder for media sensationalism. The author weighs these risks and benefits and concludes that a tribunal approval process is a transparent system capable of helping the law clearly gel in a way that provides guidelines, encourages trust in the healthcare process generally and the assisted death process specifically. I

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

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 help-hurt 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.

Checklist to meet ethical and legal obligations to critically ill patients at the end of life.

Despite improvements in communication, errors in end-of-life care continue to be made. For example, healthcare professionals may take direction from the wrong substitute decision-maker, or from family members when the patient is capable; permit families to propose treatment plans; conflate values and beliefs with prior expressed wishes or fail to inquire about prior expressed wishes. Sometimes healthcare professionals know what prior expressed wishes are but do not respect them; others do not believe they have enough time to have an end-of-life discussion or lack the confidence, willingness and skills to manage one. As has been shown in initiatives to improve in surgical safety, the use of a checklist presents opportunities to potentially minimize common mistakes and errors. When engaging in end-of-life care, a checklist can help focus on what needs to be communicated rather than how it needs to be communicated. We propose a checklist to support healthcare professionals in meeting their ethical and legal obligations to patients at the end of life. The checklist should minimize common mistakes, and in situations where irreconcilable conflict is unavoidable, it will ensure that both healthcare teams and family members are informed and prepared.

The beneficial role of a judicial process when "everything" is too much?

This narrative is written with the intent to encourage physicians as well as other healthcare professionals to use judicial processes, such as those provided by the Ontario Consent and Capacity Board, to help resolve conflict with treatment decisions between care providers and decision-makers. Through the presentation of a fictional yet common case scenario, it is argued that after all attempts at mediation have been attempted that the timely use of a third party is in the patient's, the family's and the healthcare team's best interests.