582 - Paediatric End-of-Life Care and Cardiopulmonary Resuscitation

Publication Number: 582.5790

Sara Rizakos, The Hospital for Sick Children, Toronto, ON, Canada; Andrew J. Helmers, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; Kevin Weingarten, The Hospital for Sick Children, Toronto, ON, Canada; Roxanne Kirsch, The Hospital for Sick Children, Toronto, ON, Canada

Background: Every paediatrician’s career includes the provision of care for children with life-limiting conditions. The College of Physicians and Surgeons of Ontario (CPSO) published a revised policy, “Decision-making for End-of-Life Care”, in March 2023. Most changes in this policy concern the ethics of withholding resuscitative measures, especially cardiopulmonary resuscitation (CPR).

Objective: To explore the context and ramifications of CPSO’s recent policy ,“Decision-making for End-of-Life Care”, for community and acute care paediatricians in Ontario and beyond.

Design/Methods: Bioethics analysis of the revised CPSO policy and its impact on clinicians, patients, and substitute decision-makers (SDMs) with a focus on Paediatrics, drawing from the literature to articulate relevant bioethics principles together with historical and medico-legal considerations.

Results: Analysis yielded three themes: consent/communication, moral distress, and equity. The policy clarifies that “a physician’s decision to withhold resuscitative measures is not ‘treatment’ and therefore does not require the patient or SDM’s consent”. Physicians can now chart “no CPR” even when a patient/SDM disagrees, but this is not a unilateral process – rather, sensitive and timely/longitudinal communication is essential within the broader context of high-quality end-of-life care, with provisions for conflict resolution. Altogether, these measures are an important improvement compared to prior policy iterations where clinicians were compelled (e.g. by parents) to initiate CPR even when the team did not feel this to be appropriate, thus leading to moral distress. This policy also highlights the distinction between withdrawing life-sustaining therapy (which remains contingent on patient/SDM consent) and withholding resuscitative measures, but fails to fully consider how the latter necessitates a thoughtful approach to ensure that CPR is never withheld because of a child’s protected characteristics (e.g. race, age, gender, and disability). Withholding CPR is an important high-stakes decision, as such each physician should develop a “sounding board” to calibrate this decision-making: this might include discussions with colleagues who provide CPR regularly (e.g. paediatric intensivists) and with Bioethics colleagues.

Conclusion(s): The revised CPSO policy “Decision-making for End-of-Life Care” is an important resource which must be read in the context of contemporary medico-legal and social discourse. It allows paediatricians to focus upon what they can do (comfort measures, meaning-making, cultural sensitivity) and takes CPR down from its privileged pedestal.

CPSO's "Decision-making for End-of-Life Care" Policy Revisions
Figure 1.pdf

Goals of Care and Advance Care Planning Discussions
Table 1.pdf