Manitoba physicians consider DNR guidelines
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* Dan Lett

*   © 2007 Canadian Medical Association or its licensors

The College of Physicians and Surgeons of Manitoba is circulating draft guidelines for withdrawing medical treatment in cases where doctors and families clash over whether to continue life support.

The guidelines, believed to be the first of their kind in Canada, would stipulate exactly what a physician must do before withdrawing medical treatment. The guidelines also clarify options for families who wish to continue medical treatment against a doctor's recommendations.

“We felt there needed to be more of an understanding by all parties involved in making decisions in an end-of-life case,” says Dr. Terry Babick, deputy registrar of the Manitoba college. “These are very sensitive, difficult issues.”

The draft guidelines were, in part, based on the findings of a 2003 report of the Manitoba Law Reform Commission that studied the legal implications of disputes over the withdrawal of life support.

A 12-page document outlining the draft guidelines was provided to the province's physicians in June 2006 for comment. The college does not have a firm timetable for implementing the guidelines.

Babick said despite the fact that almost all physicians face the possibility of having to withdraw life support from a patient, there are no consistent policies outlining how a decision like that should be reached and what must be done in advance to ensure the patients or their families are adequately consulted.

The guidelines state that physicians can withdraw life-sustaining medical treatment in cases where it is believed the patients will not be able to meet a minimum goal of recovering or maintaining a “level of function that enables the patient to achieve awareness of self and environment and to experience his/her own existence.”

In these cases, the guidelines state the physician may determine that further treatment is “not medically indicated” because the patient does not have a “realistic chance” of meeting the minimum goal, or, that treatment is “not medically appropriate,” in that the patient may be able to meet the minimum goal, but their chances are poor and “there will be significant negative medical effects on the patient, including, but not limited to, pain and suffering.”

If, after determining treatment is not medically indicated, a patient or family may ask that treatment continue and the physician would be asked to get a second opinion. If that second opinion indicates medical treatment is indicated, the original physician would have to continue treating the patient, or find another physician who will provide that care.

The guidelines also recommend patients or their families be given at least 4 days' notice prior to any final decision to withdraw medical treatment. Patients and their families are, at all times, entitled to seek out a physician who will provide care.

“The college is making every effort to be thoughtful in this process and see everyone's point of view,” says Babick. “But at the end of the day, there needs to be a process that everyone can work with. And we have to remember, these are decisions where often there is no right answer.”