Slow Codes Returning to Ontario?

In wake of the recent decision by the College of Physicians and Surgeons of Ontario to approve their new policy "Planning for and Providing Quality End of Life Care" – many of us are scratching our heads trying to make sense of the actions that are now required of Ontario physicians. The following excerpt from the policy demonstrates the key problems: 

A decision regarding a no-CPR order cannot be made unilaterally by the physician. Where a physician is of the opinion that CPR should not be provided for a patient and that a no-CPR order should be written in the patient’s record, the College requires physicians to discuss this with the patient and/or substitute decision-maker at the earliest and most appropriate opportunity, and to explain why CPR is not being proposed. This discussion must occur before a no-CPR order can be written.

If the patient or substitute decision-maker disagrees and insists that CPR be provided, physicians must engage in the conflict resolution process as outlined in Section 8 of this policy which may include an application to the Consent and Capacity Board. Physicians must allow the patient or substitute decision-maker a reasonable amount of time to disagree before a no-CPR order can be written.

While the conflict resolution process is underway, if an event requiring CPR occurs, physicians must provide CPR. In so doing, physicians must act in good faith and use their professional judgment to determine how long to continue providing CPR.

While a no-CPR order should require consent in some instances, it seems inappropriate to extend that to all situations. In some instances, physicians believe it is not medically indicated to offer CPR to a patient – and thus consent wouldn't apply. A patient with metastatic cancer who is already intubated in an ICU is typically not a canditate for CPR, because it would be ineffective and only cause harm. Taking the disagreement to the Consent and Capacity Board may not provide the resolution the CPSO was looking for. The CCB is only able to ajudicate where consent is clearly at issue (ie. the physician has proposed a treatment plan).  But more troubling is in the final paragraph where physicians are instructed to begin CPR (ie. disregard their clinical judgment about the ineffectiveness of such an action), but then only provide CPR for a period of time considered approrpiate by use of the same professional judgment. This almost sounds like an instruction to implement the "slow codes" that have been repeatedly dismissed as unethical.