DNR Order Policies in Manitoba

Manitoba Health

Bill 73, the Health Care Directives Act, was proclaimed in force July 26, 1993. This Act gives Manitobans the right to accept or refuse medical treatment at any time. Competent persons may express their wishes regarding the amount and type of health care and treatment they wish to receive in the event they are unable to speak for themselves. The Act also gives the right to appoint another person with the power to make medical decisions on their behalf if they are unable to speak for themselves.

The following information was issued from the Minister of Health’s Office in January 2000 upon an inquiry about the Ministry’s position on DNR Orders.

“A DNR Order, a decision to forego CPR, does not limit in any way the implementation of any other medically appropriate treatments or procedures. The patient’s physician writes DNR Orders on a patient’s medical chart. An order to reverse a DNR Order must also be written on the patient’s medical chart by the patient’s physician.”

The Minister’s Office also acknowledged the discussion which took place at a national level regarding DNR Orders and their placement practices. A joint statement was formulated by the Canadian Medical Association (CMA) Board of Directors, the Canadian Healthcare Association, the Canadian Nurses Association and the Catholic Health Association of Canada, and was developed in conjunction with the Canadian Bar Association. This statement encouraged medical facilities to have interdisciplinary committees which could develop policies, programs for policy implementation and conflict resolution mechanisms pertaining to DNR Orders. It should be noted that according to the statement issued from the Minister’s Office, “all major facilities in Manitoba have such policies in place.” ^[54]

Also of note in the Joint Statement is a recommendation for institutions to have reviews of DNR Orders at regular intervals. The conditions for the implementation of these reviews include the request of patients or patient proxies. This review could occur if there is a substantial improvement in a patient’s condition and if the patient is to undergo a surgical procedure or is transferred to intensive care. ^[55]

College of Physicians and Surgeons of Manitoba

The following is the text of a document published by the College of Physicians and Surgeons of Manitoba in February 1998. This statement was made following the decision rendered by the Manitoba Court of Appeal regarding DNR Orders in 1997.

“The decision to resuscitate must comply with the accepted standard of the medical profession. The physician must determine and document the relevant criteria accepted by the profession for the decision not to implement or discontinue therapy. The responsibility to consider the family in issues relative to patient care becomes more relevant when the patient cannot contribute. In a situation involving withdrawal or non-provision of treatment, clear communication becomes very important, even though the issue of consent is not relevant” [56]

The College recommends the following in its Guidelines: ^[57]

“All facilities are expected to have policies regarding DNR and supportive treatment orders. Policy makers should determine how controversial concepts applied to CPR should be interpreted into the policy, in light of the facility’s mission, the values of the community it serves, and ethical and legal developments. All members of the medical staff should be familiar with the policy.” [58]

The College recommends that if the person for whom resuscitation is being considered is deemed incompetent, decisions made on his/her behalf are based on the following principles:

	the treatment decisions must be based on the wishes of the person if they are known;
	when the person’s wishes are not known, treatment decisions must be based on the person’s best interests determined by
	i)  the diagnosis/prognosis; ii)  discussions with the partners and close family members; iii)  the person’s known values and preferences; iv)  aspects of the person’s culture/religion that would impact on a treatment decision. [59]

It is important to note that although informed consent from the patient or patient surrogate should be clearly understood and communicated, it is not mandatory. The expressed opinions of the patient, family and other care givers regarding DNR Orders are to be considered; but this is only a recommendation and not a prerequisite established by the College.

Survey of Manitoba Physicians

Several recent studies have charted physicians’ opinions regarding such end-of-life issues as euthanasia and assisted suicide. Although these two practices are not what theoretically constitutes a DNR Order, they do indicate how doctors feel they should exercise their discretion during these very difficult yet similar issues. Reported in the Health Law Review are the survey results of such a study of Manitoba physicians in 1996. ^[60] A summary of some of the results of that study indicate that from a sample of 122 physicians:

	52% indicated that they did not discern an ethical difference between not starting a life-support measure and stopping a life-support measure once it had begun.
	12% of physicians surveyed reported that they saw no ethical difference between stopping treatment and assisting suicide.
	6% would assist a suicide or practice euthanasia.
	71% agreed that some patients must be reduced to an unconscious state in order to combat pain or suffering.
	91% agreed that pain and suffering endured by some people while they continue to receive nutrition and hydration can outweigh the benefits of prolonging life.
	95% agreed that a patient can be given any dose of pain medication so long as it is medically necessitated, even when the patient’s death may be hastened by this action.
	83% of physicians agree that the provision of pain medication is not made less appropriate when it will certainly lead to death.
	60% believed euthanasia should be legalized where a patient has an incurable disease that causes great suffering.
	62% believed that a doctor who hastens the death of a terminally ill patient should not be subjected to criminal prosecution.
	62% also believed they would be less likely to pursue palliative care options if euthanasia were to be legalized.
	80% said they would not participate in assisted suicide or euthanasia while these acts remain illegal. If these acts were decriminalized, just over 50% of physicians indicated they would never assist a suicide or participate in euthanasia.
	However, 72% believe active euthanasia is performed by fellow practitioners.
	18% of the physicians surveyed indicated they had recieved requests from terminally ill patients for assisted suicide or euthanasia, and of these, one in seven had facilitated these requests. In practical terms, this means a significant number of physicians in Manitoba reaching into the hundreds have violated the law. If their actions were uncovered, they could be charged with offences that carry sentences as severe as life-imprisonment. [61]

The Role of the Public Trustee

What medical decisions, if any, does the Public Trustee get involved with as a policy position?

“The Public Trustee is making itself available where a physician wishes to consult with respect to resuscitation. The Trustee is seeking to clarify this position with the medical profession through the College [of Physicians and Surgeons].”
	The answer to this question was provided by then Attorney General Victor Toews in an article written in the College of Physicians and Surgeon newsletter From the College, January 4, 1999.

Does a physician, when caring for a patient who is also a client of the Public Trustee, have any obligation to involve the Public Trustee in a decision to place a DNR Order on the patient?

“If a person is a client of the Public Trustee, the physician should consult with the Public Trustee around the question of placing an order on a client’s chart. If the Public Trustee disagrees with the position of the physician, then [the College of Physicians and Surgeons] will take the steps considered necessary to resolve the issue, such as obtaining a second opinion or referring the issue to an ethics committee.”

From the College, May, 1999

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54	Statement issued from the Minister of Health's Office, January 2000.
55	These conditions, it is assumed, would be determined by the attending physician or healthcare team. Absent from the Joint Statment is any mention of a DNR Order review that would be the result of a conflict between a physician and a patient/patient surrogate.
56	Consent to DNR Orders. From the College. Vol. 34, No. 1. Winnipeg: College of Physicians and Surgeons of Manitoba. February 1998. 1.
57	It should be noted that the College defines a "guideline" as a practice generally recommended. Nowhere does it state that there is a legal obligation or mandatory order to follow these directives.
58	"'Do Not Resuscitate' and Supportive Treatment Orders." Guidelines. The College of Physicians and Surgeons in Manitoba. I - G97.
59	IBid.
60	Neil Searles. "Silence Doesn't Obliterate the Truth: A Manitoba Survey on Physician Assisted Suicide and Euthanasia." Health Law Review, No. 3, 1996. Health Law Institute, University of Alberta. 9 - 16.
61	IBid. 5.

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