Advance directives and choice

Opinion

Hey there, time traveller!
This article was published 06/02/2025 (248 days ago), so information in it may no longer be current.

I read with interest the opinion piece by Ruth Enns (Medical assistance in dying and advance directives, Think Tank, Feb. 3).

The are several points in this article that require clarification.

As an emergency physician, I deal with advance directives on an almost daily basis.

The statement that “we are now to believe that we should be able to circumvent current euthanasia/MAID restrictions by signing an advance directive” is fearmongering of the highest order.

No medical practitioners are convincing patients to sign advance directives as way of providing MAID. MAID in Canada is a very strictly regulated practice that requires consultation of a specialized team and is a completely separate process from the provision of advance directives. (As an emergency physician, I am neither qualified nor permitted to provide MAID.)

As for saying that practitioners can get a patient to sign an advance directive “even after a dementia diagnosis” is absurd.

For a physician to be obtaining a signature on a legal document when the patient does not have the capacity to consent would be a serious professional misconduct, and if Ms. Enns is aware of any such instances I urge her to contact the appropriate regulatory authorities. Many patients with dementia have made prior arrangements with loved ones or other people that they trust to be substitute decision makers on their behalf, which is itself an advance directive. (And sometimes the directive is that the patient receive full resuscitation and ICU care, and this is what is put on the advance directive.)

As for the decisions made by substitute decision-makers, I often speak with the family members of patients who have had catastrophic medical events, where we have already provided resuscitation, and have put the patient on a ventilator (essentially what is commonly called ‘life support’), only to be told by the family that the patient had discussed this eventuality with their family and did not want any resuscitation, advanced care or surgery.

These family members ask us to stop resuscitative efforts and to provide comfort care only.

There is also a continuum of care in advanced directives, as opposed to a yes/no. The order DNR (for Do Not Resuscitate) is no longer used. We now use ACP (advanced care plan) designations.

ACP-R (R for resuscitation) means that patients are to receive all treatments, including CPR and artificial ventilation. If we do not know the wishes of that patient or family, we designate them as ACP-R as a default until notified otherwise.

ACP-M (M for medical) means that we are not to provide CPR, but provide every other kind of appropriate intervention (antibiotics, anti-arrhythmic medications, etc). It should be noted that although some patients do wish to receive CPR, they would wish to be placed on a ventilator if necessary, and in those instances write that order on charts in accordance with patient wishes.

ACP-C (C for comfort) means only medications required for the comfort of the patient (like medications for pain and nausea).

It should be noted that patients receiving palliative care are generally receiving mostly comfort medications, and no active treatment for the underlying disease (like an advanced incurable cancer).

The very core of palliative care is provision of comfort to a patient who is nearing the end of their life. If we are to follow Ms. Enns’ conclusion that advance directives are a failure (and presumably that they should not exist), then a patient receiving palliative/hospice care, once their heart stops beating, must receive CPR, ventilation, and an entire protocol of advanced resuscitation.

Without an advance directive, this is exactly what would occur. (And no, I am not exaggerating.) Is this what is being seriously suggested?

Finally, the statement “Instead of choice, doesn’t the signing of advance directives actually abdicate choice?” is egregiously false. Patients want control over their medical care. Not every patient wants their life to end with CPR being performed on them.

I have had patients, with whom I am having this discussion, tell me how they had been in ICU on a ventilator before, and they never want to go through that again. An advance directive empowers the patient to have their choice respected.

When patients enter the health-care system, they want to know that they will receive the treatments that they wish, and will not receive treatments that they don’t.

That is the very definition of choice.

Dr. Douglas Eyolfson is an emergency physician in Winnipeg.