5. Express any wishes with respect to obtaining a second opinion
Uncertainty in prognosis is common and adds to the stress of designated substitute decision-makers and healthcare teams who want to be assured that they are making the ‘right’ decision for the patient. In clinical practice, such uncertainty may not be as openly acknowledged as it should be—usually not out of malicious intent, but rather to alleviate anxiety and the burden of decision-making and perhaps to ensure that decisions are more timely in nature in order to reduce the patient’s suffering. Yet failure to acknowledge uncertainty, when it is present, fails to respect the physician’s fiduciary duties and leads understandably to distrust and conflicts.
The adjudication of conflicts with respect to the use of life-sustaining treatments has engendered intense and somewhat sensationalized media coverage, increasing distrust.28-30 It is conceivable that clients engaged in estate planning may wish to insert a clause that requests a second opinion from a qualified physician with respect to her or his expected treatment outcomes and/or prognosis before any treatments are withheld or withdrawn. Furthermore, advance directives may specify that such a second opinion must be independent in nature and/or provided by a physician external to the care facility in which the client is a patient:
“In all other situations, I direct that I would be willing to undergo a trial of resuscitation and life-sustaining treatments. However, if once these treatments are initiated it should become clear, in the opinion of two appropriately qualified physicians, that I have lost and will not regain any ability to understand, process information or communicate in a meaningful way, I direct that life-sustaining treatments be withheld or withdrawn and that I receive treatments solely focused on palliative care.”
The author wishes to encourage and engage in discussion regarding the directives she proposes here. Please take a moment to express your thoughts and critical commentary in the comments section below.
About the Author
LAURA HAWRYLUCK received her MD in 1992 from the University of Western Ontario where she also served her Internal Medicine residency. She completed a Fellowship in Critical Care at the University of Manitoba in 1997 and received her MSc in Bioethics in 1999 from the Joint Centre for Bioethics and the Institute of Medical Science at the University of Toronto. From 1999-2001 she was Assistant Professor of Critical Care/Internal Medicine, Queen’s University, Kingston, Ontario. In March 2000 she was appointed Physician Leader of the national Ian Anderson Continuing Education Program in End-of-Life Care at the University of Toronto and is currently Associate Professor of Critical Care Medicine at the University of Toronto. In 2002, she was awarded the Queen’s Golden Jubilee Medal for contributions to Canada in recognition of her work in creating the Anderson Program and improving end of life care for Canadians. Dr. Hawryluck is co-author and editor of “Law of Acute Care in Canada” to be published shortly by Carswell, a division of Thomson Reuters.
Dr. Hawryluck is deeply involved in international humanitarian projects. She has worked with critical care and burn units in Indore India and Cote d’Ivoire on a variety of quality improvement and educational initiatives. She was co-creator and co-Director for RCCI of the first Doctorate in Medicine Program in Critical Care in the entire country of Nepal. She worked with the Nepal Medical Council as an international consultant to enact a Code of Ethics and Professionalism for all physicians in Nepal.