Dying Patients: Ethical, Legal, and Clinical Management

Introduction

Care of the dying patient is a core competency for the MCCQE1 and a critical aspect of Canadian medical practice. This topic integrates clinical management (Palliative Care) with complex Ethical, Legal, and Organizational (ELO) challenges.

For MCCQE1 preparation, you must demonstrate the ability to manage end-of-life (EOL) symptoms while navigating consent, capacity, substitute decision-making, and Medical Assistance in Dying (MAID). This aligns directly with the CanMEDS roles of Medical Expert, Communicator, Collaborator, and Professional.

Ethical Principles in End-of-Life Care

The management of dying patients relies on the four pillars of medical ethics.

Advance Care Planning and Decision Making

Understanding the hierarchy of decision-making is high-yield for MCCQE1 preparation.

Hierarchy of Decision Making

When a patient becomes incapable, the physician must turn to the appropriate decision-making authority.

Goals of Care (GOC)

GOC discussions should occur before a crisis.

• Resuscitative (R): Full code, including CPR and intubation.
• Medical (M): Medical management (antibiotics, fluids) excluding CPR/intubation.
• Comfort (C): Symptom management only; allowing natural death.

Medical Assistance in Dying (MAID)

Since 2016, and updated via Bill C-7 (2021), MAID is legal in Canada. This is a frequent topic in MCCQE1 ethics scenarios.

Eligibility Criteria

To be eligible for MAID, a person must meet all of the following:

1. Be eligible for health services funded by a government in Canada.
2. Be at least 18 years of age and capable of making decisions.
3. Have a grievous and irremediable medical condition.
4. Make a voluntary request (not result of external pressure).
5. Give informed consent to receive MAID after being informed of means to relieve suffering (including palliative care).

The Procedural Steps

Conscientious Objection

Physicians are not obliged to provide MAID, but in most provinces (e.g., Ontario via CPSO policy), they must provide an effective referral to a non-objecting provider or agency. They cannot abandon the patient.

Palliative Symptom Management

Effective management of symptoms is the clinical cornerstone of caring for dying patients.

Common Symptoms and Treatments

Palliative Sedation

Palliative sedation is the use of sedative medications to relieve intractable symptoms when other treatments have failed.

• Intent: Relieve suffering, not to hasten death.
• Principle of Double Effect: An action with both a good effect (relief of suffering) and a bad effect (potential respiratory depression/death) is ethically permissible if the intent is the good effect.

The Pronouncement of Death

For the MCCQE1, you may be asked about the procedure for pronouncing death.

Checklist for Pronouncement

• Verify patient identity.
• Check for responsiveness (verbal/tactile stimuli).
• Observe for absence of spontaneous respiration (1 min).
• Check for absence of carotid pulse (1 min).
• Check pupils (fixed and dilated).
• Auscultate heart for absence of heart sounds (1 min).
• Document time of death and findings.
• Notify family and attending physician (if you are the resident).

Canadian Guidelines

• CMA Code of Ethics and Professionalism: Highlights the duty to respect patient autonomy and provide compassionate care.
• Criminal Code of Canada: Governs the legality of MAID.
• Provincial Health Care Consent Acts: Govern the hierarchy of SDMs (e.g., Ontario HCCA).
• Canadian Consensus Guidelines for Palliative Care: Provide standards for symptom management.

Key Points to Remember for MCCQE1

• Hydration: Artificial hydration in the dying phase often worsens secretions and edema without improving comfort. It is standard practice to discontinue it.
• Feeding: Loss of appetite is natural. Force-feeding or tube feeding in advanced dementia does not prevent aspiration pneumonia or prolong life.
• Truth Telling: In Canada, you cannot withhold a diagnosis from a competent patient at the family’s request (unless there is a substantial risk of serious physical harm to the patient, which is rare).
• Capacity: Capacity is decision-specific and time-specific. A patient with mild dementia may still have the capacity to appoint an SDM or decide on goals of care.
• Emergency: In a true emergency, if wishes are unknown and no SDM is available, treat to preserve life (presumed consent).

Sample Question

# Sample Question

Case Scenario

A 78-year-old male with end-stage metastatic pancreatic cancer is admitted to the hospital with pneumonia. He is cachectic, semi-conscious, and intermittently agitated. His advance directive, completed two years ago while capable, clearly states he does not want intubation, CPR, or ICU admission. However, his daughter, who is the Power of Attorney for Personal Care (Substitute Decision Maker), arrives at the bedside distraught. She demands, “Do everything to keep him alive, including putting him on a breathing machine if necessary. I am his decision-maker, and I revoke his previous wishes.”

Which one of the following is the most appropriate course of action?

• A. Intubate the patient immediately if respiratory distress worsens to avoid legal liability.
• B. Follow the daughter’s direction as the Substitute Decision Maker’s wishes override the patient’s prior capable wishes.
• C. Respect the patient’s advance directive and decline intubation, focusing on comfort measures.
• D. Consult the hospital ethics committee and intubate the patient pending their decision.
• E. Administer high-dose opioids to induce unconsciousness immediately.

Explanation

The correct answer is:

• C. Respect the patient’s advance directive and decline intubation, focusing on comfort measures.

Explanation: In Canadian medical law and ethics, the primary role of a Substitute Decision Maker (SDM) is to interpret and enact the previously expressed capable wishes of the patient.

• Option C is correct: An advance directive created when the patient was capable represents the patient’s autonomy. The SDM is legally bound to follow these wishes. The SDM cannot override the known, capable wishes of the patient simply because they are distressed or disagree.
• Option A is incorrect: Acting against a valid advance directive constitutes battery.
• Option B is incorrect: The SDM’s authority is not absolute; it is a “substituted judgment” based on what the patient would have wanted, not what the SDM wants.
• Option D is incorrect: While ethics consultations are helpful in ambiguous cases, this case presents a clear advance directive. Intubating “pending decision” violates the patient’s expressed wish and causes harm (maleficence).
• Option E is incorrect: This describes euthanasia (without MAID protocols) or inappropriate use of sedation. Palliative sedation is titrated to symptom relief, not immediate unconsciousness without trial of other measures.

References

1. Medical Council of Canada. MCCQE Part I Objectives: Ethical, Legal and Organizational Aspects of Medicine. Available at mcc.ca.
2. Canadian Medical Association. CMA Code of Ethics and Professionalism.
3. Department of Justice Canada. Medical Assistance in Dying. justice.gc.ca.
4. Toronto Notes 2024. Ethical, Legal and Organizational Medicine.
5. College of Physicians and Surgeons of Ontario (CPSO). Policy: Planning for and Providing Quality End-of-Life Care.