I don’t want my doctor providing end of life care. Doctors are suppose to maintain life, not end it. Let another profession do end of life like hospice professionals. Can they be trusted to have the patients interests at heart. I don’t think so.
The Hippocratic oath is clear, “do no harm”. The Bible is clear, “Thou shall not kill”. Contrary to what Dr. Low said, there is always a way to improve quality of life when things go downhill near the end. Palliative care is the solution.
I am very concerned about the comments thus far. This is not a forum about physician assisted dying, this is a conversation about when someone dies (naturally and expectedly) at home, what should the role of family physicians be? I believe that the role of the family physician is to support patients during their entire life cycle – from birth until death. I have been privileged to be able to support families during this difficult time in their lives by coming to their homes at the time of their loved ones’ death. This removes the need of having to involve strangers and the coroner – which can all be very stressful and unnecessary. My one comment is that the home DNR forms need to be reassessed. They are currently a blanket one-size-fits-all format that lumps CPR together with intubation and pressors. The forms need to either be more narrow in their scope or require a tiered format, similar to the POLST program in the US.
Certifying death at home is an important gesture for the family at a difficult time.In the sum of an md’s care for a patient,this one act will be remembered by the patients loved ones.
Agree it can provide comfort particularly if the family physician knows the family and there is mutual respect.
My experiences with being present for this has always been very humbling and truly an honour. I do have to admit that it would be difficult to manage this if it were obligatory especially if travel distance is an issue. I most certainly feel honoured to be called when I have followed patients during their palliative course. Totally agree the death certificates need to be revamped.
I enjoyed reading the article on certifying death in the home. I have done this many times in the home setting for my own palliative care patients and those patients that are palliative in my call group.I find the families are very grateful. I do have a problem though when I am on call and a colleague’s patient dies “unexpectedly”. Often the Coroner will ask that I attend and fill out the death certificate. I find this difficult to do as I have no records to access on the deceased patient with often little information from family members who are often distraught. The deceased is usually fully clothed lying on the floor which makes an informed examination quite difficult. When I have done this in the past there are often multiple questions from the family that I am not able to answer. In these situations I believe that the Coroner should attend and then if he or she believes the death to be of natural causes then the Coroner should give permission for the body to be removed to the funeral home. The family physician of the deceased who would have the patients full history can then sign the certificate with the proper information at a later time.
I believe that if a family physician is able to provide palliative care and certify death, it will bring comfort for both the patient and the family. However, most of our doctors are already overworked and stressed, this cannot be obligatory.
I am a family physician who does a lot of home palliative care. My group of family physicians handles about 70 dying patients at a time in our community. We carry a beeper 24/7 so that we can handle queries from the supporting families. We do many housecalls for each patient. But we have the home care nurse pronounce death in the home when it happens and then we provide the death certificate to the funeral home. I wish we could attend to pronounce and perhaps we could but it would be an extra load on my group. I think our patients are satisfied with having the nurse do the pronouncing. It is because the nurses support us that allows more physicians to be interested in providing this care in the home.( perhaps we should study this question)
I have been happy to provide home care when needed and though it is an added stressor in my too busy life I will always be prepared to assist my patients and their families in this way.
However, I will not ever be a party to killing for any reason and would rather resign than be forced to do so. I see that when pain and suffering and exhaustion both physical and emotional set in that it almost seems like an option but like all other evils it is not the right thing to do.
Neither do I agree with the current push to force Mothers to consider abortion in their first or second prenatal visit by IPS screening. I think it is appalling. I work too hard to protect and preserve life and these policies are contrary to all I stand for.
Home care has been very poor to date for the elderly and sick and many of my patients flat out refuse to go to hospitals now no matter how sick because of the way are treated. They would rather stay home and take their chances. I think we can improve our hospitals by remembering why they were created in the first place: to provide a caring, safe,loving place for those too ill to be cared for at home and where nursing under the physician’s care was centralised. I think we have lost sight of this with goal. We have a disproportionate number of support staff eg.dietary and food and kitchen staff but neither the patients nor their relatives nor the physicians can get a healthy meal when they need it. We also have an enormous administration staff and offices and their budget and yet only one emergency room doctor on call serving a huge number and no beds to put the patients in on the wards.
I truly hope the leaders in our profession will support us who work so hard to do our jobs well and say no to killing under whatever euphemistic term it called.
I work as a physician as part of a palliative care team. I do this in consultation as well as for my own patients, when the need arises. This “cradle to grave” care (I also deliver babies) is always appreciated by my patients. They understand that I will not abandon them when they are dying, even if at home. They understand my commitment to ensure their death is as peaceful and meaningful as possible, that their time has as much quality as possible.
I often pronounce patients at home, but I am rarely in the home at the time of death. The agency nurses, usually grouped in teams doing mostly palliative care within their agency, are very helpful as my “eyes and ears” in the home. I still do home visits initially and as needed.
I feel the support for death at home makes it possible in our community.
Barriers to success include: occasionally, 60 hours of help a week from CCAC in the last 30 days is not enough help; there is no way to make a home death work well if the person lives alone, unless family or friends are available to essentially move in, as PSW staff are not allowed to give medications at all; we have an expected death at home package which the nursing agencies and funeral homes appreciate, but the local police and EMS have in the past few years chosen to ignore it and abandon the education previously done and instead insist on considering the home a crime scene until the coroner releases the body!; and lastly, a local hospice would essentially replace the need for those who don’t want to die at home to go into hospital.
I believe that the vast majority of Family Physicians in Ontario are overwhelmed and burned out by the excessive medical and administrative work load . It is not correct to oblige them to provide home death certificate . Because of the scarcity of other suitable professionals to assume this task in rural settings , the family physicians might feel morally more responsible to perform this task .But in my opinion it should always be a voluntary honor and never a duty for any Family Physician regardless of their work setting . Palliative care physicians or other properly educated & trained professionals are the most suitable for this task .
I agree that going to the home to comfort the family and certify death when you know the patient is a very important task. However in cases when the death is totally unexpected I am very uncomfortable completing a legal document requiring a specific diagnosis as cause of death. I feel this is the coroners role to attend and with their forensic skills establish the cause.
I think a family physician does have a role in certifying patient’s death at home. The difficulty is that it we would have to be on call 24/7 for this to work and as someone has already indicated, this is not financially compensated. More importantly, it would require a system where you could have a group of physicians linked so that when one is unavailable or away, there would still be the ability to see the family and patient.
I have been fortunate to have been part of this process for a few of my patients. I know the family have felt comforted to be able to ask questions and have someone they know involved. In many situations, it has allowed the patient to die at home rather than at an institution as family members may feel overwhelmed in the caregiver role without the comfort of their family physician. Especially when a patient wants to die at home, this allows the family to feel they have been able to fulfil their loved ones wishes and gives an overall sense of accomplishment and satisfaction.
I certainly do not feel this should be an obligation of physicians, but do hope that more family physicians would participate in the process, but we are often left on our own without support especially in managing a patient at home. A system of an interdisciplinary team approach with back up from a palliative care physician and perhaps chaplain and nursing support would enable more physicians to be able to provide this service.
Although not in the purview of the CPSO it would be helfpul to allow nurses (not just NP’s) to pronounce an expected death with the support of the FP. This is about team care and a palliative nurse who is known to the family may be more supportive than the FP. It is helpful to know we do not have to wait for the death certificate to move the body to the funeral home. It is very helpful to fill out the certificate in advance in palliative situations as this does allow for preparation. However, making a separate visit to confirm someone is no longer breathing especially if in a funeral home seems strange. I have and continue to provide this service to my patients. I believe our current training programs do not support home visiting and should be expected to include this. With our mobile culture, I have patients who are much too far away for home visiting to be practical. This is related to our system that allows patient choice in who they see regardless of geography and then the expectation that we are able to serve them at home.
This is not about end of life care! This is about professional responsibility. When I was a family doctor I would always respond to attend to a deceased patient of mine at their home. It was an honour and privilege, a comfort to the family, and my own way to grieve the loss. As a coroner, I understand, 1) yes the family doctor is paid poorly for the service, 2) yes, it can be dangerous, especially in the middle of the night. The answers? The coroner can help in allowing police to transfer the deceased to a funeral home where the family doctor can attend in safety and convenience. The coroner does not otherwise have to take the case and is not paid for this helpful service. The other option is to get out of family practice as I did. We tarnish the image of our profession by telling the public that we first expect remuneration for everything. I used to have to absorb huge costs not covered by government. If you can’t afford the work, get out, or fight for change. Leaving family practice sends a stronger message. This is but one reason we are now short of family doctors, but also why we and the government are forced into necessary reforms. Family physicians are now paid much better in comparison to when I left 12 years ago. Do your job!
Re end of life care.
I suggest that this concept has changed since the common use of laparoscopic surgery. Whereas someone who had a obstructve colon mass and was sent home on pallitive care the processof dying can be made much easier with a laparascopic removal of the mass and allowing a n observation period of the patient without the costs and implications of palliative care. I have 2 such cases who currently are still living up to 10 years after the event. In both cases was the patient told to go home and die. This decision is a poor one when they can still enjoy time on earth with their family.
I think the idea of attending at home to certify death is unnecessarily cumbersome. I practice in palliative care and almost all deaths at home are certified by the nurse on call through the care provider. I have seen all these patients numerous times over the weeks and months preceding the death so the families are well supported. We have worked through the dying process and reinforced what to do, using the end-of-life folder provided by the nursing service, several times. I complete the death certificate within 24 hours. I am not convinced that my presence in the home to pronounce death is necessary and as others have commented, makes caring for palliative patients more difficult than it needs to be. Pronouncing death is well within scope of practice for a competent palliative nurse.
Agree with last comment. Need to individualise. Definitely could be very important and welcome under right conditions. Needs to align with patient/family’s wishes. Would be most meaningful/helpful if the physician has been integral in patient’s care, and perhaps not as appropriate when the patient has not seen the family physician regularly or not an important relationship, or is just not welcome.
I am always thought that the emphasis on family physicians certifying death was setting the bar awfully low. What about the care that precedes the death; what about home visits in the weeks and months preceding death to help guide the individual and family through this challenging time in their lives. I think these are the lost opportunities, not the certification of death.
As a family physician I do not feel it is my role to certify death at home. It is not something I want to do and am uncomfortable doing. Perhaps the government or college can enlist those physicians who actually want to do this.
I don’t feel I would provide comfort, especially since I do not feel good about doing this.
It would make no difference to me if my family physician was there at a loved one’s death; actually would prefer them not to be.
I don’t want my doctor providing end of life care. Doctors are suppose to maintain life, not end it. Let another profession do end of life like hospice professionals. Can they be trusted to have the patients interests at heart. I don’t think so.
AgreeThe Hippocratic oath is clear, “do no harm”. The Bible is clear, “Thou shall not kill”. Contrary to what Dr. Low said, there is always a way to improve quality of life when things go downhill near the end. Palliative care is the solution.
AgreeTakes time from office. Poorly paid.
AgreeI am very concerned about the comments thus far. This is not a forum about physician assisted dying, this is a conversation about when someone dies (naturally and expectedly) at home, what should the role of family physicians be? I believe that the role of the family physician is to support patients during their entire life cycle – from birth until death. I have been privileged to be able to support families during this difficult time in their lives by coming to their homes at the time of their loved ones’ death. This removes the need of having to involve strangers and the coroner – which can all be very stressful and unnecessary. My one comment is that the home DNR forms need to be reassessed. They are currently a blanket one-size-fits-all format that lumps CPR together with intubation and pressors. The forms need to either be more narrow in their scope or require a tiered format, similar to the POLST program in the US.
AgreeCertifying death at home is an important gesture for the family at a difficult time.In the sum of an md’s care for a patient,this one act will be remembered by the patients loved ones.
AgreeAgree it can provide comfort particularly if the family physician knows the family and there is mutual respect.
AgreeMy experiences with being present for this has always been very humbling and truly an honour. I do have to admit that it would be difficult to manage this if it were obligatory especially if travel distance is an issue. I most certainly feel honoured to be called when I have followed patients during their palliative course. Totally agree the death certificates need to be revamped.
I enjoyed reading the article on certifying death in the home. I have done this many times in the home setting for my own palliative care patients and those patients that are palliative in my call group.I find the families are very grateful. I do have a problem though when I am on call and a colleague’s patient dies “unexpectedly”. Often the Coroner will ask that I attend and fill out the death certificate. I find this difficult to do as I have no records to access on the deceased patient with often little information from family members who are often distraught. The deceased is usually fully clothed lying on the floor which makes an informed examination quite difficult. When I have done this in the past there are often multiple questions from the family that I am not able to answer. In these situations I believe that the Coroner should attend and then if he or she believes the death to be of natural causes then the Coroner should give permission for the body to be removed to the funeral home. The family physician of the deceased who would have the patients full history can then sign the certificate with the proper information at a later time.
AgreeI believe that if a family physician is able to provide palliative care and certify death, it will bring comfort for both the patient and the family. However, most of our doctors are already overworked and stressed, this cannot be obligatory.
AgreeI am a family physician who does a lot of home palliative care. My group of family physicians handles about 70 dying patients at a time in our community. We carry a beeper 24/7 so that we can handle queries from the supporting families. We do many housecalls for each patient. But we have the home care nurse pronounce death in the home when it happens and then we provide the death certificate to the funeral home. I wish we could attend to pronounce and perhaps we could but it would be an extra load on my group. I think our patients are satisfied with having the nurse do the pronouncing. It is because the nurses support us that allows more physicians to be interested in providing this care in the home.( perhaps we should study this question)
AgreeThis should be planned by the attendinfg physician with the family
Agreei believe that presence of the family doctor at the time of death gives comfort to the family and it is an honour.
AgreeI have been happy to provide home care when needed and though it is an added stressor in my too busy life I will always be prepared to assist my patients and their families in this way.
AgreeHowever, I will not ever be a party to killing for any reason and would rather resign than be forced to do so. I see that when pain and suffering and exhaustion both physical and emotional set in that it almost seems like an option but like all other evils it is not the right thing to do.
Neither do I agree with the current push to force Mothers to consider abortion in their first or second prenatal visit by IPS screening. I think it is appalling. I work too hard to protect and preserve life and these policies are contrary to all I stand for.
Home care has been very poor to date for the elderly and sick and many of my patients flat out refuse to go to hospitals now no matter how sick because of the way are treated. They would rather stay home and take their chances. I think we can improve our hospitals by remembering why they were created in the first place: to provide a caring, safe,loving place for those too ill to be cared for at home and where nursing under the physician’s care was centralised. I think we have lost sight of this with goal. We have a disproportionate number of support staff eg.dietary and food and kitchen staff but neither the patients nor their relatives nor the physicians can get a healthy meal when they need it. We also have an enormous administration staff and offices and their budget and yet only one emergency room doctor on call serving a huge number and no beds to put the patients in on the wards.
I truly hope the leaders in our profession will support us who work so hard to do our jobs well and say no to killing under whatever euphemistic term it called.
I work as a physician as part of a palliative care team. I do this in consultation as well as for my own patients, when the need arises. This “cradle to grave” care (I also deliver babies) is always appreciated by my patients. They understand that I will not abandon them when they are dying, even if at home. They understand my commitment to ensure their death is as peaceful and meaningful as possible, that their time has as much quality as possible.
AgreeI often pronounce patients at home, but I am rarely in the home at the time of death. The agency nurses, usually grouped in teams doing mostly palliative care within their agency, are very helpful as my “eyes and ears” in the home. I still do home visits initially and as needed.
I feel the support for death at home makes it possible in our community.
Barriers to success include: occasionally, 60 hours of help a week from CCAC in the last 30 days is not enough help; there is no way to make a home death work well if the person lives alone, unless family or friends are available to essentially move in, as PSW staff are not allowed to give medications at all; we have an expected death at home package which the nursing agencies and funeral homes appreciate, but the local police and EMS have in the past few years chosen to ignore it and abandon the education previously done and instead insist on considering the home a crime scene until the coroner releases the body!; and lastly, a local hospice would essentially replace the need for those who don’t want to die at home to go into hospital.
I believe that the vast majority of Family Physicians in Ontario are overwhelmed and burned out by the excessive medical and administrative work load . It is not correct to oblige them to provide home death certificate . Because of the scarcity of other suitable professionals to assume this task in rural settings , the family physicians might feel morally more responsible to perform this task .But in my opinion it should always be a voluntary honor and never a duty for any Family Physician regardless of their work setting . Palliative care physicians or other properly educated & trained professionals are the most suitable for this task .
AgreeI agree that going to the home to comfort the family and certify death when you know the patient is a very important task. However in cases when the death is totally unexpected I am very uncomfortable completing a legal document requiring a specific diagnosis as cause of death. I feel this is the coroners role to attend and with their forensic skills establish the cause.
AgreeI think a family physician does have a role in certifying patient’s death at home. The difficulty is that it we would have to be on call 24/7 for this to work and as someone has already indicated, this is not financially compensated. More importantly, it would require a system where you could have a group of physicians linked so that when one is unavailable or away, there would still be the ability to see the family and patient.
AgreeI have been fortunate to have been part of this process for a few of my patients. I know the family have felt comforted to be able to ask questions and have someone they know involved. In many situations, it has allowed the patient to die at home rather than at an institution as family members may feel overwhelmed in the caregiver role without the comfort of their family physician. Especially when a patient wants to die at home, this allows the family to feel they have been able to fulfil their loved ones wishes and gives an overall sense of accomplishment and satisfaction.
I certainly do not feel this should be an obligation of physicians, but do hope that more family physicians would participate in the process, but we are often left on our own without support especially in managing a patient at home. A system of an interdisciplinary team approach with back up from a palliative care physician and perhaps chaplain and nursing support would enable more physicians to be able to provide this service.
Although not in the purview of the CPSO it would be helfpul to allow nurses (not just NP’s) to pronounce an expected death with the support of the FP. This is about team care and a palliative nurse who is known to the family may be more supportive than the FP. It is helpful to know we do not have to wait for the death certificate to move the body to the funeral home. It is very helpful to fill out the certificate in advance in palliative situations as this does allow for preparation. However, making a separate visit to confirm someone is no longer breathing especially if in a funeral home seems strange. I have and continue to provide this service to my patients. I believe our current training programs do not support home visiting and should be expected to include this. With our mobile culture, I have patients who are much too far away for home visiting to be practical. This is related to our system that allows patient choice in who they see regardless of geography and then the expectation that we are able to serve them at home.
AgreeThis is not about end of life care! This is about professional responsibility. When I was a family doctor I would always respond to attend to a deceased patient of mine at their home. It was an honour and privilege, a comfort to the family, and my own way to grieve the loss. As a coroner, I understand, 1) yes the family doctor is paid poorly for the service, 2) yes, it can be dangerous, especially in the middle of the night. The answers? The coroner can help in allowing police to transfer the deceased to a funeral home where the family doctor can attend in safety and convenience. The coroner does not otherwise have to take the case and is not paid for this helpful service. The other option is to get out of family practice as I did. We tarnish the image of our profession by telling the public that we first expect remuneration for everything. I used to have to absorb huge costs not covered by government. If you can’t afford the work, get out, or fight for change. Leaving family practice sends a stronger message. This is but one reason we are now short of family doctors, but also why we and the government are forced into necessary reforms. Family physicians are now paid much better in comparison to when I left 12 years ago. Do your job!
AgreeRe end of life care.
AgreeI suggest that this concept has changed since the common use of laparoscopic surgery. Whereas someone who had a obstructve colon mass and was sent home on pallitive care the processof dying can be made much easier with a laparascopic removal of the mass and allowing a n observation period of the patient without the costs and implications of palliative care. I have 2 such cases who currently are still living up to 10 years after the event. In both cases was the patient told to go home and die. This decision is a poor one when they can still enjoy time on earth with their family.
I think the idea of attending at home to certify death is unnecessarily cumbersome. I practice in palliative care and almost all deaths at home are certified by the nurse on call through the care provider. I have seen all these patients numerous times over the weeks and months preceding the death so the families are well supported. We have worked through the dying process and reinforced what to do, using the end-of-life folder provided by the nursing service, several times. I complete the death certificate within 24 hours. I am not convinced that my presence in the home to pronounce death is necessary and as others have commented, makes caring for palliative patients more difficult than it needs to be. Pronouncing death is well within scope of practice for a competent palliative nurse.
AgreeI believe that the family’s wishes should be stated. I am happy to attend at the death of one of my patients at home, should the family so desire.
AgreeAgree with last comment. Need to individualise. Definitely could be very important and welcome under right conditions. Needs to align with patient/family’s wishes. Would be most meaningful/helpful if the physician has been integral in patient’s care, and perhaps not as appropriate when the patient has not seen the family physician regularly or not an important relationship, or is just not welcome.
AgreeI am always thought that the emphasis on family physicians certifying death was setting the bar awfully low. What about the care that precedes the death; what about home visits in the weeks and months preceding death to help guide the individual and family through this challenging time in their lives. I think these are the lost opportunities, not the certification of death.
AgreeAs a family physician I do not feel it is my role to certify death at home. It is not something I want to do and am uncomfortable doing. Perhaps the government or college can enlist those physicians who actually want to do this.
I don’t feel I would provide comfort, especially since I do not feel good about doing this.
It would make no difference to me if my family physician was there at a loved one’s death; actually would prefer them not to be.
Agree