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The men who would not die
Zongwu Jin, aged 66 Mr
Jin of Calgary was admitted to Foothills Provincial
General Hospital after he fell and hit his head.
His condition worsened to the point that treating
physicians decided resuscitation attempts would
likely be fruitless. The family initially agreed
to the recommended course of treatment but then
had second thoughts and wanted to bide their time
in anticipation of the arrival of Mr Jin's son
from China, an independent medical assessment
and a meeting with the hospital's ethics committee.
So they asked the court to ensure Mr Jin would
be treated in the meantime. Justice Martin acquiesced.
Mr Jin is now up out of bed and walking, apparently
on his way to a full recovery.
Samuel Golubchuk, aged 84
The Manitoba man was admitted to Grace Hospital
in Winnipeg in October with pneumonia and pulmonary
hypertension. He had suffered a brain injury in
2003 from a fall, for which he had part of his
brain removed. His condition deteriorated rapidly
while in hospital and doctors told the family
they wanted to take him off life support on November
30. The family refused, saying this goes against
their Orthodox Jewish faith. An injunction over-ruling
the doctors was granted while the court decides
Mr Golubchuk's faith. On January 11, the judge
heard that Mr Golobchuk had improved, regaining
some neurological function and was classified
on his chart as "awake."
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Two recent Canadian end-of-life
cases have pitted doctors against their elderly patients'
families. The courts have granted the families injunctions
in both cases, Zongwu Jin in Calgary and Samuel Golubchuk
in Winnipeg (see "The men who would not die," right),
prompting a warning from the Canadian Medical Association
that the authority to determine medical care is shifting
physicians to lawyers.
These cases have also shone a light
on the void where many say coherent end-of-life decision
making guidelines should be.
WHO'S
THE BOSS?
"If the [Golubchuk] case goes against the hospital on
the grounds that once you plug in you can't unplug,
I think people will be a lot slower to plug in, and
some people may die who should have been plugged in,"
Arthur Schafer, director of the University of Manitoba's
Centre for Professional and Applied Ethics told the
Globe and Mail. "So the social implications of
a victory for Mr Golubchuk, his children and their lawyer
would, I think, make Canadian hospitals deviate from
good medical ethics."
But are doctors best placed to
make these decisions? Jocelyn Downie, PhD, a lawyer
at the Health Law Institute at Dalhousie University,
isn't convinced. "These decisions are frequently moral
ones not medical ones, or are at least medical and moral,"
she argues. "I don't believe that physicians have special
knowledge or skills in terms of assessing what's in
the best interests of patients. They have medical information
and skills that are essential for the substitute decision-makers'
decision-making, but their information and skills are
not sufficient."
POLICY
VOID
Canadian healthcare institutions have a total lack or
"staggering range" of policies surrounding the withholding
and withdrawal of treatment, Dr Downie wrote in the
Journal of Palliative Care, adding that, unlike stem
cell research or nanotechnology, CPR and life-sustaining
technologies are not new, so there is really no excuse
for the neglect of policymaking.
Physicians never were compelled
to try to revive Mr Jin against their better judgement,
but that doesn't change the fact that the court decided
they would have been obligated to, say lawyers for the
Calgary Health Region which has decided to appeal the
decision.
The limited scope of the injunction,
Mr Jin's eventual recovery and the fact that the judge
posed, but did not actually confront the question of
decision-making authority likely mean Alberta's court
of appeal won't bother hearing the CHR's case.
At least one physician involved
in the case has been very vocal about his stance. Dr
Tom Stelfox, a physician in the Department of Critical
Care at the University of Calgary, co-wrote an editorial
in the November 20 CMAJ condemning the hodgepodge
that stands in for clear care-and-capacity guidelines.
Dr Stelfox proposes "an explicit
national standard mandating the inclusion of patients'
families and caregivers in the decision-making process"
and consent legislation that includes guidance on the
withholding and withdrawal of treatment.
Consent legislation or not, the
College of Physicians and Surgeons of Manitoba issued
an end-of-life policy statement on January 30. The policy
enshrines physicians' decision-making authority and
ensures that if patients or their families want to contest
those decisions they will have adequate time to appeal.
"The policy may make things complicated
for doctors at certain times," College president Dr
Bill Pope told NRM, "but at least it gives them
a framework under which to operate."
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