Sunday, January 15, 2012

Canadian court to address end of life support

The Supreme Court of Canada will soon be taking up the issue of whether doctors need consent before taking a patient off life support. As reported here in The Globe and Mail:

The country’s top court has granted leave to appeal to the doctors of . . . a man who has been in a coma at Toronto’s Sunnybrook Health Sciences Centre since October, 2010. His doctors diagnosed him as being in a “permanently vegetative state” and recommended he be taken off life support, but his wife and substitute decision-maker . . . strongly opposed. Now the doctors have turned to the Supreme Court in hopes of disconnecting Mr. Rasouli from the medical machines that are keeping him alive.

The outcome of the case could set a national precedent on protocol for end-of-life care when physicians and families don’t see eye-to-eye. The issue is fraught: Medical technology can now keep patients technically alive, so their loved ones sometimes keep them connected to machines for months or years, even when doctors advise against it.

As it stands, all provinces but New Brunswick require consent from the patient or substitute decision-maker for medical treatment, and Ontario is the only one with a tribunal that makes decisions on a patient’s behalf.  

Of course, the ideal is for the patient and family and doctor to have talked through such matters in advance, but where that has not occurred, a clear legal standard will come in handy.

In my former hospital, we had a procedure in place for those instances in which a doctor felt that a patient or family was demanding a harmful or ineffective treatment.  But as I re-read that policy today, it seems to be focused on the initiation of such treatment.  I am not sure whether it should or could apply to the withdrawal of treatment, i.e., the kind of case being considered here by the Canadian court.

I think, too, in the United States, that these would be matters of state, and not national, jurisdiction.  Perhaps readers who are more familiar with the various states' laws on these issues will provide us all with the benefit of your comments.


Bruce Ramshaw said...

These are typically very emotional and complex situations. I believe these disagreements between the family and the physician would be much less common if we had more patient and family-centered care teams who developed loving relationships with patients and, in this case, families. Within the care teams, it is usually not the physician who would develop the most intimate relationship with the family. These non-physician care givers can develop trust and provide significant emotional support for families in end of life situations like this. I say this as a surgeon who has been involved in end of life situations over a 17 year career and who has worked as a part of a patient-centered care team for over six years. I believe that these kinds of issues would almost always be managed more efficiently and effectively within a care team than relying on the individual physician practice model (augmented by hospital policy and the legal system) that is most prevalent today.

Paul said...

On my own standpoint, it's really up to the relatives' decision whether or not to pursue or not to pursue life support. If the family can afford it then why not continue it? Losing someone is had and I think all people are scared of it. Let's just give them the time they needed until they have fully decided.

Paul Levy said...

In Canada, and in many cases in the US, the cost is not paid by the family. It is paid by the government, i.e., the broad base of taxpayers. Does that affect your answer?

Susan Shaw said...

What about the other costs incurred when care is provided to a person who will not/cannot receive the intended benefit? I'm talking about the pain and suffering experienced by the patient, the fallout from false hopes for the family, and the moral distress and resulting increase in burnout in the caregivers.

I don't think we can eliminate conflict over care decisions, but I do think can prevent it most of the time, and, when it does occur, manage it better than we currently do. Dr Ramshaw presents one of many strategies that should be examined and considered. It's certainly been my experience that having families join me and the full ICU team on our daily rounds has decreased misunderstanding on both the parts of the families and the caregivers.

LA said...

What about the state laws in effect like the Texas Futility Statute and the Froedert Policy at that institution in Wisconsin? If patients do not have a living will or designated a health care proxy and have not or were not able to discuss their wishes with their physician, their caregivers must be aware of any state or hospital policies which exist. Although not always feasible, patients may be transferred to another facility which will accept the patient and provide care as the patient/caregiver prefer.
Having just reviewed these issues in a Health Law class, I found some state statutes the most troubling and difficult to accept.

Barry said...

As an internist/intensivist working in the Ontario health services system for almost 20 years, I'd like to add a couple of my own comments in respect of the issues raised in the Globe and Mail article cited in your blog, below.

Much of this very contentious debate revolves around varying definitions of key terms and concepts such as "benefit", "harm", "burden" and even "dead" and "alive". Care-providers and care-receivers can have very different interpretations of these terms. These broad semantic gaps are not easily bridged...even by legislation.

We in Ontario do indeed have bodies (tribunals) that can intervene in an assistive manner in some of these cases. The Consent and Capacity Review Board can determine if a particular patient has the capacity to make healthcare decisions for him or herself and it can determine if a patient's or a substitute decision maker's (SDM) advance directive is reliable or not.

In addition we have the "Office of the Public Guardian and Trustee" which has the power to step in and make healthcare decisions on behalf of an incapable patient where there is no other capable SDM or where the SDM is making decisions that are found, by way of a rarely invoked and cumbersome medical/legal/ethical process, to be materially inconsistent with the best estimate of the patient's wishes.

When I was at Harvard around the time of your last Federal Election I heard a fair bit about the mythical "death panels" that we in Canada were alleged by some to have here. I need to make sure that you know that such things simply do not exist here.

The issues that are brought into sharp relief by the Rasouli/Sunnybrook case have been festering in critical care units for many years. These issues are among the nuts and bolts of any critical care professional's practice and can be the most harrowing, disheartening and deflating for all providers of critical care services, not just physicians. The conflicts arise from a white-hot blend of scientific, ethical, legal, religious, cultural, financial, and even personal and professional issues. As such, it is very difficult to imagine a ruling, even from so august a body as our Canadian Supreme Court, that will lead to a real resolution.

That said, clarity from lawmakers will certainly be helpful, at least to one side of the debate or the other, and will be heard far beyond our Canadian borders.