Hassan Rasouli is at the centre of an ethical debate about who decides to withdraw life support when medical treatment is deemed futile. But it would be far better if hospitals devised a policy to make sure these questions are raised, long before patients reach such a tragic predicament.
Bedbound and dependent on machines, Mr. Rasouli, 60, sustained a brain infection after surgery for a brain tumour in October, 2010. Since then, he has required round-the-clock care, with machines breathing, feeding and hydrating him; medications maintain his blood pressure.
Two critical-care physicians, Brian Cuthbertson and Gordon Rubenfeld at Sunnybrook Health Sciences Centre in Toronto, see no medical purpose in keeping Mr. Rasouli on life support. They propose to shift him to palliative care – a recommendation with which the family disagrees. This matter has made its way through the courts.
An unexpected development has come in the form of a changed diagnosis: Mr. Rasouli is now in a minimally conscious, not a persistent vegetative state. And his medical case turns on whether he can communicate; a neuroscientist is conducting tests as part of a research project in order to determine if he is consciously aware but trapped in a paralyzed body.
This new diagnosis will alter the debate. It is difficult to make the case for withdrawal of life support when a patient has some awareness, even if the long-term prognosis is grim. These shifting facts do little to advance the doctors’ appeal to the Supreme Court of Canada, which is expected to be heard in mid-May. The Rasouli family’s lawyer has brought a motion to quash the appeal.
Across Canada, doctors have been on the front lines of such issues, trying to hold delicate end-of-life discussions with families and conducting research into how much treatment is too much in a patient’s last days.
Hospitals also have a strong role to play. They should consider creating a policy that requires health-care providers to discuss treatment options with patients booked to undergo an operation, procedure or intervention – especially one with risks to the brain – should a serious complication arise.
Eliciting values and treatment preferences before a critical illness strikes would help prevent tragedies – in which no one knows what the patient wants.