The Supreme Court of Canada was right when it agreed to hear the case of a patient on life support, despite shifting medical facts. In doing so, it is expected to provide much-needed guidance on end-of-life treatment.
The issue – who decides – has been a divisive, emotional one. Giving doctors unilateral decision-making power seems extreme, yet it is equally perverse for families of incapable patients to insist upon costly interventions of no medical benefit and some potential harm.
The absence of direction has left a policy vacuum, and potentially treatment vacuums in Canadian hospitals. Will physicians hesitate to start trials of therapy in critically ill patients if they think they cannot withdraw them when later deemed futile?
To answer the question of who decides, two critical-care physicians, Brian Cuthbertson and Gordon Rubenfeld of Sunnybrook Health Sciences Centre, have taken their case to Canada’s highest court. They say there is no medical purpose in keeping Hassan Rasouli on life support and have proposed shifting him to palliative care.
The 60-year-old retired engineer has been at that Toronto hospital since October, 2010, when a brain infection incurred after surgery for a brain tumour left him in a persistent vegetative state. After that, he received round-the-clock care, with machines doing all the things he can’t: breathe, hydrate and nourish.
Then, unexpectedly, his diagnosis changed. He is now in a minimally conscious state – able to make a “thumbs-up” gesture – in responding to verbal requests, with his wife, Parichehr Salasel, translating to Farsi. Efforts are now being made by doctors to determine if he is capable of communication.
This dramatic development threw the case in doubt, and the Rasouli family filed a motion to quash the appeal as moot. The court disagreed, deciding to hear this landmark appeal in December.
Mr. Rasouli may not be the ideal case on which to base the discussion, but the Supreme Court, which is comfortable with policy and broad principles, is best positioned to hear it. Greater direction is urgently needed.
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