The Rasouli case before Canada’s highest court on Monday is very relevant to Canadians because approximately three quarters will die in hospital, many while receiving critical care treatment in an intensive care unit. Although the advanced forms of artificial life support provided in the intensive care units can be life-saving; when an underlying illness is irreversible, the extended use of critical care can unnecessarily prolong suffering.
A critical illness may arise unexpectedly – such as after a motor vehicle crash, severe infection or after major surgery. More often a critical illness represents a complication of a serious condition that has been slowly progressing over the years. Both situations are highly stressful and emotionally challenging. Indeed these stresses can have both short-term and often long-term consequences to both patients and their families. We are learning that recovery can take years to achieve, but for many, the physical and mental disability is permanent. Sadly the most susceptible – patients with pre-existing medical conditions or the elderly – may never return to their baseline level of function. These patients frequently require more assistance with care and suffer a loss of independence and erosion into their quality of life.
As with any aspect of medical care, the decision to offer a treatment is based upon the relative benefit to potential harm. We hope that the questions placed before the court facilitate awareness about the importance of having a realistic discussion about the capacity of medical and surgical treatments to treat disease. Too often invasive, painful and ineffective tests or treatments are continued that are not providing benefit. In this regard, both physicians and patients are losing an opportunity to focus more upon the control of symptoms (pain and suffering) and the opportunity for important conversations, last wishes and thoughts, and a chance for the patient to reflect and achieve a state of peace and calmness.
We also hope that this case will reduce the misunderstanding about the role of palliative care in treating patients. Many care-providers, patients and families erroneously make a distinction between palliative care and active medical treatment. Regrettably, many view palliative care as “giving up.” This is a misunderstanding of what palliative care can do for a patient. Palliative care is a continuum throughout the patient’s journey and applied to relieve pain and suffering – a goal that is always present in any treatment plan and is a basic human need. Early in a chronic condition the relative balance is towards traditional “active” treatments, however, as the disease progresses treatment starts to appropriately focus on relieving pain and suffering and meet the needs of the patient and allow them to meet their goals. The most important goals rated by patients include a desire to be with family, participate in their decision-making, make peace with their god and not to be a burden on their families.
Far from hastening death, a recent study in cancer patients, suggests that the early introduction of palliative care treatments at the time of the diagnosis of cancer lead to improved outcomes – including better survival. Therefore, palliative care should be an integral part of any treatment plan. Embracing a comprehensive treatment plan that is reflective of changes in their health and based upon their values as opposed to separating each medication, surgery or treatment into its elements will serve to help a patient to meet their goals. Ultimately this strategy will afford them the dignity, and freedom from suffering that is a basic human and constitutional right.
The Canadian Critical Care Society hopes that the question before the Supreme Court of Canada will provide clarity about these important aspects of care and will encourage an honest, frank and realistic discussion about the goals of care between patients, their families and their doctors.
Claudio Martin is president and John Granton is past-president of the Canadian Critical Care Society.