A hospital patient deemed vegetative is now able to make a "thumbs up" gesture – a sign to family that he is aware, but not yet strong enough to persuade doctors to drop a recommendation to withdraw life support.
The symbol marks a dramatic turn for Hassan Rasouli, 60, who until recently was in a persistent vegetative state. An affidavit filed with Canada's top court says he's now minimally conscious, and doctors' reports say he can "voluntarily control" certain behaviours – suggesting he may be aware but trapped in a paralyzed body.
This new diagnosis seems certain to inflame an already divisive ethical debate about who decides to withdraw life support. And it raises the discomfiting notion – the stuff of relatives' nightmares – of a patient being aware but unable to communicate when the machines are turned off.
"He is still there," Mojgan Rasouli, 29, said of her father who has been at Toronto's Sunnybrook hospital since October, 2010, after sustaining a brain infection after surgery for a brain tumour. "He can feel us and we can feel him."
The case before the Supreme Court of Canada was begun by two doctors from Sunnybrook Health Sciences Centre, Brian Cuthbertson and Gordon Rubenfeld, who saw no medical purpose in keeping Mr. Rasouli on life support and proposed shifting him to palliative care.
The affidavit, filed by Dr. Cuthbertson, chief of critical care at Sunnybrook, spawned activity in and out of the courtroom. Gary Hodder, lawyer for the Rasouli family, filed a motion to quash the appeal as moot. A leading neuroscientist, Adrian Owen, travelled to Mr. Rasouli's bedside at Sunnybrook on Tuesday, to conduct investigations to determine whether he can communicate.
His investigations come on the heels of a study he published in the medical journal The Lancet, revealing that 19 per cent of patients believed to be in an irreversible vegetative state showed signs of full consciousness when tested with an electroencephalography machine.
This is a murky area. Medicine is as much art as science, and sometimes even the most seemingly hopeless of patients experiences a change in condition. Whether Mr. Rasouli can communicate is a crucial question on which the medical case is expected to turn.
If he can, he "may be able to, or even capable of, expressing end-of-life wishes, such as whether to discontinue life support," said Mark Handelman, an expert in health-care law.
If he cannot, Dr. Cuthbertson and other treating physicians "remain of the view that the standard of care does not require continuation of mechanical ventilation given his condition," the affidavit says. It says Mr. Rasouli has also been diagnosed with other conditions, including spastic quadriplegia, which are extremely unlikely to improve in the long term.
Mr. Rasouli, a retired engineer, receives round-the-clock care: A mechanical ventilator does his breathing; a tube inserted into his stomach provides nutrition and fluids, while a catheter drains his urine. Medications maintain his blood pressure and he must be turned to prevent bed sores.
Sunnybrook neurologist Richard Swartz initially diagnosed him to be in a persistent vegetative state. But he noted things had "clearly changed" when he assessed Mr. Rasouli in late January, nearly 11 months from his last visit.
The patient was "consistently able to show a 'thumbs up' " to verbal requests, with his wife, Parichehr Salasel, translating to Farsi. "… Importantly, he has consistently shown visual pursuit, one of the earliest signs of MCS [minimally conscious state]"
Lawyer Harry Underwood, who represents critical-care physicians Dr. Cuthbertson and Dr. Rubenfeld, declined comment. Dr. Swartz could not be reached.
Mr. Hodder said the new diagnosis "changes the entire texture of the situation. We're now talking about someone who has some degree of consciousness."
Bernard Dickens, professor emeritus of health law and policy at University of Toronto, says if it turns out Mr. Rasouli is aware, his lawyers could argue that disconnecting him from life support would cause him moral anguish and could violate the "do no harm" oath of physicians.
For the Rasouli, family, however, this is important not only personally but for other patients facing the same painful issue.
"This could help other families, future patients," Ms. Rasouli said. "Maybe some families give up. Everything is possible."