Turning Health Workers Into Tortoruers

Turning Health Workers Into Torturers, Dec. 20, 2007.

Last week, a judge reserved his decision and continued a temporary injunction to keep Samuel Golubchuk, an 84-year-old man with brain damage and multi-organ failure, hooked up to a ventilator and other life-support in a Winnipeg intensive-care unit. Mr. Golubchuk's doctors want to stop the ventilator, believing it to be futile. Mr. Golubchuk's family, citing their religious beliefs, want it to continue.

This case is the latest in a series of so-called "futility" cases that turn the right-to-die debate on its head. In the early right-to-die cases -- such as the famous 1976 case of Karen Ann Quinlan-- the patient or family want to stop treatment and the doctors want to continue. The Quinlan-type cases are straightforward: It is now widely accepted that patients, or the families of incapable patients, have the right to refuse life-sustaining treatment even if it results in their deaths.

In "futility" cases, like the Golubchuk case, the roles are reversed: Doctors and nurses want to stop treatment, but the family insists on continuing it. There is no consensus about these cases, and they are horribly complicated. They require striking a balance between the desires of families and the moral distress of health care teams.

Families feel they are protecting their loved ones' chance for life. The views expressed in regard to the Golubchuk case are typical: "When there is life there is hope. He is breathing, his brain functions, he holds their hands," the family's lawyer said. Unfortunately, as is often the case, we do not know what Mr. Golubchuk himself would have wanted.

Doctors and nurses feel they are being turned into torturers, forced to inflict painful procedures on patients who have no hope of recovery. They feel that they are violating their professional ethics, including the precept: "First, do no harm." For example, a nurse said she was appalled by Mr. Golubchuk's condition. He was retaining 45 litres of water, and his skin was swollen to the point of bursting. According to the nurse, "he was rotting from the inside out."

These cases are hugely distressing for health care teams because they feel they are being forced to act against their professional values. In 1999, I appeared as an expert witness in a similar case in Montreal. The case was so stressful that the lead intensive-care doctor had a cardiac arrest and died right in the coroner's court, and I found myself performing cardiopulmonary resuscitation rather than giving expert testimony.

In the 1980s, doctors and nurses tried to develop a precise definition of futile care-- for example, treatment that had less than a one in 10,000 chance of success. This approach broke down, however, when it was realized that the issue was sometimes not the quantitative chance of survival but the quality of life.

In the 1990s, we tried to deal with these cases by approaching them like conflicts in other areas of our lives. For example, I led a group of intensive-care doctors and nurses to develop a process of negotiation and mediation to try to find common ground between the health care team and families in cases where they disagree on the merits of continuing treatment. These processes often worked to defuse conflict and build common understanding; but not always, as the Golubchuk case shows.

While conflict about end-of life care between patients and families and health care teams is not uncommon, it is usually resolved locally. Conflict resulting in court battles gaining national attention occurs only about once a year. In these intractable cases, lawyers get involved because there is no middle ground. When he takes his decision, the judge in the Golubchuk case will need to be Solomonic.

The way forward in these cases is to acknowledge both the desires of families and the moral distress of health care teams. The family should be able to continue treatment, but the health care team and hospital should not be forced to provide care which they find morally and professionally distressing.

The family of Mr. Golubchuk should be given a period of time to find a health care team and hospital who share their belief that the treatment being provided is worthwhile. If they cannot, that should serve to inform them that rather than saving their father's life, they are prolonging his death.

Marni Soupcoff, National Post