JULY 2008


End-of-life war outlives Golubchuk

At stake is MDs' right to decide on withdrawal of care

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On June 24, after seven and a half months on life support in a Winnipeg ICU, Samuel Golubchuk, the 84-year-old man made famous by the lively court battle he sparked, died.

The uncomfortable legal and eth-ical questions to which his case gave rise, however, continue to threaten doctors' authority in end-of-life dec-ision-making.

Not long after Mr Golubchuk was admitted to the Grace Hospital ICU with pneumonia, physicians told his Orthodox Jewish family there was no point in keeping him on a respirator and feeding tube — his chances of recovery were zero percent, they said. But the family refused on religious grounds. Doctors told the family they planned to unhook him anyway. The family decided to take them to court.

That's when things really got ugly. International media picked up the story and a right-wing American group dubbed Mr Golubchuk "Canada's Terry Schiavo." On February 13, a Manitoba judge sided with the Golubchuk family and extended an interim injunction preventing doctors from withdrawing care until a full trial could be heard in September.

As days of waiting for a resolution turned into weeks, and weeks into months, the ICU physicians' discomfort with providing "useless" and potentially painful treatment grew. Three of them — Drs Anand Kumar, David Easton and ICU director Bojan Paunovic — announced in May and June they could no longer ethically justify treating Mr Golubchuk.

"If we honestly attempt to follow the court mandate to focus on keeping Mr Golubchuk from his natural death, we will likely have to continue to surgically hack away at his infected flesh at the bedside in order to keep the infection at bay," Dr Kumar wrote in May, calling further treatment "tantamount to torture." "This is grotesque. To inflict this kind of assault on him without a reasonable hope of benefit is an abomination. I can't do it."

"Suddenly I have been faced with an almost impossible decision," Dr Easton wrote in a letter to the Winnipeg Free Press. "Do potential legal consequences and threat of 'jail' take precedence over my duty to not inflict further harm to the patient?" He decided they did not.

The three doctors refused to provide any more care for Mr Golubchuk or do further critical care rounds, prompting warnings from the hospital's chief med-ical officer that the hospital's ICU might have to be shut down because of understaffing. A new physician was found to care for Mr Golubchuk, but soon after he died "of natural causes."

Along with Mr Golubchuk, most of the lawsuit is now dead. It is unclear whether any of the elements of the case — for instance, seeking damages from the doctors and the hospital — will continue. In the meantime, because the doctors never succeeded in removing Mr Golub-chuk's respirator and feeding tube, the Golubchuk family has claimed victory.

"We won the injunction," the family's lawyer, Neil Kravetsky, told NRM. "That is a precedent. There are no others in this kind of case. So people who are faced with what Samuel Golubchuk's family was faced with, they know there is something to rely on in the future."

Not everyone agrees. "At the human level I think one has to feel relief for Mr Golubchuk, because he was not in a vegetative state but in a near-vegetative state — he was feeling pain and discomfort," says Winnipeg bioethicist Arthur Schafer, PhD. "But on the other hand we won't have a court ruling that will clarify the situation."

The Manitoba College rushed out guidelines earlier this year to assert doctors' right to the final say, regardless of families' opinions — a position that Dr Schafer supports. Mr Kravetsky calls the guidelines "the most insensitive, hypocritical, unfeeling document I have ever read."

"We need resolution on this issue," one of the three doctors who resigned told The Globe and Mail anonymously. "These cases are just occurring over and over again."



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