Medical Fallibility and End-of-Life Care decisions

Hassan Rasouli

The Winnipeg Free Press editorial on Saturday, April 28 looked at the issue of Medical Fallibility in relation to End-of-Life care decisions and the Rasouli case under the title: Consider Medical Fallibility. The editorial points out that Hassan Rasouli, who was deemed to be in a PVS state, is now responding on command by giving a "thumbs up." The article also points out that a study done by Dr Adrian Owen examined 16 patients who were deemed to be PVS and found that 5 were cognizant.

The article stated:

Science and technology have improved our understanding of the body, illness and injury, but art -- a physician's experience that helps interpret symptoms of disease and disability -- still plays a huge role in medicine. The diagnosis and prognosis of a patient who appears to be in a persistent vegetative state is a good illustration of the limitations of medical art and science. 

Last fall, neuroscientist Adrian Owen, based at the University of Western Ontario, co-wrote a study published in the Lancet of 16 patients deemed to be in a persistent vegetative state -- a condition in which people on life-support exhibit no sign of being aware of themselves or their environment. The study used a new method of tracking brain activity through electroencephalography; three patients repeatedly responded appropriately to commands. Almost 20 per cent of the group classified as essentially brain-dead appeared to be cognizant, the paper asserted. 

The finding could have broad implications. Medical methods to distinguish those who are vegetative or who, in fact, are in a minimally conscious state are imprecise. Doctors insist they are best-placed to decide when it is appropriate to turn off life-support, which sometimes leads families to pursue court action to maintain the intervention. 

For Torontonian Hassan Rasouli, 60, the study's findings are personal. Mr. Rasouli has been on life-support since late 2010. His doctors believe it is time to disconnect the ventilator and move him to palliative care and are fighting for the legal authority to do so. 

But Mr. Rasouli, other doctors say, is responding to commands, including giving the "thumbs-up" sign. Dr. Owen has been called in to see if the man can communicate. 

Across Canada, hospitals and physicians' groups have written guidelines for deciding when to withdraw life-support to those deemed to be in a vegetative state. The Manitoba College of Physicians and Surgeons has a detailed process for informing families of such discussions, decisions and the appeals available. Ultimately, the court is the final arbiter, a difficult solution, but the best available. 

Dr. Owen et al indicate medical science, which has some way to go yet in diagnosing the injured brain's limitations and potential, may yet offer a better way to settle such disagreements. And, as one legal expert noted, if the diagnostics determine a patient is actually in a minimally conscious state, at least he then may have a chance to express his own opinion about whether it is time to move to the palliative ward. 

Republished from the Winnipeg Free Press print edition April 28, 2012 A18

The Euthanasia Prevention Coalition successfully intervened in the Rasouli case at the Ontario Court of Appeal and EPC has applied for intervention standing in the Rasouli case at the Supreme Court of Canada. The Rasouli case concerns the question - Who has the right to decide to withdraw life-sustaining medical treatment. The doctors at Sunnybrook hospital say that they can withdraw life-sustaining treatment without needing consent. The lower court and the Ontario Court of Appeal unanimously decided that the doctors were required to obtain consent before withdrawing life-sustaining medical treatment.