Living and Dying in Manitoba

Recently, the Council of Canadians with Disabilities and the Manitoba League of Persons with Disabilities held a conference concerning the fact that in Manitoba, the College of Physicians and Surgeons have determined that doctors have the right to withdraw medical treatment without the consent of the person or the person's family.

Link to the Youtube video of the event. http://www.youtube.com/watch?v=5qEI-yqDw2A&feature=share

The presentation features Rhonda Wiebe, Jim Derksen from the Council of Canadians with Disabilities, Dean Richert lawyer and co-chair Council of Canadians with Disabilities - Human Rights Committee, and Valerie Wolbert & Catherine Rodgers - People First Canada.

This is the same power that the physicians in Ontario are seeking in the Rasouli case.

In the Rasouli case, the family sought a court injunction to prevent doctors from withdrawing the ventilator from Mr. Rasouli. Justice Himel decided that the family did not need a court injunction because consent was necessary before the ventilator could be withdrawn, and if the doctors could not attain consent they could bring the case to the Consent and Capacity Board in Ontario.

In Manitoba, the Golubchuk family sought an injunction to prevent doctors from withdrawing the ventilator from Mr. Golubchuk. Once again, the physicians stated that they had the right to decide to withdraw treatment, without the consent of the family.

These decisions are based on the values of the physician, who would have the sole right to decide whether or not the treatment or the patient's life is futile.

This is a very important issue for people with disabilities and other people who's lives are deemed to lack "quality of life." by the physicians.

Idaho imposes rationed care on its citizens.

On July 1, Idaho health care workers will gain the right to refuse end-of-life care that the worker considers objectionable. People with disabilities and the frail elderly need to be concerned.

There are huge ethical problems with futile care treatment decisions especially considering how modern bio-ethics are defining futile care treatment decisions.

David Irwin, spokerperson for the AARP stated to the media:

"Our members contacted their legislators by the thousands, and they moved forward with it anyway," Irwin said. "For our members to have their issue fall upon deaf ears was extremely problematic."

Heading into election season, Irwin said Idaho AARP has surveyed its 180,000 members (90 percent of whom vote regularly) to see which issues matter most to them.

Repealing the health care conscience bill is near the top of the list.

The only issue more important to Idaho AARP members is resolving Idaho's state budget problems."

I believe that health care workers should have the right to conscientious objection, but the new law in Idaho will create an inequality of care that will result in people with disabilities or other vulnerable people dying from a lack of care based on the discriminatory attitudes of individual health care workers.

Many people believe that the way to control the rising cost of health care, and the way to stop the practise of providing extra-ordinary, excessive and burdensome medical treatment is to ration it, whether the patient desires to receive it or not.

Governor Otter

Idaho Governor Butch Otter expressed reservations about the bill to Senator Brad Little. He stated:

"Forcing health care professionals to provide services they find morally objectionable is unacceptable; however, negatively impacting patients' rights - especially when it comes to end-of-life decisions - is equally problematic," Otter wrote. "I encourage the Legislature to revisit these issues and the definition of heath care service to ensure patients receive the care they may need with dignity and respect, and without imposing on the morals of a provider."

I agree with the Governor Otter, but I wonder why he didn't send the bill back for revision before signing it into law?

I believe that to always provide futile, extra-ordinary treatment or to withhold treatment based solely on the whether or not the medical care giver considers it objectionable represent two extremes. The ethical answer lies somewhere between both extremes.

I would suggest that medical treatment should be provided to someone unless the benefit of the treatment is minimal or the burden of providing the treatment is excessive. Further to that, any case, such as the Golubchuk case from Winnipeg, whereby the family has religious objections to withholding or withdrawing a particular medical treatment, that their religious freedom should be respected.

Terri Schiavo

Also, hydration and nutrition should never be considered to be medical treatment, but rather normal care. Therefore people should never have fluids withheld or withdrawn with the intention of causing that persons death by dehydration.

We have a lot to learn from our medical ethics heritage. The Hippocratic Oath stated: "Do No Harm". So long as we uphold the Hippocratic Oath we will be able to respect the needs of all patients while respecting the limits of medical treatment.

Link to the article in the CDA Press in Idaho: http://cdapress.com/news/local_news/article_443903c6-b7a4-5faf-929d-b66271b7115d.html

End-of-life guide a risk, MPs told

Jim Derksen

The following story appeared in the Winnipeg Free Press today. Rhonda Wiebe and Jim Derksen made a presentation in Ottawa to the Parliamentary Committee on Palliative and Compassionate Care yesterday. The focus of the presentation was the direction Canada needs to go to ensure dignity and equality for people with disabilities in relation to medical treatment and end-of-life care.

Wiebe and Derksen focused on the Manitoba College of Physicians and Surgeons policy that gives the physician the right to determine the level of medical treatment or when treatment will be withheld. This policy has significant ramifications for people with disabilities.

The article stated:

End-of-life guide a risk, MPs told

By Jen Skerritt - June 17, 2010

Giving Manitoba doctors the power to pull the plug on a patient discriminates against disabled people who may fall short of the minimum standards to remain on life-support, local advocates told a Parliamentary committee Wednesday.

Jim Derksen and Rhonda Wiebe, Winnipeg members of the Council of Canadians with Disabilities, said certain policies -- including Manitoba's end-of-life guidelines -- put disabled patients at risk of improper treatment because of common attitudes that "it's better to be dead than disabled." They spoke out in front of a federal palliative and compassionate care committee in Ottawa, and voiced their concerns about legalizing assisted suicide and other inequities in end-of-life care.

Manitoba's medical regulatory body is the first in Canada to introduce guidelines for physicians to follow when dealing with end-of-life issues. They say the minimum goal of life-sustaining treatment is for patients to recover to a level in which they can be aware of themselves, their environment and their existence.

In the event families and physicians don't agree life-support should be withdrawn, doctors have the final say.

Derksen said some patients with cognitive impairment or conditions such as dementia may not be able to articulate that awareness, forcing doctors to make a judgment call. He said there is no objective test or brain scan performed to determine whether a person meets the minimum standard to remain on life-support.

"In other words, if there's too much disability, the patient (does not) meet the minimum goal," Derksen said. "That, to me, is pretty wrong and probably unconstitutional."

His concerns over Manitoba's College of Physicians and Surgeons end-of-life guidelines come just shy of the second anniversary of Samuel Golubchuk's death. The 85-year-old man died in Grace Hospital on June 24, 2008, at the centre of a controversial debate over who should decide when a person is pulled off life-support. Golubchuk's eight-month battle to remain alive pitted a patient's right to continue treatment against Winnipeg physicians who argued continuing to care for the elderly man was "tantamount to torture." They said Golubchuk had no self-awareness and that their decision to terminate support is in no way biased against disabled persons.

The court injunction Golubchuk's children sought to keep him alive died with him, and the question of who gets to decide when someone dies hasn't been fully answered.

Winnipeg Regional Health Authority officials conducted a review of Golubchuk's case to shed light on how to better handle conflict between patients and physicians, but the report is still in draft stages.

A spokesman from the Manitoba College of Physicians and Surgeons was unavailable for comment Wednesday.

Wiebe said she's concerned some medical professionals could be swayed by a common stereotype that living with a disability is "miserable." She said there should be more supports in place within the medical system to ensure disabled patients aren't treated differently. Wiebe said she wants the public to know a disabled person's quality of life is as good as anyone else's.

"We see that as a human rights violation because if you are a person with a cognitive disability you may not meet that standard," Wiebe said. "It shouldn't be a medical decision."

Link to the article in the Winnipeg Free Press: http://www.winnipegfreepress.com/breakingnews/dont-give-mds-power-to-pull-plug-disabled-96545859.html

Golubchuk case sets precedent

The Golubchuk family have dropped their lawsuit against Winnipeg Grace Hospital, after their father, Samuel Golubchuk died a natural death on June 24, 2008.

Doctors at Grace Hospital had decided that it was futile to treat Golubchuk. They informed the family that they were planning to withdraw the respirator, fluids and food from their father against their wishes and the known beliefs of Samuel.

To read more about the Golubchuk case go to:
http://alexschadenberg.blogspot.com/2008/06/more-on-samuel-golubchuk.html

The Golubchuk family won a court injunction requiring the hospital to maintain life support until the matter could be decided by the courts.

Neil Kravetsky, the lawyer for the Golubchuk family stated that:
"the injunction set an important legal precedent even though the case didn't run its full course."

Kravetsky noted:
"In similar circumstances one can argue on the basis of this Court of Queen's Bench decision, ... other families can now point to the case to seek similar injunctions."

Commenting on the case going go to trial Kravetsky said:
"To be frank with you, that's most often where most people get to anyway. There haven't been any cases that I know of that got to trial."

Kravetsky commented on the lawsuit by saying:
"the claim is not being pursued because Golubchuk's death made the main point moot for the man's children. The family wasn't into the money. Their main concern was for their father's life."

Kravetsky noted that:
"Had it gone to the final hearing, the court would have made a determination on whether the injunction would continue indefinitely. Intrinsically that would answer who would have the final say (on who decides when to stop or continue medical care)."

Kravetsky outlined the purpose of the case:
"The point of this whole exercise from the family's point of view was two-fold. One was to save their father's life, but what, really, people missed and the media missed was not so much whether they were right or wrong, but whether we as Canadian citizens have a right to mke that decision."

Kravetsky concluded that:
"We'll be in big trouble if a final decision comes down at any time to say we don't have that right."

Link to the article:
http://www.winnipegsun.com/News/Winnipeg/2008/08/18/6486031-sun.html

Dis-Graced Winnipeg hospital seeks new name

Samuel Golubchuk died a natural death on June 24, 2005; at Grace Hospital in Winnipeg, only after his family got a court order to stop the doctors at Grace Hospital from pulling the feeding tube and respirator from Golubchuk, against his wishes and the consent of his family.

More information on the Golubchuk case: http://alexschadenberg.blogspot.com/2008/06/more-on-samuel-golubchuk.html

Comments after Golubchuk's death: http://alexschadenberg.blogspot.com/2008/06/samuel-golubchuk-dies-on-june-24.html

Grace hospital has now decided to seek a new name. This may be because of the media attention from the Golubchuk trial, or this may be because the Winnipeg Regional Health Authority has taken over control of the hospital from the Salvation Army.

The proposed names include:
St. James General Hospital
Sturgeon Creek General Hospital
Assiniboine Trails General Hospital
Winnipeg West General Hospital.

The Winnipeg Regional Health Authority is seeking input into choosing a new name.

The Grace Hospital has operated under that name for more than 100 years.

Go to the article at: http://www.cbc.ca/canada/manitoba/story/2008/07/15/grace-hospital.html

Samuel Golubchuk dies on June 24

On Tuesday, June 24, Samuel Golubchuk died a peaceful and natural death.

The death of Samuel Golubchuk needs to be remembered by the courage that his children Miriam and Percy had in defending his wishes and his faith.

Very few parents can say that their children would go this far to protect them.

The link to the Winnipeg Free Press Article:
http://www.winnipegfreepress.com/breakingnews/story/4190883p-4781717c.html

We still need to pressure the Manitoba College of Physicians and Surgeons to amend their Statement on Withholding and Withdrawing Life-Sustaining Treatment.

Judge Schulman stated in his decision to grant a temporary injunction from removing life-sustaining treatment from Golubchuk that the issue of "who decides" when removing life-sustaining treatment is not settled in law.

Jocelyn Downie stated on June 9th to a conference in Winnipeg Manitoba that doctors do not have the right to remove life-sustaining treatment against the wishes of the patient.

Downie stated that there is no legal precedent in Canada that gives doctors the authority to remove a feeding tube or issue do not resuscitate orders against a patient’s wishes.
http://alexschadenberg.blogspot.com/2008/06/manitoba-doctors-do-not-have-right-to.html

The Manitoba College believe that physicians have the right to decide when to withhold or withdraw life-sustaining treatment.

This needs to change.

Link to the College of Physicians and Surgeons of Manitoba Statement on Withholding and Withdrawing Life-Sustaining Treatment.
http://www.cpsm.mb.ca/statements/1602.pdf

Doctor offers to treat dying Winnipeg man

Finally there is some reasonable progress in the Golubchuk case.

Grace Hospital has a doctor who has agreed to provide medical care for Samuel Golubchuk. The other doctors who were attempting to put pressure on the system by refusing to provide medical care for Golubchuk will not have to be involved in the case and will not be in a position to refuse to provide medical treatment to the other patients.

There are several problems with the Golubchuk case.

The first concern is the lack of effective communication between the hospital and the family. An antagonistic relationship forced the Golubchuks to seek a legal recourse to a situation that was best solved by proper negotiation and mediation.

The second concern is the lack of respect for the particular moral beliefs of the orthodox Jewish community. By pressuring everyone to fit within one decision-making model they are creating a culture that will require other families who have particular moral beliefs to seek legal remedy when the physician or the hospital is unwilling to respect their beliefs.

Not everyone will make the same decisions that the Golubchuk family have made. Nonetheless, we need to respect the diversity of our nation and uphold the right of a family to defend the wishes of their family members when it comes to maintaining life-support.

Finally, there is a lot of propaganda connected to the Golubchuk case.

Arthur Shafer has been quick to deride the decisions made in the Golubchuk case and he has been willing to exaggerate the claims of Dr. Anand Kumar, who painted a worse case scenario in order to defend his decisions that the family has litigated against him.

We need to lower the tension and introduce a mediator to allow the family and the hospital to find common ground without the current hostility that has surrounded this case.

http://ca.news.yahoo.com:80/s/cbc/080618/canada/canada_winnipeg_doctor

Extra-ordinary Treatment vs Ordinary Care

This morning I was interviewed on CBC radio in Winnipeg Manitoba concerning the Golubchuk case.

I was asked what level of treatment constitutes ordinary care, and should be always provided, and what constitutes extraordinary treatment that is optional.

First: The Golubchuk case is unique because Samuel Golubchuk is an orthodox Jewish man who holds a distinct set of principles. I respect the Golubchuk family and I uphold their right to defend the principles that they and their father hold.

When people call me and ask specific medical questions I always differentiate between medical decisions that will be of benefit and carry a minimal amount of burden and those that provide very little benefit and may have a significant level of burden.

When a treatment is of benefit and the burden of the treatment is minimal then the treatment should be provided. When the treatment provides a minimal benefit or causes a significant level of burden then the treatment should be considered optional, based on the wishes of the person or their substitute decision-maker.

Basic care provisions, often referred to as ordinary care, should be considered obligatory. Basic care provisions include warmth, care, comfort, pain relief, fluids and food (unless it is physiologically impossible to provide, or the person is nearing death, or if its provision is a significant burden to the person) and other basic necessities of life. The respirator should not be considered obligatory but may be necessary for the continuation of life.

We must never cause death, but only allow death to occur.

Therefore we must reject any action or omission that directly and intentionally causes the death of a person. This is an issue of fundamental justice and equality.

You cannot allow one person to directly and intentionally cause the death of another person. This would give one person the power over life and death of another person. You can never control this and it will always result in a direct threat, by action or omission, of the lives of the most vulnerable.

More on Samuel Golubchuk

I was interviewed today by CBC radio in Manitoba concerning the Golubchuk case in Winnipeg.

It appears that the doctors are intentionally pressuring the system into a crisis in order to get their way and stop providing treatment for Samuel Golubchuk.

We need to remember that Samuel Golubchuk is an orthodox Jewish man. His family is defending their faith position by asking that nothing be done that would result in his death. I may not make the same treatment decisions as the Golubchuks but I respect the family's right to defend their father's wishes and his faith position.

Further to the issue of the physicians intentionally pressuring the system to reject treatment for Samuel Golubchuk, the legal system clearly gives the institution the advantage. Grace Hospital has hired, at taxpayers' expense, the best legal team in Manitoba to represent their position while the Golubchuk family are left to their own limited resources to protect the values of their father. Clearly, the system leans heavily towards supporting the hospital's agenda.

I am concerned that it is not possible to have a fair legal trial when the hospital has such legal advantages.

I am also very dissappointed with the fact that Grace Hospital has not provided a mediator for this dispute. Communication between Grace Hospital and the family has broken down. It is likely that other decisions may be possible if the family and the hospital could communicate in a non-confrontational manner.

It is also too bad that the physicians and Grace Hospital continue to refuse to respect the orthodox Jewish faith perspective of the Golubchuk family. The circumstances of this case are not common and require a special sensitivity to solve.

Golubchuk injustice

The Samuel Golubchuk trial is being moved to mid-September from its original date in mid-November.

Many people would rightly say that this case needs to be heard sooner rather than later.

The facts are that the original trial date was based on the reality that the legal counsel for the Golubchuk family was already scheduled for trial in September and unable to represent the Golubchuk family in trial at that time.

Several important witnesses for the Golubchuk family also indicated that they would be unavailable in September.

Therefore the original timing for the trial was based on the ideology that the family should have proper legal representation.

The injustice is clear.

The family who are fighting to protect the wishes and values of their father are being trounced on by Goliath, the health care system and all of its resources. The lawyer for the Golubchuk family was simply told to reschedule his other commitments or they would have to find another lawyer.

It is interesting that Grace Hospital was represented by a large team of lawyers from big law firms, while the Golubchuk family is represented by a lawyer who does not work for a major law firm.

Well, nonetheless, David did beat Goliath.

Manitoba doctors do not have the right to remove life-sustaining treatment against the wishes of the patient

Dr. Jocelyn Downie, the Canada Research Chair of Health Law and Policy said at a End-of-Life Ethics & Decision-Making conference at the University of Manitoba in Winnipeg today that doctors do not have the legal right to withdraw life-sustaining medical treatment against a patient’s wishes.

Downie stated that there is no legal precedent in Canada that gives doctors the authority to remove a feeding tube or issue do not resuscitate orders against a patient’s wishes.

Downie directly contradicted the statement of the College of Physicians and Surgeons of Manitoba who assert in their February 1, 2008 policy statement that a physician could unilaterally decide to remove life-sustaining treatment, including fluids and food, in certain circumstances.

The Statement said that even when a patient is likely to regain a level of self-awareness, that the physician could still withdraw life-sustaining medical treatment if the doctor has agreement from at least one other physician. If the family disagrees the doctor must seek agreement with the family, but if agreement cannot be achieved the doctor must give 96 hour notice before removing life-sustaining treatment, including fluids and food.

Downie said that the guidelines need to be revised because they go too far. Doctors can't medically determine whether a life is worth living.
http://www.winnipegfreepress.com/breakingnews/story/4184124p-4774196c.html

The comments made by Downie may also affect the case of Samuel Golubchuk, an orthodox Jewish man who’s family is seeking to have his life-sustaining treatment continued while Grace Hospital in Winnipeg is seeking to withdraw it.
http://alexschadenberg.blogspot.com/2008/03/response-to-college-of-physicians.html
http://alexschadenberg.blogspot.com/2008/05/new-york-doctor-to-testify-in-favor-of.html

New York Doctor to testify in favor of Sustaining Life Support for Orthodox Jewish Man

A neurologist from New York has agreed to testify as a medical expert on behalf of the family of Samuel Golubchuk an Orthodox Jewish man from Winnipeg Canada.

Dr. Leon Zacharowicz agreed to work on the case pro-bono after being contacted by Agudath Israel of America. Dr. Zacharowicz is planning to go to Winnipeg sometime this summer to examine Golubchuk himself in preparation for the trial that is currently scheduled for November 2008.

Dr. Edward Reichman, a leading expert and lecturer in the field of medical ethics stated that according to Jewish ethics "If a person’s life is dependent on the ventilator, the decision to take them off the ventilator would be equal to homicide"

Dr. Reichman further stated to The Jewish Star that "The overwhelming majority of rabbinic authorities maintain that it would be prohibited to remove the respirator, if that would lead to the individual’s death."

Dr. Reichman predicts that "This case could be a real test case. It could become a terrible trend if it gets pushed through. It would be a tragedy, definitely for Orthodox Jews, but also for other patients. If it gets passed in Canada, it can succeed in the United States as well."

http://www.vosizneias.com/16520/2008/05/28/winnipeg-canada-ny-doctor-to-testify-in-favor-of-sustaining-life-support-for-orthodox-patient/