Death was a battle

Hey there, time traveller!
This article was published 28/12/2008 (6283 days ago), so information in it may no longer be current.

111But his eight-month battle did just that. His Orthodox Jewish beliefs were pitted against Winnipeg physicians who argued that continuing to treat the elderly man was “tantamount to torture.”

It captured headlines across the globe, and sparked public debate about how patients in their final stages of life should be treated.

Golubchuk died June 24, just days after his children Miriam Geller and Percy Golubchuk sang to him in the Grace Hospital intensive care unit to celebrate his 85th birthday. 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.

Six months after his death, the medical system is still abuzz — health officials are only halfway through a review of Golubchuk’s case that they hope will shed light on how to better handle conflict between patients and physicians. An independent arbitrator is an option they might consider.

Miriam and Percy aren’t included in that review and said physicians brushed off their concerns the first day their father was admitted in the ICU. They allege the medical system failed, and set a dangerous precedent for patients and families.

When doctors and patients clash, Percy said, patients’ rights are overruled.

“The main issue is human rights, and freedom of religion,” he said.

Golubchuk was admitted to the Grace Hospital ICU in October 2007, suffering from pneumonia and pulmonary hypertension. He was put on life-support Nov.3. Within a week, doctors said further treatment of Golubchuk would be futile. His children disagreed.

Golubchuk’s children said their father was still responsive — he couldn’t speak, but he was awake and would squeeze their hands, blink and twitch his feet. Doctors said these were reflexes, and that Golubchuk had no hope of recovery or quality of life.

Critical care specialists Drs. Anand Kumar and Bojan Paunovic said Golubchuk had no self-awareness and that their decision to terminate support is in no way biased against disabled persons.

“The fact is that a very large portion of patients admitted to every ICU are disabled in some way,” said an e-mail statement from the doctors.

“Will the ICU stay result in survival or hospital discharge? If not, then all we are doing is extending the process of someone’s death.”

It was a story his children had heard before.

Five years earlier, Golubchuk suffered a brain injury when he fell, but he could still communicate and understand. Miriam said she remembers being told her father would have no quality of life, which turned out to be untrue — she and her brother were able to take him bowling, to bingo, and even to the casino.

Golubchuk’s children said communication with hospital staff ended the moment the two sides couldn’t agree.

No patient advocate, ethicist or mediator was brought in to facilitate discussion between physicians and Golubchuk’s family.

Miriam and Percy got a lawyer who advised them a court injunction could stop doctors from withdrawing their father’s life-support. Friends described Golubchuk as a man of unwavering faith who kept kosher even as a young soldier in the Second World War.

His children said no one should be able to dictate when someone dies.

“We didn’t have any say in the matter,” Percy said. “That’s why we had to go to court.”

Justice Perry Schulman of Manitoba Court of Queen’s Bench set a new precedent when he ordered hospital staff to do everything necessary to keep Golubchuk alive.

It was a victory for Golubchuk, and a blow to some medical professionals who were outraged they may have to undertake treatment they thought would cause undue suffering and harm to a frail man on the verge of death.

Kumar and Paunovic call the judge’s initial decision “illogic” since it forced doctors to continue treatment based on the fact that doctors started life-support in the first place. After several weeks of assessment in the ICU, the doctors said there was enough evidence Golubchuk would never recover.

“It was the refusal of any other physician to accept the patient in transfer that forced the WRHA to arrange a form of therapy never previously offered at Grace, an arrangement that is unique in the history of the hospitals in the city,” the doctors said in an e-mail. “Patients requiring such support are normally transferred to either HSC or St. Boniface hospital.”

111Golubchuk’s children suspect the statement was timed to legitimize the argument made by Grace Hospital staff and to sway public opinion against them.

Dr. Brian Postl, CEO and president of the Winnipeg Regional Health Authority, said the court decision put the health-care system and some medical staff in a stressful and “uncomfortable” position.

“Certainly the judicial involvement was a precedent, since there was a court injunction saying things had to continue that, quite frankly, were quite difficult to continue,” he said. “How many more interventions were undertaken that might not have been without the legal injunction and what impact did that have on staff and other resources?”

Things turned heated when critical care specialist Kumar resigned from Grace Hospital, saying continuing to treat Golubchuk’s deteriorating condition was a grotesque “abomination.”

His resignation letter, read aloud in court in a bid to persuade the judge to move Golubchuk’s trial up by two months, painted a disturbing picture of medical staff forced to surgically “hack away” at Golubchuk’s infected flesh.

Two more specialists — Paunovic and Dr. David Easton — followed suit, leaving the community hospital intensive care unit short half their physicians.

Physicians said treating the ailing man would go against the medical principle of “do no harm,” and all three refused to cross the ethical “line in the sand.”

Golubchuk’s children said the allegations that their father was covered in bedsores was a lie. Miriam alleges doctors spoke publicly about their father’s condition to vilify their crusade.

On their daily visits to the ICU, “it was like you had the plague. You get these dirty looks from the doctors, from the nurses,” she said. “It didn’t make us feel very good.”

Complicating matters was the fear that cases like Golubchuk’s could strain limited health-care resources and take critical beds from patients with a chance of getting better.

“Clearly if this kind of thing were to be a frequent event it would have an impact on our capacity to care for others who have needs or arrived after our resources are tied up,” Postl said.

Two intensive care beds at the city’s biggest trauma centre had to be closed so nurses could scramble to Grace to provide Golubchuk with kidney dialysis.

Health officials have said it costs about $2,200 a day for a patient to be cared for in an ICU. That means Golubchuk’s stay in hospital may have cost more than $450,000.

Miriam said doctors were unabashed in telling the family their father would be a drain on the short supply of beds and money the region needs to treat other patients. She said everyone who wants medical treatment should be entitled to receive it.

111The college’s statement has a clause naming court as a place where doctors and patients could settle end-of-life disputes. Pope said legislation would likely be too broad for any specific patient case and the dispute would wind up in court anyway.

However, he admits that most patients who are gravely ill would die before their case goes to trial, making a court ruling on the matter unlikely.

“Often in these situations the patient does die before it can be resolved,” Pope said.

There are no Canada-wide guidelines on withdrawing life-support, but four years ago the Law Reform Commission released a report saying the Manitoba health-care system needed to establish clear and uniform guidelines. Other jurisdictions, like Ontario, have a Consent and Capacity Review Board established to deal with end-of-life cases quickly. Instead of waiting months for a court trial, a three-member panel is convened within a week. They hear both sides, try to mediate and if no compromise can be reached, the panel makes a ruling.

In the end, Golubchuk won.

He died on his terms and opened the door for other patients to seek court injunctions if they disagree with a doctor’s decision.

Postl said that’s a concern, too, particularly since those conflicts could spill over into other areas of medicine. He wonders if a doctor tells a patient he has an inoperable brain tumour, could someone seek an injunction to force a surgeon to operate?

One medical source, who wanted to remain anonymous, said the heart of the debate surrounding Golubchuk wasn’t really about end-of-life issues at all — it was about the inability of doctors to communicate with patients. Instead of conducting internal review and promising to do better, the source said the WRHA needs to get at the root of the problem and determine why a communication failure spiralled to extremes.

“If the WRHA wants to do something interesting, innovative and bold, they would look at this as a system failure,” he said.

“It’s really about figuring out why the plane crashes — not how to do better next time. Doctors and patients — why can’t they talk to one another, why do arguments happen? What are the bad choices that made this intractable?”

Postl admits the WRHA is trying to find ways to facilitate more balanced and shared discussions between patients and families.

That’s little comfort for Golubchuk’s children, who haven’t had any contact with health officials since their father died.

Miriam believes the college needs to change their position statement so doctors don’t have free rein to have the final say in end-of-life issues, and doctors need to start listening to what patients and families have to say.

“They’re not listening to us,” she said. “A doctor is not God.”

jen.skerritt@freepress.mb.ca