Withdrawing Life Sustaining Treatment – Terminal Extubation: Hassan Rasouli Part II

Hassan Rasouli, previously diagnosed as being in a permanent vegetative state, has now been diagnosed to be in a minimally conscious state. The reason for the change – his physicians noted that he is able to give a thumbs-up when asked by his wife and able to track with his eyes. His physicians are Drs. Brian Cuthbertson and Gordon Rubenfeld, two critical care specialists at Sunnybrook Health Science Center in Toronto Canada, one of the largest trauma centers in Canada, who have petitioned the Canadian Supreme Court for the authority to withholding life sustaining treatment without the consent or approval of the patient’s wife and family and without the review and consent by the Canadian Consent and Capacity Board – as the law requires of them.

We now know that his doctors, who where adamant about terminally extubating him without the consent of the family, were wrong in their assessment that his was in a vegetative state was permanent, (assuming that it was a vegetative state to begin with). Not only did they want to extubate him without the consent of his wife and family, they also wanted to do so without review by an ethics committee, or Consent and Capacity Act of Canada that the law required of them, nor, most curiously, would they provide the Court with a copy of the Mr. Rasouli’s medical records. The doctors argue that no consent is needed because ending someone’s life is “not treatment.” In short, they wanted to proceed without any questions, oversight or ethically required transparency.

When questioned about this originally, Drs. Cuthbertson and Rubenfeld posited that if they were wrong, they would bear the responsibilities and consequences of their unilateral decision. This was a fatuous statement because if Rasouli was terminally extubated, there would be no evidence or basis to question their decision and thus impossible for them to be held responsible for anything.

In bringing this case to the Canadian Supreme Court they wish to set a precedent that any physician may terminally extubate without consent of the surrogate decision makers nor be subjected to any questions, oversight or ethically required required transparency.

In the United States it has been made clear by the courts, that the critical distinguishing factor between terminal extubation and physician assisted suicide or euthanasia is the patient’s clearly established rejection of artificial life sustaining treatment. Therefore, unambiguous documentation must make this clear. Only by being forthright about these factors can real transparency reflecting respect and dignity for the patient’s life truly exist. 

 In France, at the Centre Hospitalier Universitaire, Henri Mondor,  just outside Paris, they follow a standardized collective decision-making process, noting that “… terminal extubation, very common in the United States, but much less so in France, reinforces the transparency of end-of-life decisions in intensive care units.” They explain:

“This process included three stages. In the initial phase, withdrawal of ventilator support was discussed at a department staff meeting.

 The meeting’s conclusions were transcribed into the medical file, and the possibility of extubation was raised with the family during a planned interview.

At least a 24-hour period of reflection was necessary before a new interview, and any opposition, hesitation or lack of understanding by the family at this first interview resulted in suspending the decision.” …

It is a fundamental right and requirement for a patient, to consent to terminal extubation, and only after all risks have been explained and all options presented. In the case of Hassan Rasouli his wife, as surrogate decision maker must consent,

It is this rejection of treatment that distinguishes respecting the patient’s decisions from assisting in a patient’s suicide.

Even in circumstances where consent has been given, physicians must be extremely reluctant and guarded to end a patient’s life, especially in cases where the patient is not suffering from a terminal disease. Surrogate decision makers often have an incentive, personally, emotionally and financially that may make their “consent” to the withdrawal of life sustaining treatment, suspect. 

Must consent to treat, as well as consent to withdraw treatment, be required?

None of this should be interpreted that Drs. Cuthbertson or Rubenfeld are acting in bad faith and do not have the interests of the patient as paramount. Whether or not that are mistaken in Mr. Rasouli’s case does not mean that they will not be correct in the next hundred cases. The issue is whether on not consent is a prerequisite to ending someone’s life. Stated otherwise, must consent to treat as well as consent to withdraw treatment required.

Wearing two hats is always dangerous – filled with conflict of interest. Drs. Brian Cuthbertson and Gordon Rubenfeld however, seem to want to wear two hats: deciding what the best medically and when it is best to end a patient’s life. Cuthbertson and Rubenfeld must have concluded that a patient’s personal beliefs – their personal life history and experiences, religious beliefs, and cultural customs should be subjugated to their personal beliefs. Yet, their expertise is as critical care physicians, not as oracles.  In areas other that critical care medicine they have no more ability than anyone else and should not hold sway over other peoples decisions.

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