Saturday, June 28, 2008

We Have Been Here Before: an Update

I wanted to update you on one of the cases I cited recently in reflecting again on care in extremis.

This past Tuesday, Sam Golubchuk died in the Intensive Care Unit of Grace Hospital in Winnipeg, Manitoba. I had cited Mr. Golubchuk’s case because of a difference in goals between his family and his physicians. The case gained attention initially when one of his physicians resigned his privileges in the hospital rather than continue to provide care for Mr. Golubchuk that the physician considered futile and unethical. Since that resignation, two other physicians also resigned their privileges for the same reason. While the hospital was able to work with other physicians to keep the ICU unit open, there was concern that more resignations by physicians, or resignations by nurses, might force closure of the unit, and disrupt care for all ICU patients, including Mr. Golubchuk.

In the end, it did not come to that. Mr. Golubchuk died while still receiving therapeutic care. (I have come to call that a celestial discharge.)

This satisfied his family. They felt Mr. Golubchuk’s Orthodox Jewish faith required continued therapeutic care unless and until he died. They went to court, and were successful in getting an injunction so as to continue care until the court could review the case. His death has made the legal issue moot.

However, it hasn’t made the ethical issues moot. Again, what are appropriate goals when best medical advice is that further care is futile? What in such cases are the limits of the autonomy of the patient, exercised by the patient’s surrogates? What are the limits of the autonomy of the professionals? How should a patient’s religious values be respected? What are the rights of other patients who might be affected by these decisions?

Mr. Golubchuk rests with his ancestors. His family feels they have fulfilled the requirements of his and his family’s faith. This is well and good. On the other hand, we in health care can’t yet rest. We still have a lot of thinking and conversing to do to determine how we might act in similar cases in the future.

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