Do no harm?
June 18, 2008 11:51 AM Subscribe
To treat, or not to treat? Samuel Golubchuk is 84 years old, in a coma on life support in a Winnipeg hospital, and the subject of ethical, religious, and legal debates. Three doctors have refused to continue providing care, while one has stepped in, potentially keeping the intensive care unit in operation.
I only get pieces of what's going on from the links, but I get the following, in terms of medical facts.
The patient is 84 and in poor health.
He is in a minimally conscious state described as permanent.
There are issues with severe decubitus ulcers complicated by infection.
The patient already has had to contend with sepsis and attendant organ damage, including renal failure.
He is ventilator-dependent.
Given these facts, it's likely he will not survive very long even if he is aggressively treated. Moreover, the articles seem to distinguish between care and treatment only sloppily. It certainly is possible to care for a patient without treating him; this is the essence of palliative care, which is now its own subspecialty.
I wouldn't like to do the Bill Frist thing and diagnose from afar. But I have been directed by family to treat patients who had no hope of survival. Sometimes they become very concerned about one tiny thing we can fix when what's killing their loved one is inexorable and progressive. Usually we can come to an understanding. Religious folks come to understand relentless deterioration as itself a sign from God about what should be happening. I would hope this man's family understands that withholding treatment doesn't cause death, but only allows natural death to occur in a more timely fashion. Religious traditions that don't parse between those two situations are, in my limited experience, fortunately sparse.
Mind you the patient has a say in this. And if the family consistently says, "We knew him, this was his wish, never to give up," it becomes very hard, even in hopeless situations, to disregard that. In some of these situations, I've observed a consensus start to grow between the doctor and the family, and at some point they agree there's a line even the most gung-ho patients wouldn't want to cross. So I wonder as a consequence, what kind of serious breakdown in communication has happened here?
posted by adoarns at 12:15 PM on June 18, 2008 [15 favorites]
Given these facts, it's likely he will not survive very long even if he is aggressively treated. Moreover, the articles seem to distinguish between care and treatment only sloppily. It certainly is possible to care for a patient without treating him; this is the essence of palliative care, which is now its own subspecialty.
I wouldn't like to do the Bill Frist thing and diagnose from afar. But I have been directed by family to treat patients who had no hope of survival. Sometimes they become very concerned about one tiny thing we can fix when what's killing their loved one is inexorable and progressive. Usually we can come to an understanding. Religious folks come to understand relentless deterioration as itself a sign from God about what should be happening. I would hope this man's family understands that withholding treatment doesn't cause death, but only allows natural death to occur in a more timely fashion. Religious traditions that don't parse between those two situations are, in my limited experience, fortunately sparse.
Mind you the patient has a say in this. And if the family consistently says, "We knew him, this was his wish, never to give up," it becomes very hard, even in hopeless situations, to disregard that. In some of these situations, I've observed a consensus start to grow between the doctor and the family, and at some point they agree there's a line even the most gung-ho patients wouldn't want to cross. So I wonder as a consequence, what kind of serious breakdown in communication has happened here?
posted by adoarns at 12:15 PM on June 18, 2008 [15 favorites]
I dunno, it seems like everyone (except possibly the patient and the taxpayers of Canada) is getting a fair shake here. The doctors who have the ethical objection to providing what they consider harmful treatment are allowed to opt out. The doctors that find it ethical to continue treatment are allowed to opt in. The family's wishes are being honored, and nobody seems to know what the patient's wishes were. I mean, I'm strongly in the Kumar camp myself, but that doesn' t make the others' viewpoints less valid or motivated by conscience. We're never going to agree on what constitutes a fair shake for the patient in this sort of situation.
Meanwhile, poor bioethicist Peter A. Singer has had to go through life saying over and over and over, "No, I'm not that Peter Singer." Now that's suffering.
posted by FelliniBlank at 12:18 PM on June 18, 2008
Meanwhile, poor bioethicist Peter A. Singer has had to go through life saying over and over and over, "No, I'm not that Peter Singer." Now that's suffering.
posted by FelliniBlank at 12:18 PM on June 18, 2008
The family has a website.
Oddly enough, the last "urgent" update was in March.
And thank you, adoarns. Not of one of these links is offering a straight-up assessment of the man's condition, ethics aside.
posted by grabbingsand at 12:18 PM on June 18, 2008
Oddly enough, the last "urgent" update was in March.
And thank you, adoarns. Not of one of these links is offering a straight-up assessment of the man's condition, ethics aside.
posted by grabbingsand at 12:18 PM on June 18, 2008
Given that the comments pretty much sum up the internet in one screen of text, I'm afraid the read the article and ruin it.
posted by Kid Charlemagne at 12:22 PM on June 18, 2008
posted by Kid Charlemagne at 12:22 PM on June 18, 2008
I've been following this in the papers and the three doctors declining shifts in CCU has been the bigger story than Mr. Golubchuk himself. Most hospitals here have limited numbers of critical care and emergency physicians and losing one, let alone three, in a small community hospital is devastating. Fortunately, the Winnipeg Regional health Authority (of which I am an employee) has been able to shift staff between hospitals to cover shifts.
The issue here is that people seem to forget that Doctors, as professionals, have a personal and legal mandate to obey the code of conduct set forth by their professional organizations, and I agree with them completely in this instance.
One doctor described the continuing treatment on his bedsores as, if I recall the exact words, 'repeatedly hacking away at his flesh', since there is no other option that continued surgical excision of the infected tissue.
Fear of death and fear of losing a loved one are powerful emotions to overcome, but at some point, enough is enough.
posted by WinnipegDragon at 12:26 PM on June 18, 2008
The issue here is that people seem to forget that Doctors, as professionals, have a personal and legal mandate to obey the code of conduct set forth by their professional organizations, and I agree with them completely in this instance.
One doctor described the continuing treatment on his bedsores as, if I recall the exact words, 'repeatedly hacking away at his flesh', since there is no other option that continued surgical excision of the infected tissue.
Fear of death and fear of losing a loved one are powerful emotions to overcome, but at some point, enough is enough.
posted by WinnipegDragon at 12:26 PM on June 18, 2008
One more point. The family is also fighting for his continued care based on his religious freedom as an Orthodox Jew. I'm not sure exactly what it is about the faith that requires continued care, but that is one of the points they have made multiple times in court.
posted by WinnipegDragon at 12:28 PM on June 18, 2008
posted by WinnipegDragon at 12:28 PM on June 18, 2008
"When a person is born, it's written down when they're going to die. So it's God that decides this, not the doctors," said Miriam Gellar, Golubchuk's daughter.
So if the doctors decide not to treat him, and he dies, God didn't see that coming?
posted by mr_crash_davis at 12:29 PM on June 18, 2008 [3 favorites]
So if the doctors decide not to treat him, and he dies, God didn't see that coming?
posted by mr_crash_davis at 12:29 PM on June 18, 2008 [3 favorites]
That's what I was trying to get at. I missed that detail in the link mr_crash_davis. 'Hastening death' meant something very different three hundred years ago.
posted by WinnipegDragon at 12:32 PM on June 18, 2008
posted by WinnipegDragon at 12:32 PM on June 18, 2008
People have sick ideas about 'doing no harm.' To me, doing harm is keeping an octogenarian barely alive and suffering horribly. Can you say with a straight face that this man would want to be alive right now?
WinnipegDragon writes "One more point. The family is also fighting for his continued care based on his religious freedom as an Orthodox Jew. I'm not sure exactly what it is about the faith that requires continued care, but that is one of the points they have made multiple times in court."
There are some people who insist on using religion to accomplish disgustingly selfish things, and these are some of those people.
posted by mullingitover at 12:51 PM on June 18, 2008
WinnipegDragon writes "One more point. The family is also fighting for his continued care based on his religious freedom as an Orthodox Jew. I'm not sure exactly what it is about the faith that requires continued care, but that is one of the points they have made multiple times in court."
There are some people who insist on using religion to accomplish disgustingly selfish things, and these are some of those people.
posted by mullingitover at 12:51 PM on June 18, 2008
Kids. Who'd have 'em? The little bastards won't let you fuck when you get old, but they're only too happy to keep you alive and suffering indefinitely because they haven't got the balls to take responsibility for turning the machine off.
I'm off to make my Living Will right now! And then I'ma spend all my money on fast living and loose women so those rotten kids won't get their hands on it.
posted by PeterMcDermott at 12:57 PM on June 18, 2008 [2 favorites]
I'm off to make my Living Will right now! And then I'ma spend all my money on fast living and loose women so those rotten kids won't get their hands on it.
posted by PeterMcDermott at 12:57 PM on June 18, 2008 [2 favorites]
People have sick ideas about 'doing no harm.' To me, doing harm is keeping an octogenarian barely alive and suffering horribly. Can you say with a straight face that this man would want to be alive right now?
Can you? You're an anonymous internet poster who never met him. Family may not be an ideal proxy but it is the best option. I certainly wouldn't trust a doctor particularly when they so selectively employ their Hippocratic oath when it suits them and not other times.
If they have made the patient's state clear to the family and they still wish to continue treatment then that is the family's call not the doctors. To do otherwise is to give doctors far too much control over all our lives which I believe would be a far greater harm.
posted by srboisvert at 1:13 PM on June 18, 2008
Can you? You're an anonymous internet poster who never met him. Family may not be an ideal proxy but it is the best option. I certainly wouldn't trust a doctor particularly when they so selectively employ their Hippocratic oath when it suits them and not other times.
If they have made the patient's state clear to the family and they still wish to continue treatment then that is the family's call not the doctors. To do otherwise is to give doctors far too much control over all our lives which I believe would be a far greater harm.
posted by srboisvert at 1:13 PM on June 18, 2008
The "religion" link in the post points not to some Orthodox Jewish site but to an antiabortion web site that seems more allied with the Catholic church on first impression. A better overview of Jewish beliefs considering these things is here; an Orthodox rabbi sums it up thusly:
So long as the heart still functions and the blood circulates, death has not yet set in. But this does not mean that a lingering life, especially when experiencing great pain, must be prolonged at all costs and in all circumstances. While one may not actively cause or hasten the onset of death, and one may therefore never withhold normal and natural means to sustain life—such as food, drink, blood, or oxygen (or air)—one need not artificially prolong life . . . by administering antibiotics . . . to suppress infection. Thus, one may allow nature to take its course by withholding such treatment. On the responsibility for making such decisions . . . affecting life and death, it should be emphasised that these should, wherever possible, be left to disinterested parties, preferably including experts, including moral specialists such as experienced rabbinic authorities.
posted by TedW at 1:15 PM on June 18, 2008 [7 favorites]
So long as the heart still functions and the blood circulates, death has not yet set in. But this does not mean that a lingering life, especially when experiencing great pain, must be prolonged at all costs and in all circumstances. While one may not actively cause or hasten the onset of death, and one may therefore never withhold normal and natural means to sustain life—such as food, drink, blood, or oxygen (or air)—one need not artificially prolong life . . . by administering antibiotics . . . to suppress infection. Thus, one may allow nature to take its course by withholding such treatment. On the responsibility for making such decisions . . . affecting life and death, it should be emphasised that these should, wherever possible, be left to disinterested parties, preferably including experts, including moral specialists such as experienced rabbinic authorities.
posted by TedW at 1:15 PM on June 18, 2008 [7 favorites]
That is incredibly helpful TedW. Thanks!
posted by WinnipegDragon at 1:21 PM on June 18, 2008
posted by WinnipegDragon at 1:21 PM on June 18, 2008
Family may not be an ideal proxy but it is the best option.
Not necessarily; I would not want this lady making decisions for me. It is a more common occurence that family members don't agree as to the course of action; sometimes they have any number of conflicting motives and goals behind their positions.
posted by TedW at 1:26 PM on June 18, 2008
Not necessarily; I would not want this lady making decisions for me. It is a more common occurence that family members don't agree as to the course of action; sometimes they have any number of conflicting motives and goals behind their positions.
posted by TedW at 1:26 PM on June 18, 2008
srboisvert writes "Can you? You're an anonymous internet poster who never met him."
Well, I haven't met him, but let's hear from someone who has:
a nurse said she was appalled by Mr. Golubchuk's condition. He was retaining 45 litres of water, and his skin was swollen to the point of bursting. According to the nurse, "he was rotting from the inside out."Yep, that sounds like the life I look forward to in my twilight
srboisvert writes "If they have made the patient's state clear to the family and they still wish to continue treatment then that is the family's call not the doctors."
Well, I'm with Singer on this one:
The way forward in these cases is to acknowledge both the desires of families and the moral distress of health care teams. The family should be able to continue treatment, but the health care team and hospital should not be forced to provide care which they find morally and professionally distressing.posted by mullingitover at 1:34 PM on June 18, 2008 [1 favorite]
The family of Mr. Golubchuk should be given a period of time to find a health care team and hospital who share their belief that the treatment being provided is worthwhile. If they cannot, that should serve to inform them that rather than saving their father's life, they are prolonging his death.
If they have made the patient's state clear to the family and they still wish to continue treatment then that is the family's call not the doctors. To do otherwise is to give doctors far too much control over all our lives which I believe would be a far greater harm.
posted by srboisvert at 1:13 PM on June 18 [+] [!]
Doctors can and should make this call. There are hospital legal teams for just such issues. Families very often are completely unable to make these decisions ethically or appropriately, for precisely the same reasons that physicians are not supposed to care for their family members.
posted by docpops at 1:53 PM on June 18, 2008
posted by srboisvert at 1:13 PM on June 18 [+] [!]
Doctors can and should make this call. There are hospital legal teams for just such issues. Families very often are completely unable to make these decisions ethically or appropriately, for precisely the same reasons that physicians are not supposed to care for their family members.
posted by docpops at 1:53 PM on June 18, 2008
If they have made the patient's state clear to the family and they still wish to continue treatment then that is the family's call not the doctors.
These are ICU doctors; they are around dying people on life support on a daily basis. Thus, I would imagine that it takes something really bad (see mullingitover's post above) to get not one, not two, but three of these doctors to opt-out. Is it truly fair to force doctors to continue treatment indefinitely, even when they feel they cannot ethically do so? It may be the family's call, but in severe cases like these, I think that the feelings of the doctors should be taken into account.
The doctor in the first link was willing to risk jail rather than continue to treat Mr. Golubchuk; that doesn't sound like "selectively employ[ing] their Hippocratic oath" to me. In fact, it sounds like he takes that oath quite seriously.
posted by vorfeed at 2:04 PM on June 18, 2008
These are ICU doctors; they are around dying people on life support on a daily basis. Thus, I would imagine that it takes something really bad (see mullingitover's post above) to get not one, not two, but three of these doctors to opt-out. Is it truly fair to force doctors to continue treatment indefinitely, even when they feel they cannot ethically do so? It may be the family's call, but in severe cases like these, I think that the feelings of the doctors should be taken into account.
The doctor in the first link was willing to risk jail rather than continue to treat Mr. Golubchuk; that doesn't sound like "selectively employ[ing] their Hippocratic oath" to me. In fact, it sounds like he takes that oath quite seriously.
posted by vorfeed at 2:04 PM on June 18, 2008
If the family can find a doctor willing to keep him alive, then they ought to be able to do that; if they can't, then no doctor should be forced to do something he is ethically or otherwise opposed to.
Of course, the situation is complicated by the fact that in Canada (a) taxpayers pay for all medical care and (b) patients and doctors are prohibited from privately contracting for care. I wonder if the family would feel as strongly about keeping him alive if they had to pay the hundreds of thousands of dollars it may cost. And I wonder if doctors offered increased monetary incentives would feel as strongly about letting him die.
posted by mw at 2:18 PM on June 18, 2008
Of course, the situation is complicated by the fact that in Canada (a) taxpayers pay for all medical care and (b) patients and doctors are prohibited from privately contracting for care. I wonder if the family would feel as strongly about keeping him alive if they had to pay the hundreds of thousands of dollars it may cost. And I wonder if doctors offered increased monetary incentives would feel as strongly about letting him die.
posted by mw at 2:18 PM on June 18, 2008
Of course most people recoil from the thought of ending up like poor Mr. Golubchuk. But then again, I've heard people argue in all apparent seriousness that they'd rather be dead than end up parapalegic; surveys of people who have actually ended up disabled after traumatic accidents show that most adjust after about a year and end up right back at the same baseline happiness as before the disability. I'm not sure that people in good health are very good judges a priori of whether they'd prefer to die or to spend another couple of weeks in pain, but potentially able to derive some moments of enjoyment from listening to their favorite music and being with family.
I don't know. I suppose it's easier in a case as extreme as the linked story (rotting from the inside out? blergh) to say that someone would OF COURSE prefer to die instead. But I think sometimes our culture's almost-pathological fear of confronting death and declining health makes people imagine that there could not be anything worse than ending up in a hospital in pain with a chronic or fatal disease, and that there is nothing good or redeeming that could balance that out.
This blog post is pretty timely and interesting to read in conjunction with the linked story. I was particularly struck by the section that read:
It is critical to understand that people looking death in the eye have a different perspective. You or I might think that we would never agree to a risky, potentially painful treatment that offered only a tiny hope of providing “some” benefit. But you and I have not been told that we have cancer. The instinct to survive is stronger than we realize. This is why so many patients will grasp at straws.
I suppose I just think the issue of end-of-life care is much tougher than so much of the public discourse that surrounds it. Almost everybody says, "Well of course I would rather go to hospice or die at home than die in a hospital," but we have a very high proportion of people who do end up dying from chronic diseases in a hospital, either hoping that things will turn around or wanting to stick around a little longer for their own reasons. I have no idea what the solution is, but I hate that stories like this make it easy for people to crack jokes about shooting themselves when they turn 50 or pledging that that'll never be them, because they want the plug pulled immediately. (Not criticizing the post, which is interesting; just musing on the types of stories that get told in the media and what sorts of conclusions they almost force us to jump to.)
posted by iminurmefi at 2:23 PM on June 18, 2008
I don't know. I suppose it's easier in a case as extreme as the linked story (rotting from the inside out? blergh) to say that someone would OF COURSE prefer to die instead. But I think sometimes our culture's almost-pathological fear of confronting death and declining health makes people imagine that there could not be anything worse than ending up in a hospital in pain with a chronic or fatal disease, and that there is nothing good or redeeming that could balance that out.
This blog post is pretty timely and interesting to read in conjunction with the linked story. I was particularly struck by the section that read:
It is critical to understand that people looking death in the eye have a different perspective. You or I might think that we would never agree to a risky, potentially painful treatment that offered only a tiny hope of providing “some” benefit. But you and I have not been told that we have cancer. The instinct to survive is stronger than we realize. This is why so many patients will grasp at straws.
I suppose I just think the issue of end-of-life care is much tougher than so much of the public discourse that surrounds it. Almost everybody says, "Well of course I would rather go to hospice or die at home than die in a hospital," but we have a very high proportion of people who do end up dying from chronic diseases in a hospital, either hoping that things will turn around or wanting to stick around a little longer for their own reasons. I have no idea what the solution is, but I hate that stories like this make it easy for people to crack jokes about shooting themselves when they turn 50 or pledging that that'll never be them, because they want the plug pulled immediately. (Not criticizing the post, which is interesting; just musing on the types of stories that get told in the media and what sorts of conclusions they almost force us to jump to.)
posted by iminurmefi at 2:23 PM on June 18, 2008
I oppose his continued treatment purely in the interests of triage. The treatment provided to him takes away resources from patients who may benefit from treatment. No doctor should be permitted to treat him. Care, yes. Treatment, no.
posted by ten pounds of inedita at 2:44 PM on June 18, 2008
posted by ten pounds of inedita at 2:44 PM on June 18, 2008
Let's all take a moment now to talk to our loved ones about our wishes should we be unable to make decisions for ourselves. Perhaps even put them down on paper.
posted by brevator at 2:48 PM on June 18, 2008
posted by brevator at 2:48 PM on June 18, 2008
The treatment provided to him takes away resources from patients who may benefit from treatment.
But surely the relevant point is who owns those "resources" and how their owners wish to employ them.
posted by mw at 2:58 PM on June 18, 2008
But surely the relevant point is who owns those "resources" and how their owners wish to employ them.
posted by mw at 2:58 PM on June 18, 2008
Sorry, momentarily forgot this case is in Canada, so everyone (and therefore no one) owns the resources. So, the correct answer is to, at the very least, allow this family to pay for private health care if they are willing and able.
posted by mw at 3:02 PM on June 18, 2008
posted by mw at 3:02 PM on June 18, 2008
Doctors can and should make this call. There are hospital legal teams for just such issues. Families very often are completely unable to make these decisions ethically or appropriately, for precisely the same reasons that physicians are not supposed to care for their family members.
posted by docpops at 4:53 PM on June 18 [+] [!]
At one point (in the US, in the late 90s), a doctor at the Mayo clinic informed my grandfather, (lucid, but in the grasp of irreversible, major organ failure at the end of decades of illness) that any future treatment wasn't going to help at all, and would only (slightly) prolong his suffering.
What he actually said--gently, with respect and affection, and in the company of the family, was--was, "Danny, it's time to go."
It was a measure of relief for everyone, patient included. I hope to have such a physician at my bedside, who will guide me with dignity and compassion at a time when I and my family may be too frightened and worn out to go it alone.
posted by availablelight at 3:06 PM on June 18, 2008 [8 favorites]
posted by docpops at 4:53 PM on June 18 [+] [!]
At one point (in the US, in the late 90s), a doctor at the Mayo clinic informed my grandfather, (lucid, but in the grasp of irreversible, major organ failure at the end of decades of illness) that any future treatment wasn't going to help at all, and would only (slightly) prolong his suffering.
What he actually said--gently, with respect and affection, and in the company of the family, was--was, "Danny, it's time to go."
It was a measure of relief for everyone, patient included. I hope to have such a physician at my bedside, who will guide me with dignity and compassion at a time when I and my family may be too frightened and worn out to go it alone.
posted by availablelight at 3:06 PM on June 18, 2008 [8 favorites]
So, the correct answer is to, at the very least, allow this family to pay for private health care if they are willing and able.
It surely is not, and the reasons why private health care is not and never will be the answer is, as far as I'm concerned, not even debatable.
posted by ten pounds of inedita at 3:46 PM on June 18, 2008
It surely is not, and the reasons why private health care is not and never will be the answer is, as far as I'm concerned, not even debatable.
posted by ten pounds of inedita at 3:46 PM on June 18, 2008
Sure glad I didn't raise four little religionists. I told them all to figure it out for themselves when they asked me about their little friend's churches.
Of course when they call and visit they keep reminding me that inflation and our profligate spending is eating up their inheritance.
posted by notreally at 4:06 PM on June 18, 2008
Of course when they call and visit they keep reminding me that inflation and our profligate spending is eating up their inheritance.
posted by notreally at 4:06 PM on June 18, 2008
...the reasons why private health care is not and never will be the answer is, as far as I'm concerned, not even debatable.
That would seem to leave you at somewhat of a disadvantage, since the debate will continue whether you're a part of it or not.
posted by Riki tiki at 4:09 PM on June 18, 2008 [2 favorites]
That would seem to leave you at somewhat of a disadvantage, since the debate will continue whether you're a part of it or not.
posted by Riki tiki at 4:09 PM on June 18, 2008 [2 favorites]
When Dad passed away, he had previously made it very clear to all of us that if it came down to only a machine keeping him alive? He wanted that machine off. In fact, the act of getting hooked up to a machine kinda freaked him out. Dad had gone to medical school and spent several years working for funeral homes. He was no stranger to death, but in the final moments with my Mom, she confided in me that he admitted to being afraid.
Then the doctors came in with the tube they stick down you're throat. Mom confided in me that in that moment Dad got ...a little mad.
A few hours later we were all standing around his bed. Mom filled out the necessary paperwork taking full responsibility and "in accordance with his wishes" and all that fodderal. The irony is, Dad used to work at that hospital as a security guard, just a couple years earlier. There were doctors in that building who cared about Dad so much, if there were any way to keep this man alive on his own power, I had full confidence they woulda already done it. In fact, they already had just a couple few years before when Dad... well that's another story.
They'd taken him apart and put him back together once before. This time I knew that they knew they'd pulled all the miracles out of this particular hat. He was like as much family to many of the employees there as he was to us. Dad had that kinda affect on people, but legally, they didn't want to be held responsible for what happened next.
At Mom's request, the tube was removed by a doctor. Dad breathed his last breaths on his own accord, and I held a cold and clammy hand that was no longer his. I watched him go. I saw him leave, like a hand withdrawing from inside a puppet's head. I saw him go.
There's what doctors need to do: the hypocratic oath - honor the life that is there before them in the now as best as they can. There's what family and friends need to do, which is honor the man in their past, that they have known all their lives, in the present as best as they can.
Then there's the truth. Laws cannot quantify it. Words fail to properly describe it. You don't know the truth even when you watch it 'die' in front of you. These things of flesh and bone we ride around in? They're shells. They're machines. They are made out of carbon and iron and calcium.. lubricated with H2O. Hooking a machine up to keep another machine going makes sense only if it's a stop measure; a temporary act intended to allow time for a possible way to get that other machine up and running again on its own power. If you can't do that, then having one machine holding up another machine is ...well, redundant, and on the whole, unnecessary.
Samuel Golubchuk is 84 years old, in a coma on life support in a Winnipeg hospital, and it's disrespectful of his life not to let him discover the truth for himself.
posted by ZachsMind at 4:35 PM on June 18, 2008 [4 favorites]
Then the doctors came in with the tube they stick down you're throat. Mom confided in me that in that moment Dad got ...a little mad.
A few hours later we were all standing around his bed. Mom filled out the necessary paperwork taking full responsibility and "in accordance with his wishes" and all that fodderal. The irony is, Dad used to work at that hospital as a security guard, just a couple years earlier. There were doctors in that building who cared about Dad so much, if there were any way to keep this man alive on his own power, I had full confidence they woulda already done it. In fact, they already had just a couple few years before when Dad... well that's another story.
They'd taken him apart and put him back together once before. This time I knew that they knew they'd pulled all the miracles out of this particular hat. He was like as much family to many of the employees there as he was to us. Dad had that kinda affect on people, but legally, they didn't want to be held responsible for what happened next.
At Mom's request, the tube was removed by a doctor. Dad breathed his last breaths on his own accord, and I held a cold and clammy hand that was no longer his. I watched him go. I saw him leave, like a hand withdrawing from inside a puppet's head. I saw him go.
There's what doctors need to do: the hypocratic oath - honor the life that is there before them in the now as best as they can. There's what family and friends need to do, which is honor the man in their past, that they have known all their lives, in the present as best as they can.
Then there's the truth. Laws cannot quantify it. Words fail to properly describe it. You don't know the truth even when you watch it 'die' in front of you. These things of flesh and bone we ride around in? They're shells. They're machines. They are made out of carbon and iron and calcium.. lubricated with H2O. Hooking a machine up to keep another machine going makes sense only if it's a stop measure; a temporary act intended to allow time for a possible way to get that other machine up and running again on its own power. If you can't do that, then having one machine holding up another machine is ...well, redundant, and on the whole, unnecessary.
Samuel Golubchuk is 84 years old, in a coma on life support in a Winnipeg hospital, and it's disrespectful of his life not to let him discover the truth for himself.
posted by ZachsMind at 4:35 PM on June 18, 2008 [4 favorites]
That would seem to leave you at somewhat of a disadvantage, since the debate will continue whether you're a part of it or not.
You folks can debate it all you like; it's not going to change. Since I'm not wasting energy on a fruitless non-debate, I must conclude that sometimes things aren't how they "seem".
posted by ten pounds of inedita at 4:40 PM on June 18, 2008
You folks can debate it all you like; it's not going to change. Since I'm not wasting energy on a fruitless non-debate, I must conclude that sometimes things aren't how they "seem".
posted by ten pounds of inedita at 4:40 PM on June 18, 2008
These are ICU doctors; they are around dying people on life support on a daily basis. Thus, I would imagine that it takes something really bad (see mullingitover's post above) to get not one, not two, but three of these doctors to opt-out
Actually, the critical care docs that I know are the most likely to suggest that someone should just go home and die. Typically they're right. Being around it and watching intensive care not save people on a daily basis makes them much less sensitive to death, and much more willing to say that it would be better to give up the few days and die at home.
posted by a robot made out of meat at 5:37 PM on June 18, 2008
Actually, the critical care docs that I know are the most likely to suggest that someone should just go home and die. Typically they're right. Being around it and watching intensive care not save people on a daily basis makes them much less sensitive to death, and much more willing to say that it would be better to give up the few days and die at home.
posted by a robot made out of meat at 5:37 PM on June 18, 2008
It is a more common occurence that family members don't agree as to the course of action; sometimes they have any number of conflicting motives and goals behind their positions.
I can't guess how common, but it does happen. Perhaps it is the rule, and in most cases a forceful personality (the matron of the family, eg) carries a consensus. In my ICU experience, most families come around within a few days to the inevitability of death. The consolidation period seems so chaotic to an inexperienced observer it wouldn't seem so, but this is just powerful emotions and family dynamics working themselves out.
Being around it and watching intensive care not save people on a daily basis makes them much less sensitive to death
This is true but a detachment from death attends most physicians. It would be difficult to function otherwise. But certainly intensive care does not save all. It is the last exigency for the critically ill, and therefore often is the last stop for those who are unsalvageably to die. Nationwide, up to one fifth of ICU admissions die before discharge. I'm not a critical care doc, but having spent some time in a unit, I've seen how they're able to appraise patients very quickly: which ones will be okay and which won't, which deserve a shot even against some odds and which will get their pro forma stay before the family meeting. As many would be quick to say physicians are not God and most are acutely aware of the limitations of their craft. Scared family members want something done but they also ultimately must put trust in the physician, who knows that almost every medical intervention has risks as well as benefits.
posted by adoarns at 8:21 PM on June 18, 2008
I certainly wouldn't trust a doctor particularly when they so selectively employ their Hippocratic oath when it suits them and not other times.
Well, in that case why don't you go there and treat this guy yourself, eh? See how far you will get with an 84 year old.
As far as Hippocratic oath goes, you probably should read it first, before making any comments about it. You know, so that you may sound half way intelligent.
Here it is:
I swear by Apollo Physician and Asclepios and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
Now show me where it says doctors are obligated to make patients immortal.
posted by c13 at 8:54 PM on June 18, 2008 [1 favorite]
Well, in that case why don't you go there and treat this guy yourself, eh? See how far you will get with an 84 year old.
As far as Hippocratic oath goes, you probably should read it first, before making any comments about it. You know, so that you may sound half way intelligent.
Here it is:
I swear by Apollo Physician and Asclepios and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
Now show me where it says doctors are obligated to make patients immortal.
posted by c13 at 8:54 PM on June 18, 2008 [1 favorite]
The key phrase here is "no brain function." It cannot be used in the same sentence as "life support," because a person with no brain function is dead and has no life to support. No brain function is not a minimally conscious state. It is a state of death. In the USA proof of no brain function means a person is legally dead. They can be buried. The ventilator is usually turned off first.
The reason that brain death is defined this way is that when a brain ceases all functions and has been correctly diagnosed as ceasing all function, no recovery is possible; no recovery has ever been observed in such a case.
The fact that a body can be made to continue cardiorespiratory function after its brain is dead is an academic curiosity, no more. Unless the organs are being preserved for transplant - which they would not be in the case of an 84-year-old - it is extremely wasteful of scarce resources to preserve that cardiorespiratory function any longer than necessary for the family to say its goodbyes to the corpse.
Of course, Hasidic Jews among others do not accept this definition of death. While the heart is beating, a Jew is alive and the doctors are supposed to do everything they can to keep it beating. This is an old story in ICUs - patient dies, the Hasidic Jewish family insists ventilation and cardiac support be continued. Usually the heart stops by itself after a while.
posted by ikkyu2 at 11:39 PM on June 18, 2008 [1 favorite]
The reason that brain death is defined this way is that when a brain ceases all functions and has been correctly diagnosed as ceasing all function, no recovery is possible; no recovery has ever been observed in such a case.
The fact that a body can be made to continue cardiorespiratory function after its brain is dead is an academic curiosity, no more. Unless the organs are being preserved for transplant - which they would not be in the case of an 84-year-old - it is extremely wasteful of scarce resources to preserve that cardiorespiratory function any longer than necessary for the family to say its goodbyes to the corpse.
Of course, Hasidic Jews among others do not accept this definition of death. While the heart is beating, a Jew is alive and the doctors are supposed to do everything they can to keep it beating. This is an old story in ICUs - patient dies, the Hasidic Jewish family insists ventilation and cardiac support be continued. Usually the heart stops by itself after a while.
posted by ikkyu2 at 11:39 PM on June 18, 2008 [1 favorite]
Now show me where it says doctors are obligated to make patients immortal.
I guess you just don't want to hear what I am saying. The treatment of this patient is clearly uncomfortable for the (state sponsored) physicians. That they whip out the hippocratic oath in this case is simply backup for wanting to no longer treat him. Doctor's routinely cause harm in order to heal. They don't balk at it because of an antiquated oath.
Sure his condition is gross. He is extremely unlikely to recover. He uses up precious and expensive medical resources. His family is quite possibly wrong.
Yet when I go into the hospital I want the treatment I need as determined by me or my proxies. I certainly don't want to navigate the crazy landscape of hospital workers' moral qualms.
posted by srboisvert at 4:10 AM on June 19, 2008
I guess you just don't want to hear what I am saying. The treatment of this patient is clearly uncomfortable for the (state sponsored) physicians. That they whip out the hippocratic oath in this case is simply backup for wanting to no longer treat him. Doctor's routinely cause harm in order to heal. They don't balk at it because of an antiquated oath.
Sure his condition is gross. He is extremely unlikely to recover. He uses up precious and expensive medical resources. His family is quite possibly wrong.
Yet when I go into the hospital I want the treatment I need as determined by me or my proxies. I certainly don't want to navigate the crazy landscape of hospital workers' moral qualms.
posted by srboisvert at 4:10 AM on June 19, 2008
srboisvert: Doctor's routinely cause harm in order to heal.
Well yeah. And in each case that I've been a party in that decision, the doctor carefully weighed the risks and benefits. Doctors routinely refuse to perform surgical interventions they feel will expose the patient to unneeded or unjustified risk. We regularly support the ethical free-will of doctors over the desires of legal proxies in clear cases of abuse, neglect and self-harm.
And reading the article, the problem isn't treatment of the patient, the problem is escalation of treatment to surgical interventions that offer no hope of restoring quality of life or health. Should treatment include amputation of limbs? Assuming no shortage of organs, should he get a kidney transplant to relieve the renal failure? There are hundreds of desperate therapies that could be used to keep a person alive at any cost.
posted by KirkJobSluder at 7:34 AM on June 19, 2008
Well yeah. And in each case that I've been a party in that decision, the doctor carefully weighed the risks and benefits. Doctors routinely refuse to perform surgical interventions they feel will expose the patient to unneeded or unjustified risk. We regularly support the ethical free-will of doctors over the desires of legal proxies in clear cases of abuse, neglect and self-harm.
And reading the article, the problem isn't treatment of the patient, the problem is escalation of treatment to surgical interventions that offer no hope of restoring quality of life or health. Should treatment include amputation of limbs? Assuming no shortage of organs, should he get a kidney transplant to relieve the renal failure? There are hundreds of desperate therapies that could be used to keep a person alive at any cost.
posted by KirkJobSluder at 7:34 AM on June 19, 2008
Yet when I go into the hospital I want the treatment I need as determined by me or my proxies.
Sorry, I'm not a McDonald's. Medicine does not -- and should not -- function that way. If you ask for inappropriate medication, should doctors be required to give it to you? What if you ask your doctor to cut off your hand? Should the physician be obligated to do so because you or your proxy demanded it? An available treatment is distinct from an appropriate treatment. This treatment is clearly inappropriate, and as such, shouldn't be given.
posted by LittleMissCranky at 11:48 AM on June 19, 2008 [5 favorites]
Sorry, I'm not a McDonald's. Medicine does not -- and should not -- function that way. If you ask for inappropriate medication, should doctors be required to give it to you? What if you ask your doctor to cut off your hand? Should the physician be obligated to do so because you or your proxy demanded it? An available treatment is distinct from an appropriate treatment. This treatment is clearly inappropriate, and as such, shouldn't be given.
posted by LittleMissCranky at 11:48 AM on June 19, 2008 [5 favorites]
Doctor's routinely cause harm in order to heal
However, usually the harm is either a calculated and transient injury leading to a greater benefit (ie, cutting someone open to remove an inflamed appendix) or is an unfortunate consequence of the regression to the mean of otherwise safe risks. Doing definite harm in order to chase after an extremely uncertain or unachievable benefit is not only not ethical, it is unsophisticatedly silly.
Although I feel like I must repeat, I don't like that it's come to such a public and ugly head. Maybe there was no other way, but usually exhaustive conversation is what prevents rows like these from erupting into the public sphere.
posted by adoarns at 4:41 PM on June 19, 2008
Yep, that confirms it: same old story. The Talmudic definition of death doesn't agree with the one that physicians routinely use today. Not new; no way around it that I've ever been able to discover.
Worth noting that mechanical ventilation wasn't possible when the Talmudic scholars came up with their definition; at that time, a brain dead person would stop breathing and become heart dead too in 8 minutes, so the fine point we make today about braindead people on mechanical ventilators was completely moot at the time. Talmudic law evolves very slowly.
posted by ikkyu2 at 10:41 AM on June 25, 2008
Worth noting that mechanical ventilation wasn't possible when the Talmudic scholars came up with their definition; at that time, a brain dead person would stop breathing and become heart dead too in 8 minutes, so the fine point we make today about braindead people on mechanical ventilators was completely moot at the time. Talmudic law evolves very slowly.
posted by ikkyu2 at 10:41 AM on June 25, 2008
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posted by srboisvert at 12:08 PM on June 18, 2008 [1 favorite]