Hassan Rasouli has been on life support at Sunnybrook since October of 2010 and doctors want the right to take him off his ventilator.
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TORONTO -- Many of us will spend our final days in a cold hospital bed, dependant on expensive medical care to keep us alive.
But who will ultimately decide when our time has come? Will it be our Maker or hospital accountants?
Will physicians be able to unilaterally withdraw treatment when they decide further care is futile? Or will the final decision remain with the patient and their family?
Who gets to decide who lives and who dies?
On Monday, the Supreme Court of Canada will wade into that ethical minefield as two doctors from Sunnybrook hospital in Toronto seek to unilaterally pull the plug on a patient they've decided no longer medically benefits from being on a mechanical ventilator.
No matter what the family wants.
The case surrounds Hassan Rasouli, a 60-year-old retired mechanical engineer and devout Shia Muslim. He's been on life-support at Sunnybrook since October 2010 after contracting bacterial meningitis in the hospital following successful surgery for a benign brain tumour.
The once vibrant father of two, newly arrived from Iran, slipped into a coma and after six weeks, his medical team announced to his family that there was no hope, and they would be removing his ventilator and feeding tube the next day.
A doctor herself in her native Iran, his wife, Parichehr Salasel, stood in front of Rasouli's bed and told them that they'd have to kill her first.
"In the view of Shia Muslims, life is sacred. A person is entitled to remain alive until all signs of life are gone. Preventable death must be prevented," the family says in their factum.
When doctors and families can't agree, such end-of-life disputes usually proceed to the Consent and Capacity Board (CCB) where an independent expert panel mediates on what should be done. Instead, the critical care doctors at Sunnybrook went to court to insist that they didn't need consent to withdraw futile medical treatment.
So far, the judges have ruled against them. Last year, the Ontario Court of Appeal upheld a lower court ruling that found the physicians needed to obtain the family's permission or refer the case to the CCB.
But the Sunnybrook doctors pressed on and appealed to the Supreme Court, determined to have a definitive legal answer to a debate that will only grow as the population ages and more expensive medical machinery exists to keep people alive almost indefinitely. "If the Court of Appeal's decision stands, patients and their surrogates will be legally entitled to insist upon receiving an array of futile treatments."
In the meantime, Rasouli defied his doctors and actually began to improve. As his devoted family remained at his bedside, talking to him, reading to him, convinced that he was still there, he began to respond. He was able to catch balls when gently tossed into his hands, give a thumbs up or peace sign when requested, track them with their eyes. A neurologist confirmed his slight progress and upgraded him to "minimally conscious" (MCS) from his previous vegetative state. Patients in MCS have a 33% chance of making a marked recovery.
Still, the Supreme Court refused the family's application to quash the doctors' case.
The Sunnybrook physicians insist Rasouli is only exhibiting reflexes. "It is clear that Mr. Rasouli's family loves him very much, and that they desperately wanted to believe that he was conscious and improving. Unfortunately, it is also clear this coloured their interpretation of his behaviour," they say in their factum.
"The purpose of critical care medicine, including life-support measures, is to support the patient long enough to allow recovery from a reversible illness. Where, as in Mr. Rasouli's case, there is no reversible illness from which he can or will recover, life-support serves no medical purpose."
But it is not that clear cut or definitive. This is a family who believes there is still hope and the life of a vulnerable man hangs in the balance. And perhaps, one day, ours as well.
"It is not a matter of medical judgment that people need food, water and air," Rasouli's family argues.
"Patients, patients' families and the public at large are entitled to reassurance that physicians are not hastening their patients' preventable death without consent or oversight,"