Safeguards and consent
Most people would opt for palliative care. However, sometimes, close family members of a mentally incompetent patient refuse to consent to a timely transfer to palliative care.
Consider N, an 85-year-old widow who was admitted to intensive care at Kitchener’s Grand River Hospital on April 18, 2009, with a perforated intestine that required emergency surgery. During several ensuing weeks in the intensive care unit, she suffered a heart attack, stroke and repeated septic shocks. Then, her kidneys failed and she was placed on permanent dialysis. Finally, while progressively undergoing multi-system organ failure, she was infected with superbugs resistant to antibiotics that plagued her with painful open bedsores on her buttocks.
On June 21, 2009, Dr. William Plaxton, an intensive-care physician at Grand River Hospital, concluded that there was no longer any realistic hope for her recovery. With the concurrence of three other physicians on her medical team, he recommended that N be removed from the ventilator and placed in palliative care in the expectation that she would die within hours.
However, due to a series of brain injuries, N could not understand the reasonably foreseeable consequences of any decision relating to her care. Therefore, Plaxton asked her adult son and designated substitute decision maker, NP, to consent to the proposed change of treatment.
NP refused to consent. Backed by his Mother’s three other adult children, he told Plaxton that N wanted to live and the family “was certain that a miracle would happen.”
Plaxton appealed to the Ontario Consent and Capacity Board, a quasi-judicial agency established to resolve such disputes. In a hearing on July 16, 2009, the Board heard from NP, Plaxton and another of N’s physicians, Dr. Paul Hosek, medical director of the intensive care unit at Grand River Hospital. Hosek testified that while he was “one of those persons who took the position that everything that could be done for a patient to continue life should be done,” he agreed with Plaxton and other members of N’s medical team that she would not recover and despite their best efforts at pain control, would continue to suffer while on the ventilator. Instead of prolonging her suffering, Hosek said he would “rather allow her to pass away peacefully.”
In a ruling on July 17, 2009, the Board held that in recommending N’s removal from the ventilator, Plaxton and Hosek had acted in her best interests. Consequently, the Board directed NP to consent to this plan of treatment.
With this decision, did the Board sanction the commission of euthanasia? Not at all.
Euthanasia is a form of murder that consists in the deliberate killing of someone for reasons of purported compassion. In contrast, there is nothing morally or legally objectionable to the actions of a care-giver who withdraws a life-sustaining ventilator from a patient like N, who, in the best medical judgment of her physicians, is facing imminent and inevitable death.
But alas, cases like N’s are not unusual. What can you do to protect yourself if you become mentally incompetent from either euthanasia, should that crime ever be legalized in Canada, or the denial of palliative care when appropriate to your circumstances?
One safeguard is to spell out your wishes in a Life-Protecting Power of Attorney obtainable from the Euthanasia Prevention Coalition (www.epcc.ca). In addition to directing that “fluids and food (nutrition and hydration) be provided to me, by any means, unless death is inevitable and truly imminent,” this document states: “I direct that my attorney(s) request and consent to care, treatment, services and procedures, including hospice/palliative care, which are appropriate to my condition and are beneficial for me.”
In the end, there is no substitute for trustworthy relatives and friends. Those patients are most fortunate who can count upon someone who loves them to help protect their life and assure that their wishes for medical care are always respected – even in their final hours.