THE GOLUBCHUK CASE: FAITH & FUTILITY

Grace is the name of the hospital where Samuel Golubchuk died. Grace in no way is descriptive of the path his death took.

In my last post, I wrote about distrust of doctors and the American health care system. The extent of that distrust can be jaw-dropping, especially living as I do near Boston, where patients come from around the world for health care. Clearly, not everyone distrusts doctors and large systems.

In my own nascent study of contemporary medical care for dying patients, I’ve belatedly discovered the case of Samuel Golubchuk in Winnipeg, Manitoba, where a medical board overseeing health care in and around Winnipeg had attempted to inject order into the medical futility chaos. The board essentially gave physicians and hospitals veto power over patients or their surrogates in end-of-life decisions.

Golubchuk had suffered a catastrophic brain injury, and in late 2007 his condition was complicated by serious conditions deemed irreversible after he was moved to Grace from a residential care facility. When ICU doctors at Grace wanted to remove him from life support, his two adult children disagreed, and successfully sued to force care to continue. The family said removing the ventilator or feeding tube would violate his beliefs as an Orthodox Jew by acting to hasten his death. And though the family succeeded in getting a temporary injunction to force care to continue, three doctors resigned rather than continue the court-ordered care (half the ICU physicians), and Samuel Golubchuk was on life support when he died in June 2008 at age 85. After their father’s death, the brother and sister dropped the suit.

After the three colleagues resigned, another physician met with the family and their lawyer, and volunteered to oversee Golubchuk’s care. Days later, he delivered a eulogy and was a pallbearer at Golubchuk’s funeral. “I was honored and privileged to care for him,” the doctor told the mourners.

A reference from months earlier, in February 2008, caught my eye. It was from a story on LifeSiteNews.com: “The 84-year-old cognitively disabled patient’s family has been battling hospital doctors who are determined to starve and dehydrate him to death regardless of the family’s wishes.” Such a straightforward, journalistic writing style, and a matter-of-fact way of ascribing murderous intent to the doctors. The writer might have referred to Golubchuk as a dying man, but went instead with “cognitively disabled patient.” And perhaps the physicians might have been given a nod for compassion rather than being “hospital doctors determined to starve and dehydrate him to death.”

Consider that people at the end of life naturally stop eating and drinking. Forcing fluids when dying is in process can itself be cruel and painful, and no one knows this better than a doctor in ICU -- except maybe an ICU nurse.

I know little about these Canadian doctors, and perhaps they are equal parts Jack Kevorkian and Hannibal Lecter. I have my doubts, and question the motives behind media portraying them as having no regard for the sanctity of human life. This is dehumanizing and unfair.

In the opinion of the physicians, basic care of Golubchuk had ceased to be therapeutic, and made the transition to bad care. Though medical professionals regularly administer painful treatments, it is with the assumption of therapeutic purpose. Remove that purpose, even in dispute with family, and they are pointlessly inflicting pain on an elderly dying human. Such was Golubchuk’s physical state that changing his dressing or catheters was “tantamount to torture,” according to the attending who resigned. But hardened ideology demands dismissing “torture” as overstatement. As one web commenter wrote: “What I don't like is doctors exaggerating the level of pain their treatment is causing. It's obvious that doctors in Manitoba ... really are pushing for legalized killing.” The comment was as telling as it was anonymous.

Nowhere in the various media reporting on the case could I find the voice of an ICU nurse involved in Golubchuk’s care. And if I trust anyone’s judgement on whether the man’s care was bad or good, torture of necessary therapy, it is the nurses tasked with doing most of the actual hands-on work.

Though the Golubchuk case didn’t fully play out in court, the Winnipeg Regional Health Authority is investigating how officials can better handle such disputes between physicians and patients. This medical regulatory body “was the first in Canada to introduce guidelines for physicians to follow when dealing with end-of-life issues,” the Winnipeg Free Press reported. “They say the minimum goal of life-sustaining treatment is for patients to recover to a level at which they can be aware of themselves, their environment and their existence. In the event families and physicians don't agree that life support should be withdrawn, doctors have the final say.” The board’s report is due out in the spring.

Dr. Susan Block, a palliative care specialist in Boston, has called communication as demanding a procedure as surgery. But communication isn’t a uniform skill among doctors or patients. In Winnipeg, at no point was the dialogue between doctors and the Golubchuk family facilitated by a patient advocate, ethicist, or mediator, let alone a palliative care specialist. I’ve found no reference to a chaplain or rabbi’s involvement.

Here’s where I sound like a broken record: This tragic story of a man dying in a way he would never have chosen, though it played out in Canada, underscores why it is so unfortunate that “voluntary advance care planning” was removed from American Medicare payment policy. To the degree possible, the complicated and emotionally charged end of life conversation between doctor and patient needs systemic weight and encouragement.

It was acceptable for all concerned to put Samuel Golubchuk on life support in the first place. Medical judgement and Jewish law were in apparent alignment at that point. The problem came in the idea of disconnecting him from that same equipment, which the family considered no longer for a doctor to decide, but in God’s hands.

If physicians and hospitals aren’t trusted to decide when medical care is futile and a life is ending, and neither are they encouraged systemically to discuss end-of-life priorities with a patient, that’s a hell of a box in which to practice medicine.

Further, if physicians and hospitals can be forced to deliver care against their ethical judgement to honor a patient’s religious faith, could they be made to perform euthanasia or assist in the suicide of any patient who wanted to die and had no belief in the sanctity of human life? Now that is a slippery slope.

What’s the answer? God only knows. In the meantime, some legislation would help.