Doctors fail to get life support withdrawn from “minimally conscious” patient

The Supreme Court of Canada has dismissed an appeal by Toronto doctors who sought to withdraw life support from a severely brain damaged patient against his family’s wishes.

Hassan Rasouli, 61, has been kept alive on a ventilator and feeding tube since contracting meningitis after brain surgery at Toronto’s Sunnybrook Hospital in 2010. His wife, Parichehr Salasel, herself a physician in her native Iran, refused consent to end life support when his doctors concluded that further treatment offered no hope of recovery. She cited the couple’s Shia Muslim religion and claimed to see signs of awareness during her visits.

Rasouli’s status was upgraded from “persistent vegetative state” to “minimally conscious” last year, when he began giving the “thumbs-up” sign at his wife’s request.

The application to remove his life support was then before a lower court, which denied it. But his doctors appealed to the Supreme Court, arguing that withdrawal of life support offered no medical benefit and thus should not be seen as a treatment requiring consent under Ontario’s Health Care Consent Act.1

In a split decision a 5-2 majority ruled that this interpretation of the act was too narrow. “‘Treatment’ and ‘health-related purpose’ are not confined to procedures that are of medical benefit in the view of the patient’s medical caregivers,” wrote Chief Justice Beverley McLachlin.

The doctors also argued that the consent requirement placed them in an “untenable ethical situation” by forcing them to provide care they believed to be futile and not in the patient’s interests. But dilemmas in care at the end of life were “inherent to medical practice,” McLachlin said, and should not undermine the “meaningful role” in decision making that the consent act reserved for family and patient surrogates.

But, she noted, the ruling could not provide guidance in the absence of such consent legislation. “Nor does the case require us to resolve the philosophical debate over whether a next-of-kin’s decision should trump the physician’s interest in not being forced to provide non-beneficial treatment and the public interest in not funding treatment deemed of little or no value.”

Four other Canadian provinces have consent laws similar to Ontario’s, but only Ontario has a Consent and Capacity Board that normally resolves end of life disputes. The Sunnybrook doctors sought the Supreme Court’s opinion instead of referring the case to the board, which generally requires family consent for withdrawal of life support. With the judicial process played out, the option of putting the case before the board remains open, and a hospital spokesman said that such a course was under consideration.