Life support withdrawn from unwilling patient

By Michael Farrell

If 76-year-old Herman Krausz had known what he was in for when he arrived at Montréal Jewish General Hospital (MJGH) in respiratory distress, he may have chosen to go to another hospital. Against his expressed wishes and the desire of his family, Mr. Krausz was removed from his life support system.

Mr. Krausz was treated for a lung inflammation and seemed to improve, but he developed pneumonia and had to be put on a respirator. His son George says that even as Mr. Krausz' condition worsened, he was of sound mind. After learning that he was dying, Mr Krausz said repeatedly he wanted to spend the few weeks remaining to him with his family, and that he did not want the respirator unplugged.

On July 9, however, intensive care director Dr. Allen Spanier informed the family the hospital had decided to shut off the machine.

In spite of the family's objections, the hospital began gradually reducing the respirator power. A lawyer retained by the family sent a letter to the hospital the following day in a last-ditch effort. But after lowering the respirator power the doctors gave the patient morphine, which may also depress a person's breathing rate, and then disconnected the respirator.

According to George Krausz, his father was conscious for some time after the respirator was turned off. On July 13, less than 15 hours after being unplugged, Herman Krausz died.

George Krausz says once his father was declared terminal, the hospital pressured the family to take him off the respirator. It was suggested the move was justified in order to ration scarce healthcare resources. Dr. Spanier told family members, "Suppose you're walking down the street and you get hit by a car and they bring you to intensive care. Who should have priority (for) the bed?"

Budgets

Faced with shrinking budgets and the inability to charge patients who have already paid for their healthcare over the years, hospitals may feel disinclined to increase their variable costs by giving full care to their terminally ill patients.

Some hospitals, however, have developed policies and guidelines on how to decide on treatment options which respect the wishes of terminal patients and their families.

Françoise Chagnon, director of professional services at Montréal General Hospital, says that according to her hospital's guidelines, the question of withdrawal of treatment becomes an issue only when tests confirm, without a doubt, that the patient is "brain dead." "If the brain is fine and obviously the patient can't breathe, you don't just pull the plug out on that" she said, cautioning that she is unable to comment directly on the Krausz case.

According to lawyer Jean-Pierre Ménard, the Québec Civil Code says that if a patient is competent, doctors require his consent before starting or withdrawing treatment. Doctors can refuse treatment against the patient's wishes if the treatment is medically unnecessary or medically futile. This means there is no chance of recovery, and keeping the person alive will only prolong his or her agony without any significant increase in life expectancy or comfort.

Hospital has history of withdrawing treatment

MJGH has offered no explanation for acting against the wishes of Mr. Krausz and his family. The hospital said in a statement that it gave Mr. Krausz "state-of-the-art" treatment, and that his condition was incurable.

"Despite exhausting all medical treatments, the physicians caring for Mr. Krausz were unable to reverse the unrelenting course of his disease," the hospital's statement claimed. "During his last days, our goal was to ensure the delivery of humane care and comfort."

Even so, the Quebec coroner's office is now investigating Mr. Krausz's death.

This is not the first time families of patients at MJGH have been pressured into halting treatment for elderly patients.

According to Margaret Somerville, professor of law and medicine at the McGill University Centre for Medical Ethics and Law, the family of a 65-year-old comatose stroke victim went to the Québec Superior Court in 1992 to stop the hospital from "weaning" the man off a respirator and transferring him to a palliative care ward.

In another case, the family of a man known as Otto G. won a temporary court injunction ordering the hospital not to withdraw life support. The patient lived for several months afterwards.