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Monday, January 07, 2008

Samuel Golubchuk

Samuel Golubchuk is an 84 year old in a hospital in Winnipeg, Canada. For more than a month, his family has been waging a legal battle to keep the hospital doctors from removing his respirator and feeding tube while administering morphine to depress his breathing. The fact that Mr. Golubchuk is a Jew is relevant only because of his family's principles and because they are using those religious principles as a legal plank to stop the poor guy from being killed.

Now whenever patients are on respirators and feeding tubes and the hospital deems it necessary to remove the feeding tube, it's obvious that the patient can probably breathe on his own. Sedation often suppresses respiration, and enough morphine always will. In fact, the way Jay got off the respirator is that his wife prevailed upon one of the nurses to cut the drugs sharply. Since Jay is in his forties, this is not just an old-age problem.

The Canadian health care system does seem to have a policy of providing minimal care to older patients. The doctors argued that Mr. Golubchuk was dying anyway, and that they ethically could not prolong his life and his suffering. What happened is that the poor guy has limited kidney function (Jay's kidneys and his liver were also failing), got pneumonia, and got MRSA. Initially the hospital didn't want to put the poor man in intensive care and on a respirator (even though that is a very common treatment for severe cases of pneumonia). His family argued for it, and they prevailed.

The story the press and court got was that the poor old man was dying, was a veg, and that no improvement could be expected. Any care was futile, etc. The family argued that it wasn't, because he was alive. Here's an article from December 11th:
...the doctors say they want to disconnect Golubchuk’s ventilator and pull his feeding tube because there’s no hope of recovery and Golubchuk has only minimal brain function.
The family argued in court that he was responsive, and that withdrawing the ventilation and feeding tube would be an act of murder. The hospital made the first attempt to kill the man in November, but the family bitterly objected, so it ended up in court in December. As for the "only minimal brain function", the hospital never bothered to make any attempt to measure his actual brain function, and it now turns out that Mr. Golubchuk's condition is improving, because a doctor noted on his chart that he woke up.

Jerusalem Post:
A Canadian judge is due to decide this week whether to renew a temporary injunction against Winnipeg's Grace General Hospital, whose doctors want to detach an 84-year-old Orthodox Jew from a respirator and hasten his death, against his family's wishes.

However, it was learned Sunday that the patient, Samuel Golubchuk, regained consciousness several days ago and appears to be improving.

Although a hospital doctor treating Golubchuk wrote "Awoke" on his chart, the hospital did not disclose this to the court. The family said the hospital had been trying to make the patient appear to be dying and with minimal brain function. Grace General Hospital has received the backing of the Canadian Medical Association in its efforts to bring about active euthanasia.

According to the chart, which the judge was apparently not shown, the supposedly "imminently dying" Golubchuk is not only awake but has interacted with people and made purposeful movements.
The bottom line is that he's an expensive patient. He's not and hasn't been vegetative, and he is improving somewhat. It seems that the hospital did not want to perform dialysis (or the man would not have been as bloated as nurses reported). But Mr. Golubchuk's time to die apparently had not come, and he is improving.

Canadian doctors have been arguing that neither the judge nor Mr. Golubchuk's family should have a say:
"Increasingly so -- over the past few years as technology allows us to keep people alive with more complex medical situations for longer -- I think we're seeing more really difficult end-of-life type cases," said Dr. Jeff Blackmer, executive director, office of ethics, for the Canadian Medical Association, which represents 65,000 doctors.

"Our viewpoint is that we want to make sure that clinical decisions are left to physicians and not judges," he added. "These decisions are not made lightly and they're not made in haste, and they're not made with anything except the best interest of that individual patient at heart."
Yeah, yeah, yeah. If they didn't draw off the excess fluid, that alone would have suppressed the old man's breathing. Jay had the same problem.

Jay, who also had had a major heart attack which then resulted in a massive lung infection, is now doing fine. He had to have dialysis temporarily as well. It's an irony, but the expense of Mr. Golubchuk's stay in intensive care may well have been prolonged by their omission of the dialysis.

I hope Mr. Golubchuk makes it out of the loving arms of the Canadian health care system to whatever destiny holds for him.

Americans, at least, should understand that denying care to old geezers means that someone like Jay can be offed as well. Jay was not expected to live at one time. He was lying there like a log with no sign of consciousness. Yet today he's back to normal, although he's got more metal in his heart than Chief Metalheart.

Americans need to think about these matters, because the bottom line is that the care for someone else we don't wish to pay for is the care we ourselves will not receive. Life and death are not as predictable as medical statements in futile care court cases make it seem. In practice, we just do not know.

In 2006 I wrote about coming up north to care for my mother's elderly friend. That woman had been taken to the hospital 5 times in recent months, and twice she was found completely nonresponsive and was resuscitated by EMS. As it turned out, she was receiving erroneous medical care. I believe this was due to her age - I think everyone assumed that a women in her mid eighties was just failing. When I came up, the diagnosis was diabetes and old age. In one week I got her blood sugar stabilized - she was neither diabetic nor hypoglycemic. She was dehydrated, and that was all. She had been very ill with an unusual zoonotic infection, but she had survived that and was basically dying of neglect. On Saturday she was black and blue all over, tottering. By Wednesday I had her in her primary care physician's office, chirpy as a bird, sitting on his examination table swinging her legs, reproachfully telling him that no one had told her to drink water. By Friday almost all of the bruising had vanished. The visiting nurse could not believe it, and I still remember the look on her doctor's face of complete disbelief.

Several years later, she is still living on her own and taking care of her elderly brother. If she were not alive, he would have been in a nursing home all this while, which should give everyone pause when discussing medical costs. Older people do far more in society than anyone realizes. Because most women now work, the older people are often primary caretakers for the disabled and the young.

We are very quick to dismiss the lives of the elderly or the disabled. We should not write people off this way. If we need halachic law to remind us of that, hooray for halachic law! And let me throw in a nod to the Buddhists and the Catholics as well. I often wonder if I wouldn't be dead if I hadn't had a rather stubborn Catholic physician who neither believes in perpetuating corpses or burying people before they are dead. He did not give up; he treated me with a respect and a consideration that is impossible to convey in words, and I am now not even disabled.

This last summer I decided to confess to the poor guy that at one point I had been totally paralyzed, and he told me "You don't have to tell me! I know!" He made a gesture like an umpire calling a ball out, and said "I know. You were gone! You were out! I know!"

The thing is, the doctors don't know. They really don't. They can know everything about the medical aspect, but the life/death thing is pretty imponderable. No one knows how that really works.

Yeah, there was a guy on Mish's site in the comments suggesting that they should stop giving flu shots to old people. That way, they could stop being a drain on society. I suggested by his reasoning that we should stop giving any shots to children, but that somehow seemed different for him. I don't want to give doctors that much power. They aren't gods even though they may think they are.
Well, what if old folks didn't die from the flu but just got sick and required hospitalization? Or I suppose the Mish commenter would have them refused treatment?

There are people who work and are productive well into their 80s, and there are people who are disabled in their youth.

If we let the definition of human value become monetary, we truly are like the Nazis. And that worked out so darned well....
My goodness Mama, it sounds like you have pulled through some tough situations as well. I am glad you are well now!
"(doctors) aren't gods even though they may think they are"...they don't all think this, but too many of them do. I think we have a serious problem with physician arrogance in this country.

There are probably historical roots for this...once, the doctor was one of the few educated people in the community, and also, people were impressed with his life-and-death responsibility. Today, there are lots of highly educated people, and there are also many professions with life-and-death responsibility. An air traffic controller probably deals with as many lives in a week as a typical doctor does in his entire career.
I wasn't surprised when I read about a families fight with Grace Hospital to keep their father alive. They are too quick to 'pull the plug'. It nearly happened to me! I nearly died in ICU at Grace Hospital after I had been ignored for three days on the 3rd floor there after I was admitted for severe pneumonia - the nurses totally ignored me when I said I could not breath. I had pneumonia with complications. They refused to turn up my oxygen and stopped completely coming when I rang the emergency bell.

They had even recommended I be put on palliative care and left to die! Fortunately, a doctor happened to visit the man next to me one day and when he heard me struggling to breath the doctor had me sent to ICU immediately! I nearly died (A nurse told me) shortly after arriving in ICU. I was very fortunate – thank God. Fortunately the doctors gave me medicine when I was sent to HSC to see a specialist --and I've recovered nicely!

I have purchased a med-bracelet – guess what’s on it? If I am ever incapacitated DO NOT SEND ME TO GRACE HOSPITAL! It’s been two years now since that terrifying experience and I’m just glad to be alive

…I learned from a hospital employee of a different hospital where I was taken (Fortunately) that the ‘employees at the Grace had ‘recommended’ I be put on palliative’ care and left to die with no medical assistance in the form of drugs that could save my life. I am extremely fortunate to have been transferred from The Grace Hospital before I succumbed. I am stable now 2 yrs later and living quite well and healthy!

But I wonder how many have died needlessly in Grace Hospital in Winnipeg Manitoba?
Rod, are you older? I have heard reports of behavior like this involving older and disabled patients.

From the limited press accounts, it does seem as if the nurses were, ah, less than fervently concerned for Mr. Golubchuk's health.

There may not have been space in the ICU, or little space. It does seem as if one of the features of socialized health care is the de facto triage in which the older and disabled become much less likely to be given acute care due to the fact that initiating treatment may cause denial of care to a later patient.

I have heard of older patients not being fed at all in both Canadian and UK hospitals.
This story is long and speculation and emotional feeling but short on fact and common scene. The fact is he is brain dead, very old and living by mechanical means for almost a year. As a health care system with decreasing capital recourses and long waiting lists for those with treatable conditions we can no longer keep people alive artificially because they believe in this or that religious fable. If a family or a religion wants someone medically declared beyond hope kept alive then they are free to pay the cost but as a tax payer I do not want to cover the bill for nonsensical religious beliefs. Separation of church and State! and if the medical state declares a very sick old person beyond hope and just a drain on the tax payer then religion should have no say whatsoever.
Mr. Golubchuk's condition has not improved as of June 2008.

Three ICU doctors have now resigned after describing the treatment of Mr. Golubchuk as being grotesque. I wonder how many nurses have transfered to other units in protest.

Mr. Golubchuk continues to have fresh removed to fight ongoing infections. Ribs needed to be broken.
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