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Court decision on one man's fate renews debate over end-of-life care

Parichehr Salase, wife of Hassan Rasouli, an Iranian immigrant who has been in coma since 2010, leaves Osgoode Hall in Toronto May 18, 2010.

Fernando Morales/The Globe and Mail

Parichehr Salasel believed that where there was life, there was hope.

Two doctors at Toronto's Sunnybrook Health Sciences Centre disagreed, saying that it is in the best interests of her husband, Hassan Rasouli, who is in a permanent vegetative state, to be taken off life support and provided with palliative care until his death.

The seven-month medical conflict over Mr. Rasouli's fate ended on Wednesday when Ontario's top court took Ms. Salasel's side in a ruling that is expected to reignite for Canadians the emotional issue of how to handle end-of-life decisions and whether extraordinary medical interventions save lives or merely prolong dying.

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"I think it will reopen the debate Canada-wide about how to effectively and efficiently adjudicate end-of-life disputes," said Mark Handelman, a lawyer for the Euthanasia Prevention Coalition, an intervenor in the appeal. "...The public at large needs to learn a lesson from this. You have to have discussions about end-of-life care with your loved ones."

The two doctors, Brian Cuthbertson and Gordon Rubenfeld, had argued that although they required consent to provide palliative care to Mr. Rasouli, they did not need it to withdraw life-sustaining measures that are no longer medically useful. The Ontario Court of Appeal on Wednesday upheld a lower court ruling that said that they do need consent, and that if they don't get it, they must refer the case to a tribunal.

Ms. Salasel said she was pleased with the decision, adding: "I have my husband and he is still alive ... He's getting better, absolutely. He is alive and with medication, with modern medicine, he will be better."

The dilemma raised in the case is of society's own making and increasingly an issue with Canada's aging population: medical technology can now keep the sickest patients biologically alive, even though some doctors feel this does more harm than good. Distraught family members, meanwhile, often do not know their family member's wishes, or refuse to give up hope, and choose every intervention available to sustain life.

"This is such an important case, dealing with a person's life," Gary Hodder, the lawyer who represented Mr. Rasouli, said in a telephone interview. "It reflects on us as a society, it reflects on us as to our collective mental health on how it is we deal with issues such as life and death."

Mr. Hodder described the physicians as excellent, and said they were "acting in utmost good faith."

Mr. Rasouli, now 60, came to this health tragedy through a complication. After surgery on Oct. 7, 2010, to remove a benign brain tumor, he developed a post-operative complication - bacterial meningitis - causing severe and diffuse brain damage.

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Since Oct. 16, 2010, he has been on a mechanical ventilator at Sunnybrook, where he receives nutrition and hydration through a tube inserted into his stomach. Doctors say he will never regain consciousness, according to the court decision.

"These life-sustaining measures are keeping him alive and he may survive for some months if they are continued," according to the 29-page decision, written by Ontario Court of Appeal judges Michael Moldaver and Janet Simmons, with David Doherty concurring. "Without them, it is expected that he will soon stop breathing and die."

The appeal court was careful to say its decision applied only in cases where there is a risk of immediate death. That means in situations that are not life-threatening doctors can stop treatment they believe is ineffective without the approval of the province's Consent and Capacity Board, an independent tribunal that reviews and makes decisions on behalf of people who can't act for themselves. The doctors had said the board did not have jurisdiction in cases such as that of Mr. Rasouli.

For example, discontinuing chemotherapy in cancer patients is different from moving a patient from life support directly to end-of-life palliative care. Ending chemotherapy, the judges wrote, does not spell the patient's imminent death, nor does it trigger a requirement for a particular form of palliative care.

The judges wrote that this distinction addresses concern that "doctors will be prevented from withholding or withdrawing measures they consider to be medically valueless, without first having to obtain their patients' consent to do so.

"Equally, it shuts the door on their concern that patients will be able to demand treatment that their doctors consider to be medically worthless."

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A spokesman for Sunnybrook declined comment; lawyer Harry Underwood, who represented Dr. Cuthbertson and Dr. Rubenfeld, could not be reached.

As for Mr. Rasouli, he was placed on antibiotics earlier this week after suffering a fever and infection, said his wife, Ms. Salasel. But she says he's getting better. Some days he will squeeze her hand with his left hand. His left eye is open and looks at her.

"Somebody in his situation wants to be alive," she said. "Humanity is very important."

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