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From a ground-floor intensive care unit bed at Grace Hospital, a frail 84-year-old man this week has managed to turn the province's healthcare system inside out and lay bare a new front in the end-of-life debate.
How do you treat someone in their final stages of life?
Three of the unit's critical-care doctors have refused to treat Samuel Golubchuk, saying to do so is an ethical line they won't cross. Two intensive care beds at the city's biggest trauma centre had to be closed so nurses could scramble to Grace to provide him with kidney dialysis.
And one burning question remains -- what is the cost of all this to Golubchuk, our publicly funding medicare system and the professional obligations of our doctors and nurses?
"I hope all of us are able to remember that there is one human being at the centre of this controversy," said one medical source aware of the lengths the system is now going to keep Golubchuk alive. "I do support the position of the doctors who've resigned -- that they should not be 'forced' to provide treatment they feel is unethical and inhumane."
The legal backdrop further complicating this life and death drama is the pending court case, scheduled for September, to determine whether doctors at Grace will be allowed to pull the plug on Golubchuk. Under the current court order, physicians and nurses are legally obligated to do everything in their power to keep Golubchuk alive until that case has been heard.
Everything in their power has included shifting two intensive care nurses with "specialized skills" from Health Sciences Centre to help out at the Grace intensive care unit. Multiple sources who did not want to be identified told the Free Press the nurses were sent to the St. James community hospital so Golubchuk could have dialysis needed to keep him alive. Golubchuk is suffering kidney failure, which means without dialysis his body can't filter out toxins and he will die.
Experts say patients such as Golubchuk, who are in a minimally conscious state, can still feel pain; they can't receive as much pain-relieving medication if they are on dialysis.
One source said the nurses at Grace Hospital didn't have the specialized training to give continuous dialysis to the elderly man. The source also said nurses feel as though they are "flogging" someone who has no hope of getting better and that closing ICU beds could put other critically ill patients in jeopardy.
While Golubchuk's children, Percy Golubchuk and Miriam Geller, maintain their father is aware of what's going on around him, his case has sparked debate about whether a dying person's right to live trumps the increased strain on an already stretched intensive care system.
There are 74 intensive care beds in Winnipeg, and as of Thursday, 16 were available.
On average, it costs the health-care system $2,200 a day to treat a patient in an ICU bed -- that includes the cost of drugs, doctors, nurses and medical supplies, but not other things such as diagnostic and therapeutic costs.
The ICU beds are occupied by the most critically ill patients or those in unstable condition, including people who need post-operative care, pneumonia patients in need of ventilators or trauma patients who have been in serious vehicle collisions or other accidents.
Dr. David Leasa, an ICU physician in London, Ont. and president of the Canadian Critical Care Society, said part of the dilemma that critical-care physicians struggle with is whether or not a person in an ICU bed is taking away care from another patient.
"We have very difficult decisions to make with families as far as how heroic we should be," Leasa said, noting these types of decisions are made every day in ICUs across the country.
"If we are spending lots of resources, there's got to be potential for good outcome. We don't want these decisions to affect access to care for others."
Thirty years ago, when critical-care medicine began to emerge as a specialty, Leasa said, new technologies made it increasingly possible to keep patients in minimally conscious or vegetative states alive for long periods of time -- even if they had little or no hope of recovery.
However, Leasa said, in some cases, invasive treatments and 24-hour nursing care to keep people alive may cause undue harm or suffering.
Patients in vegetative or minimally conscious states can still feel pain, Leasa said, since the brain stem is still fully intact. That means patients can feel every life-saving treatment offered to them, from a breathing tube inserted through a hole made in the neck, a machine that suctions off secretions, catheters and lines inserted into the body to monitor its function, chest compressions and electrical shocks to resuscitate them and wound care to keep infections at bay.
Leasa said doctors also have to scale back pain-relieving drugs for patients on kidney dialysis since their organs can no longer handle the narcotics.
That's why, Leasa said, doctors try to strike a balance between respecting the wishes of patients and their families and what's ultimately best and possible for the patient.
Doctors sometimes need to ask, 'Are we just delaying the process of dying in this patient?'" Leasa said.
"We all have to die at some point."
Family members keeping a vigil at Golubchuk's bedside not only have a different view, but also take issue with how the medical establishment is treating him.
They say their dad knows what's going on but can't express himself.
"They talk about him right in front of him like he doesn't know what's going on," said Miriam Geller, who spends five or six hours a day at her father's bedside with brother, Percy Golubchuk. "It's not pleasant for him."
They question concerns raised by the medical community about how much it costs to care for their dad while the health authority is spending so much money on the legal battle not to keep him alive.
"They're spending all this money on seven lawyers. Who's paying for their lawyers?"
They also say health authority doctors had no right to reveal personal health information to the media about their father's bed sores and "hacking" off his infected flesh.
"Why are they doing it now?" asked Geller. "To get the public's opinion."
She noted how careful health authorities and providers usually are not to violate the Personal Health Information Act.
They said it was a violation of their father's privacy, grossly exaggerated and in very poor taste.
"Hacking off the flesh? The doctor put that like a butcher," said Golubchuk. Geller said the wound-care nurse treats the bed sores her dad wouldn't have if he received proper care.
"There should've been legislation in place years ago saying the doctor doesn't have the final right," said Golubchuk.
Indeed, four years ago, the Law Reform Commission released a report saying the Manitoba health-care system needed to establish clear and uniform guidelines for when and how end-of-life medical care can be withdrawn or withheld.
"The decision-making process must be clear and transparent and must be communicated clearly, not only to the patient and his or her family but also to the public in order to facilitate a broad understanding of how these decisions are made," the commission wrote.
The decision should also include consideration of the patient's personal, cultural or religious background, the report said.
But while the fight over Golubchuk's life and death rages, his children say it should never have come to this.
"He's a World War Two veteran and this how we repay him -- by trying to kill him?" Geller asked. "The doctors don't have a right to cut a person's life short," said her brother
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