A High Court judge has made orders permitting doctors not to administer additional ventilator support or CPR to a severely brain injured young man should his condition further deteriorate.
The man’s parents had opposed the orders, disputed doctors’ views of their son’s level of awareness and his father had said: “I want him to be kept alive. Where there’s life, there’s hope.” He also said he could not in conscience consent to the orders but he and his wife would leave it to the court to decide.
The man, aged in his thirties, has been in a minimally conscious state (MCS) for some five years in a hospital high dependency unit.
He cannot speak, walk, is tube fed, breathes through a tracheotomy, only has movement, which is uncoordinated, in one upper limb and has experienced significant brain volume loss over the years.
There is no definitive diagnosis of how the man, who had a history of psychiatric difficulties and experienced bullying at school, sustained severe brain injury some time after he went in hospital in 2012 with gastro-intestinal bleeding.
None of the medical personnel who gave evidence disagreed with his treating doctor’s conclusion he has a severe, non-traumatic, multi-factorial irreversible brain injury. While it was not known how this occurred, the court’s function was not to decide the cause or any issue of liability.
No consensus
Because the man was made a ward of court on the HSE’s application after a consensus could not be reached between doctors and his family on his treatment, the president of the High Court, Mr Justice Peter Kelly, had to decide the matter.
The judge, who visited the man in hospital last month ruled on Thursday, based on the medical evidence about which there was “virtually no dispute”, the orders were in the man’s best interests.
The case, he stressed, was not about switching off a life support machine or withholding existing supports, therapies, nutrition or hydration.
The evidence was administering increased ventilation or CPR would not improve the man’s condition, would cause him significant discomfort and pain and was against the clinical judgment of his treating doctors and other medics.
While there is “a very strong presumption” in favour of taking all steps to prolong life, there was no absolute duty on the court to consent to medical treatment for a ward in an effort to prolong life “at all costs” and without regard to any other consideration or circumstance of the ward’s best interests.
There was also no absolute duty on a doctor to provide, or on a patient to consent to, medical treatment to prolong life at all costs and without regard to other matters concerning a patient’s best interests.
The test is what treatment is in a ward’s best interests. It was also open to the court, in taking all circumstances into account, to have regard to clinical or ethical guidelines issued for example by the Medical Council or Royal Colleges.
There was no evidence of previous views expressed by the man, which was “hardly surprising” given his young age, he noted.
Extraordinary lengths
While opposing the ventilation orders, counsel for the parents, as a responsible member of the Bar, had said he could not argue against the CPR orders, the judge noted.
The man’s treating team, particularly the lead doctor, had gone to “extraordinary lengths” in seeking a consensus on the treatment between doctors and family members and there was no criticism of either doctors or parents consensus was not reached.
He sympathised with the parents and paid tribute to them and two particular doctors over their care. The doctors skill and knowledge was “matched by a level of compassion and empathy which does credit to their profession”, a fact fully acknowledge by the parents, he said.
Addressing the man’s father after delivering judgment, the judge said he had done his best. The father replied: “I understand.”
Earlier, the judge accepted uncontroverted evidence the man is in a state of MCS with limited level of consciousness and can probably feel pain.
He accepted his level of consciousness is such he is sometimes aware of the presence of persons and has some ability to enjoy the company of others as well as music or tv. It must also be presumed there was potential for distress, discomfort, anxiety and fear.
He accepted there is “sadly no realistic prospect” of any improvement in the man’s condition and he is likely to disimprove.
