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Re K (A Minor) [2006] EWHC 1007 (Fam)

President’s reasons for declaration allowing withdrawal of medical treatment from critically ill child.

Family Division: Sir Mark Potter P (9 May 2006)

Summary
President's reasons for declaration allowing withdrawal of medical treatment from critically ill child.

Background
K was born prematurely in September 2005 with an inherited condition called congenital myotonica dystrophy (CMD). She remained in hospital and subject to treatment by the hospital Trust since her birth. Within the first eleven weeks of her life, she needed four periods of mechanical ventilation to assist her breathing, and she had severe feeding difficulties. By mid-December, her development was markedly delayed, and she had little interaction with her surroundings; she was critically ill on a mechanical ventilator and on a broad spectrum of antibiotics to treat her septicaemia infection.

The medical staff reached the opinion that she had a very small prospect of recovering from her medical problems, and the Trust sought the permission of the court to allow them not to provide artificial mechanical ventilation or cardio-pulmonary resuscitation in the event of K having a further episode of collapse due to her underlying condition. On 20 December, an order was made in those terms. The order included a declaration which envisaged that K might recover from her septicaemic illness and would be weaned from assisted ventilation but would still require artificial intravenous feeding; in those circumstances, the Trust could apply to the court for further directions and guidance.

That stage had now been reached and, on 6 April, the President made a declaration to enable the medical staff of the Trust to remove from K's abdomen a tube necessary to maintain her nutrition, and to move to a regime of palliative care in order to allow her to die peacefully over a short period of time. This judgment set out the President's reasons as at the time of the application, even though K had in fact died by the time of this judgment.

Findings
The President had before him position statements filed on behalf of K's mother and father, the local authority who shared parental responsibility for K, and K's guardian who visited K in hospital and saw her, speaking also to members of the nursing staff and the mother and father who were there.

The consultant caring for K referred to the publication by the Royal College of Paediatrics and Child Health, 'Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice' (2nd Edition) May 2004. While this publication is not authoritative as to the law, it aims to provide a framework on which to construct a reasoned and compassionate approach to withholding or withdrawing treatment from patients; the Summary sets out five situations in which the authors consider it may be ethical and legal to consider withholding or withdrawal of life-sustaining medical treatment. In this case, the medical team had reached a view with great confidence that K fell into category three (the 'no chance' situation), being of the opinion that K had no chance of survival into childhood without artificial intravenous feeding; and the team was also of the opinion that K fell into category four (the 'no purpose' situation) in any event.

This was a comparatively unusual case to come before the court in the sense that the declaration sought was non-contentious, all parties concerned being in agreement with the views of the medical professionals involved that life-prolonging treatment should cease. Indeed, had the necessity for parental consent simply rested with the father and mother in this case, the matter would not have come to court, the medical professionals being satisfied that their ethical and legal obligations would not be breached by the proposed action.

Nevertheless, the court was not bound by the clinical assessment of what was in K's interests, and had to reach its own conclusion on the basis of a broad spectrum of considerations after careful consideration of the evidence before it. The President reviewed the relevant case-law, in particular: Re J (A Minor) (Wardship: Medical Treatment) [1991] Fam 33 (in relation to the heavy burden placed on those who advocate a course which would lead inevitably to the cessation of a human life); Wyatt v Portsmouth Hospitals NHS Trust and Charlotte Wyatt [2005] EWCA Civ 1181; and An NHS Trust v MB [2006] EWHC 507 (Fam), which confirmed that all cases of this kind are highly fact-sensitive, and the outcome in one particular case did not preclude a different decision in this case.

Read the full text of the judgment here