AA (A Child), Re

In deciding whether life-sustaining treatment should be withheld from a child, the court must determine the child’s best interests. Treatment may properly be withdrawn where it offers no prospect of improving the child’s quality or potential life and merely prolongs burdensome suffering. Death need not be imminent in minutes or hours. The court may consider established clinical frameworks concerning futile or burdensome treatment, although those criteria are not determinative. The decisive question remains whether continuing treatment provides an overall benefit to the child.

Great Ormond Street Hospital for Children NHS Trust applied for a declaration that withdrawing artificial hydration from AA, a 12-year-old child with profound neurological and developmental disabilities, was lawful and in her best interests.

AA was terminally ill and suffering increasingly severe, unmanageable pain. Her nutrition had already been withdrawn with the agreement of her mother and the medical professionals. The issue was whether hydration should also cease, although AA was not immediately dying and her heart and breathing continued.

1. Best interests. The court had to ascertain AA’s best interests when considering whether to declare that life-sustaining treatment could lawfully be withheld. The governing law was taken from Re KH (Medical Treatment: Advanced Care Plan) [2013] IFLR 1471, based on An NHS Trust v MB (a child represented by CAFCASS as guardian ad litem) [2006] EWHC 507 (Fam); [2006] 2 FLR 319.
2. Clinical framework. The framework identified “no chance”, “no purpose” and “unbearable” situations in which withholding or withdrawing treatment may be considered. In a “no chance” situation, treatment may delay death without improving the patient’s quality or potential life. Continuing such treatment may be futile, burdensome and contrary to the patient’s best interests. The criteria assisted the court but were not determinative.
3. Application. AA’s condition was irreversible and her death inevitable, although it was not imminent in terms of minutes or hours. Extending her life would provide no overall benefit and, on the unchallenged medical evidence, would prolong unremitting and unmanageable pain. The fact that treatment might continue life for some time did not make it beneficial.
4. Order. It was no longer in AA’s best interests to receive hydration. The declaration sought by the hospital was granted.