Kings College Hospital NHS Foundation Trust v MH

When parents and treating doctors disagree about life-sustaining treatment for a child, the court must determine the child’s best interests. There is a strong but rebuttable presumption in favour of prolonging life. The court must balance all relevant medical, emotional and welfare factors from the assumed viewpoint of the child, while treating the child’s best interests as paramount.

Life-sustaining treatment may lawfully be withheld where it would provide little or no benefit, would impose a grave and irreversible burden, or would merely prolong life without improving the prognosis. The court must form its own view and is not bound by the treating clinicians’ assessment, although responsible medical opinion and relevant professional guidance require close attention.

The applicant NHS Trust sought urgent declarations concerning treatment for Y, a seven-year-old child with spinal muscular atrophy type 1, severe irreversible hypoxic-ischaemic brain injury and rapidly deteriorating respiratory function.

Y’s treating clinicians considered that further intubation, invasive ventilation and CPR would provide no meaningful benefit and would impose a significant treatment burden. Y’s father, speaking for both parents, sought intubation and ventilation, believing that Y might recover. The application was heard by telephone out of hours because Y might die before the next court sitting.

The central issue was whether withholding intubation, invasive ventilation and CPR was lawful and in Y’s best interests.

1. Declarations granted. It was lawful and in Y’s best interests to withhold endotracheal intubation, invasive ventilation, CPR and resuscitation drugs. Pain relief and sedation were lawful if required to relieve pain or distress, even though they might reduce respiratory drive and shorten life in an end-of-life situation.
2. Where parents and treating doctors dispute life-sustaining treatment, the court may grant a declaration under its inherent jurisdiction. It cannot compel doctors to provide treatment contrary to their professional judgment. The court must nevertheless form its own view of the child’s best interests.
3. There is a strong, but rebuttable, presumption in favour of prolonging life. The court must identify and balance all relevant medical, emotional and welfare factors, considering the issue from the assumed viewpoint of the child and treating the child’s best interests as paramount.
4. The relevant factors included the value of Y’s life, the parents’ views, the likely medical benefit of treatment, the burdens and risks of further treatment, Y’s quality of life, her dignity and the consequences of permanent invasive ventilation. The proposed treatment would probably prolong life but would not improve Y’s prognosis. It was likely to initiate an irreversible cycle of intubation and extubation, with eventual permanent ventilation and confinement to intensive care.
5. The Royal College guidance was not binding, but was entitled to the closest attention and deep respect. The evidence established that further invasive ventilation and CPR would provide little or no benefit and would impose a grave burden. Those burdens outweighed the benefit of prolonging life.
6. The urgency justified an out-of-hours telephone determination, despite the absence of legal representation for the father, a wider welfare assessment and an updated second opinion. Y was joined as a party, Cafcass was invited to appoint a Children’s Guardian, and the matter was listed for further consideration after legal representation, welfare enquiries and updated medical opinions were available.