Y (No 2), Re

A strong presumption supports treatment capable of prolonging life, reflecting the sanctity and value of life. The presumption is not irrebuttable. The court must make an objective assessment of the child’s best interests by weighing the benefits of treatment and prolonged life against its burdens, risks and likely consequences. Life-sustaining treatment may be contrary to best interests even without demonstrable pain or suffering where it offers no overall benefit. Respect for parental views is important, particularly where parents have shown sustained dedication to the child, but the child’s best interests remain paramount. Treatment that merely prolongs dying and imposes a grave, irreversible burden should not be authorised.

Kings College Hospital NHS Foundation Trust sought final declarations concerning treatment for Y, a seven-year-old child with spinal muscular atrophy type 1 and severe irreversible hypoxic-ischaemic brain injury following cardiorespiratory arrests. The declarations authorised the Trust not to provide endotracheal intubation, invasive ventilation, CPR or resuscitation drugs, while permitting analgesia and sedation to relieve pain or distress.

The declarations had initially been made at an out-of-hours hearing on 23 June 2015, with reasons given in [2015] EWHC 1920 (Fam). Following updated neurological and respiratory evidence, the court considered whether the declarations should be made final, notwithstanding the father’s inability to consent to them.

1. The declarations made on 23 June 2015 were continued. The court was satisfied that withholding intubation, invasive ventilation, CPR and resuscitation drugs, while providing medication or sedation for pain and distress, remained in Y’s best interests.

2. The court applied the welfare balance-sheet approach described by Thorpe LJ in Re A [2000] 1 FLR 549 at 560. The assessment required the benefits and possible gains of treatment to be weighed against its burdens, risks, discomfort and possible losses.

3. A strong presumption favoured treatment capable of prolonging life because of the sanctity and value of life. That presumption was not irrebuttable. The court had to exercise an objective and independent judgment, with Y’s best interests paramount.

4. The court attached significant weight to Y’s family life and to the parents’ wishes. Their sustained care and dedication, and their understanding of Y’s life, warranted great respect. Their views did not determine the outcome where the evidence showed that the proposed treatment would provide no overall benefit.

5. Although the evidence could not establish clearly whether Y experienced pain or psychological distress, life-sustaining treatment could still be contrary to her best interests where it could provide no overall benefit. The medical evidence established that further invasive ventilation would not reverse or ameliorate the irreversible neurological injury. It would prolong life without altering the prognosis, and would risk prolonged suffering, a permanent vegetative state and confinement in intensive care.

6. The court also considered the importance of a dignified death, referring to Portsmouth NHS Trust v Wyatt and Wyatt, Southampton NHS Trust Interventing [2005] 1 FLR 21 at 28. Treatment that merely prolonged dying and imposed a grave, irreversible burden was outweighed by the benefits of avoiding that treatment and allowing Y to remain physically close to her parents.

The judgment describes an out-of-hours hearing on 23 June 2015, at which interim declarations were made, followed by directions on 26 June 2015 and a final hearing on 2 July 2015. The earlier reasons were given in [2015] EWHC 1920 (Fam). This judgment continued the declarations.