NHS Trust v Parents & S

In determining whether life-sustaining treatment should be withdrawn from a child lacking capacity, the court must assess the child’s welfare in the widest sense. Medical, emotional, sensory and instinctive considerations must all be considered, together with the strong presumption in favour of preserving life.

No single factor is determinative. The court must balance the benefits of continued life and relationships against the treatment’s burdens, including pain, discomfort, invasive procedures, complications and the absence of any realistic prospect of improvement. Parental views must be respected and carefully considered, but the parents’ wishes are relevant only insofar as they illuminate the child’s welfare. Where the burdens of treatment outweigh its benefits, withdrawal may be declared lawful and palliative care authorised.

The NHS Trust applied for declarations concerning S, an infant with severe and permanent hypoxic-ischaemic brain injury who had remained ventilator-dependent since birth. It sought declarations that S lacked capacity, that continued life-sustaining treatment was not in his best interests, and that treatment could lawfully be withdrawn, with specified forms of emergency treatment withheld.

The Children’s Guardian supported the application. S’s parents opposed it and sought continuation of intensive treatment, hoping that he might improve and eventually return home. The central issue was whether continued ventilation and associated treatment were in S’s best interests.

1. Declarations granted. The court declared that S lacked capacity to make decisions about medical treatment, that continued life-sustaining treatment was not in his best interests, and that withdrawal of treatment with palliative care was lawful.
2. The welfare assessment was objective and had to encompass medical, emotional, sensory and instinctive considerations. There was a strong presumption in favour of prolonging life, but it was not absolute. The court had to take an overarching view of all the circumstances, with no single factor determining the outcome.
3. The medical evidence established permanent and irreversible brain damage. S had no realistic prospect of breathing independently, feeding orally, seeing, hearing, mobilising or performing activities of daily living. Continued ventilation therefore offered no realistic prospect of improvement.
4. The burdens of treatment were substantial. They included frequent suctioning, tube replacement, imaging, medication, invasive procedures, the risk of infection, pain and discomfort, and possible future complications including contractures, epilepsy, aspiration pneumonia, apnoea and cardiac arrest.
5. The parents’ love, care, hopes and religious views were carefully considered. Their views could illuminate the value of the parent-child relationship, but their own wishes could not determine S’s objective best interests. The court accepted that parental observations might be coloured by understandable hope and emotion.
6. The proposed continuation or limitation of treatment would leave S exposed to the existing burdens without a realistic therapeutic benefit. The burdens and possible suffering outweighed the benefits of prolonging life. Option 5—withdrawal of life-sustaining treatment and high-quality palliative care—was the only option in S’s best interests.