A Hospital Trust v P & Ors

In deciding whether life-sustaining treatment should be withdrawn from a child, the court must determine the child’s best interests independently and holistically. Best interests include medical, emotional, sensory, social and psychological considerations. The court must consider the child’s likely attitude, the nature and burdens of treatment, its prospects of success, and the likely outcome. There is a strong but rebuttable presumption in favour of preserving life. Treatment may be withdrawn where its burdens, including pain and distress, substantially outweigh any benefit and there is no prospect of meaningful recovery. The court’s decision is not determined solely by clinical opinion, parental wishes or Convention rights.

The Hospital Trust applied under the inherent jurisdiction for declarations that continuing life-sustaining treatment for P, a two-year-old child with an irreversible and catastrophic brain injury, was not in her best interests and that palliative care should be implemented.

P had remained ventilated and unconscious after suffering cardiac arrest and extensive brain injury. The medical evidence was unanimous that she would not recover, that ventilation provided no therapeutic benefit, and that treatment was burdensome and likely painful. The local authority and children’s guardian supported the application. The parents left the decision to the court, while wishing that P might continue to live.

The central issue was whether withdrawal of ventilation and implementation of a palliative care plan were in P’s best interests.

1. Application granted. The court declared that it was not in P’s best interests for life-sustaining treatment to continue and that it was in her best interests for a palliative care regime to be implemented.
2. The court’s paramount consideration was P’s best interests. It had to exercise an independent and objective judgment, taking over the parents’ decision-making role. It was not bound by the doctors’ clinical assessment, although the medical evidence was highly significant.
3. The assessment required a holistic appraisal of P’s welfare. The court considered her likely attitude to treatment, the wider medical, emotional and psychological consequences, the nature and burdens of ventilation, its prospects of success, and the likely outcome. The strong presumption in favour of preserving life was important but not absolute.
4. The evidence established that P’s brain injury was permanent, that she could not interact with the world, and that no treatment could improve her condition. Ventilation and associated procedures were invasive, burdensome and likely to cause pain or distress. Continuing treatment offered no discernible benefit other than preservation of life itself.
5. P’s rights under articles 2 and 8 of the European Convention on Human Rights, and potentially article 9, were considered through the prism of her best interests. Where Convention rights conflicted with those interests, P’s best interests were determinative.
6. The court therefore authorised compassionate extubation, withdrawal of assisted ventilation, and high-quality palliative care, with appropriate pain relief and sedation and arrangements for P’s parents and extended family to be present.