NR (A Child: Withholding CPR), Re

When deciding whether life-sustaining treatment may lawfully be withheld from a child, the court must determine whether providing the treatment is in the child’s best interests. Best interests are assessed from the child’s perspective and in the widest sense, including medical, social and psychological considerations. There is a strong but rebuttable presumption in favour of preserving life. The court must assess the particular treatment, its burdens, prospects of success and likely outcomes, while taking account of the views of parents, clinicians and others concerned with the child’s welfare. No individual’s view is decisive. CPR may lawfully be withheld where, on the evidence, it is unlikely to succeed, would itself cause significant pain or distress, or would leave the child worse off than before.

King’s College Hospital NHS Foundation Trust applied for declarations that it would be lawful to withhold specified forms of life-sustaining treatment from NR, a child with severe disabilities, irreversible brain injury and life-limiting conditions. The parties agreed ceilings of care concerning inotropes and other treatment. The remaining principal dispute concerned CPR following a future cardiac arrest.

The parents opposed the CPR declaration and argued that the issue should be determined together with any future decision about extubation or withdrawal of ventilation. The court confined its determination to CPR while NR remained intubated and ventilated, and considered whether withholding CPR would be in his best interests.

The court granted a declaration that it would be lawful not to administer CPR if NR suffered a cardiac arrest. It also declared that inotropes could lawfully be withheld, subject to an exception for low-dose inotropes to correct hypotension caused by medication and for specified planned procedures.

1. The court’s task was to decide whether providing CPR was in NR’s best interests, rather than whether withholding it was independently in his best interests. The relevant principles included those stated in Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67, [2014] AC 591.
2. Best interests had to be assessed from NR’s assumed viewpoint and in the widest sense. The strong presumption in favour of preserving life was rebuttable. The views of the parents, clinicians and Guardian were relevant but none was decisive.
3. The court considered the burdens of CPR, including chest compressions, possible rib injury, defibrillation, inotropes, pain and distress. CPR was unlikely to succeed because of NR’s depleted physiological reserves and general condition. If successful, it might cause further brain injury and would lead to burdensome post-cardiac-arrest care.
4. The parents’ religious convictions, wishes and understanding of a good death were fully considered. They did not outweigh the evidence that CPR was contrary to NR’s best interests. The declaration did not compel clinicians to withhold CPR; it confirmed that doing so would be lawful.
5. The decision concerned only CPR after cardiac arrest while NR remained intubated and ventilated. It did not determine whether ventilation or other life-sustaining treatment should later be withdrawn, and did not prejudice any future application.