NR (A Child: Withdrawal of Life Sustaining Treatment), Re

When deciding whether life-sustaining treatment should continue, the court must determine whether giving the treatment is in the child’s best interests. Best interests are assessed broadly, from the child’s perspective, and include medical, social and psychological welfare. The court must weigh the treatment’s benefits and burdens, consider the child’s condition and prognosis, and take account of the views of parents, clinicians and others involved in the child’s care.

There is a strong presumption in favour of preserving life, but it may be displaced where the burdens of the child’s condition and treatment substantially outweigh the benefits. Withdrawal of treatment is legally distinct from euthanasia. The child’s best interests remain decisive, although parental religious and family views must be conscientiously considered.

King’s College Hospital NHS Foundation Trust applied for a declaration that it would be lawful and in NR’s best interests to withdraw invasive ventilation and other life-sustaining treatment. NR was four years old, had severe congenital disabilities and brain malformation, and had required invasive ventilation continuously after cardiac arrests.

The application was supported by NR’s Children’s Guardian and opposed by his parents. The court considered medical evidence about NR’s prognosis, pain, distress, limited awareness, and the burdens and benefits of continued treatment. It also considered the parents’ religious convictions, Convention rights, and their wish for any extubation to occur at home. The central issue was whether continued life-sustaining treatment remained in NR’s best interests.

1. Application granted. The court declared that it would be lawful and in NR’s best interests for invasive ventilation and other life-sustaining treatment to be discontinued.
2. The governing question was whether continuing to give the treatment was in NR’s best interests. Best interests had to be assessed from NR’s assumed perspective and in the widest sense, including medical, social and psychological welfare. The court considered the treatment’s nature, burdens, prospects and likely outcome, NR’s likely attitude, and the views of those concerned with his welfare.
3. There was a strong presumption in favour of preserving life. It was not lightly displaced, but it could yield where other considerations outweighed it. The court had to avoid speculation about NR’s subjective experience and decide the issues on the evidence.
4. NR could respond to painful and comforting stimuli, but his awareness was extremely limited. His life-sustaining treatment caused significant discomfort, pain and distress. It could prolong life for a limited period but could not improve his underlying condition, and invasive ventilation had itself caused harm. His life was markedly diminished and there was no realistic prospect of returning home for continuing care over weeks or months.
5. The medical consensus was that the burdens of NR’s condition and treatment substantially outweighed the benefits. The parents’ devotion, religious beliefs and wishes were relevant and received due weight, but they did not determine the outcome. NR’s best interests prevailed, consistently with the parents’ Convention rights.
6. Withdrawal of treatment was legally distinct from euthanasia. The declaration concerned the lawfulness and best interests of continuing treatment; it did not authorise an act intended to kill NR. Urgent planning for home extubation with palliative care was permitted if the parents wished, with hospice or hospital arrangements as alternatives. The previous ceilings-of-treatment order remained in force.