The Trust v Z and Others (Withdrawal of Medical Treatment)

In determining whether life-sustaining treatment should continue, the court must make an independent assessment of the child’s best interests. That assessment is broad and fact-sensitive. It includes medical, social, emotional, psychological and sensory considerations, together with the child’s and parents’ Convention rights.

There is a strong presumption in favour of preserving life, but it is not irrebuttable. It may be displaced where continued treatment offers no realistic prospect of recovery or improvement and its burdens, including pain, distress and invasive complications, outweigh its benefits. Treatment may be futile even though it prolongs life. The court must balance these matters proportionately and may approve withdrawal and ceilings of treatment where that balance clearly favours palliative care.

The Trust applied for declarations permitting the withdrawal of life-sustaining treatment from Z, a ten-month-old child with profound congenital neurological abnormality, further hypoxic-ischaemic brain injury, severe dystonia, gut failure and dependence on ventilation and total parenteral nutrition. Z’s parents opposed the application and wished treatment to continue. His Children’s Guardian supported it.

The court heard evidence from the treating consultants and considered supporting second opinions. The central questions were whether continued treatment remained in Z’s best interests, whether treatment was futile in the relevant sense, and whether ceilings of treatment should be imposed under a palliative care plan.

1. The court granted the Trust’s application and made the requested declarations permitting withdrawal of life-sustaining treatment and the imposition of ceilings of treatment in accordance with the proposed Redirection of Care and Palliative Care Plan.

2. The governing question was Z’s best interests in the widest sense. The court had to exercise its own independent judgment, while considering the medical evidence, the parents’ wishes, Z’s circumstances, the strong presumption in favour of preserving life, and the rights protected by Articles 2 and 8 of the European Convention on Human Rights. The framework summarised in Raqeeb v Barts NHS Foundation Trust [2019] EWHC 2531 (Admin) and [2019] EWHC 2530 (Fam) was accepted.

3. The presumption in favour of preserving life was important but could be rebutted. The court had to balance the benefits of prolonging life against the burdens of treatment, including pain, distress, invasive procedures, recurrent complications and the absence of any realistic prospect of recovery or improvement.

4. On the undisputed evidence, Z’s neurological and gastrointestinal conditions were irreversible and life-limiting. Continued intensive treatment was futile in the sense that it could not cure or improve the underlying conditions. It exposed him to continuing pain, distress and serious complications, while medication had reached its safe limits. Brief comfort from parental touch did not outweigh the wider clinical evidence.

5. The uncertainty of life expectancy did not alter the outcome. The proposed plan offered greater flexibility in managing future pain and discomfort. In the circumstances, the burdens of continued treatment clearly outweighed its benefits and withdrawal was in Z’s best interests.

6. Z was subsequently extubated and died peacefully in his parents’ arms.