Factual and Procedural Background
The Applicant, a 79-year-old female referred to as PL, suffered a catastrophic bilateral stroke resulting in severe physical disability, brain damage, and significant incapacity. She has been receiving continuous nursing care in a residential home and is maintained alive solely through Clinically Assisted Nutrition and Hydration (CANH) administered via a Percutaneous Endoscopic Gastrostomy (PEG) tube. The Applicant's son, acting as litigation friend, applied to the Court of Protection seeking a declaration that continuation of CANH was not in PL's best interests, which would lead to its lawful discontinuance and PL's subsequent death. The Sutton Clinical Commissioning Group (CCG), responsible for commissioning nursing care, remained neutral but supported court involvement. The Second Respondent, a local authority, was neither present nor represented.
The application was initially made under section 21A of the Mental Capacity Act 2005 (MCA 2005) but was reconstituted under sections 15 and 16 MCA 2005 following a Court of Appeal decision. The court held a two-day hearing, receiving evidence from medical experts, family members, and others involved in PL's care. The court was tasked with assessing PL's current condition, capacity, and best interests regarding continuation or withdrawal of CANH.
Legal Issues Presented
- What is PL's current medical condition, level of consciousness, and awareness of her surroundings?
- Does PL have the mental capacity to decide on the continuation of CANH, and is there a prospect of regaining such capacity?
- If PL lacks capacity, is it in her best interests to continue CANH, considering:
- Her previously expressed views on life-sustaining treatment;
- The quality of her current life, including enjoyment and distress;
- The prognosis if CANH continues;
- The prognosis and palliative care arrangements if CANH is withdrawn;
- The implications of withdrawing nutrition but not hydration;
- The views, wishes, and feelings of family and carers;
- PL's dignity;
- The sanctity of life principle.
Arguments of the Parties
The opinion does not contain a detailed account of the parties' legal arguments.
Table of Precedents Cited
| Precedent |
Rule or Principle Cited For |
Application by the Court |
| Airedale NHS Trust v Bland [1993] AC 789 |
Artificial feeding as medical treatment; sanctity of life principle; respect for patient self-determination. |
Confirmed CANH as life-sustaining treatment and emphasized the need to respect PL's previously expressed wishes regarding life support. |
| R (Burke) v GMC [2005] QB 424 |
Burden of proof lies with those asserting withdrawal of life-sustaining treatment; importance of sanctity of life. |
Applied the principle that the decision to discontinue life-sustaining treatment must be proved to be in the patient's best interests. |
| Re B (Care Proceedings: Standard of Proof) [2008] UKHL 35 |
Civil standard of proof ("balance of probabilities") applies in capacity and best interests findings. |
The court applied the civil standard of proof in assessing PL's capacity and factual findings. |
| Re M (Adult Patient)(Minimally Conscious State: Withdrawal of Treatment) [2012] 1 WLR 1653 |
Consideration of dignity and best interests in life-sustaining treatment decisions for incapacitated adults. |
Referenced to emphasize dignity and the nuanced approach to consciousness states in best interests decisions. |
| Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 |
Best interests must be considered broadly, including social and psychological welfare, not only medical factors. |
Guided the court's holistic approach to PL's welfare and best interests assessment. |
| Director of Legal Casework & Others v Briggs [2017] EWCOP 53 |
Application of best interests test; importance of patient wishes in life-sustaining treatment decisions. |
Supported the approach of giving significant weight to PL's previously expressed wishes, analogous to Mr. Briggs' case. |
| Ferreira v HM Senior Coroner for Inner South London and Others [2017] EWCA Civ 31 |
Deprivation of liberty considerations for incapacitated patients in hospital; cause of confinement. |
Informed the court's provisional view that no deprivation of liberty authorization would be required for PL's palliative care admission. |
| Schloendorff v. Society of New York Hospital (1914) 105 N.E. 92 |
Principle of patient self-determination over medical treatment. |
Referenced to reinforce the principle that a competent patient's refusal of treatment must be respected. |
| Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital [1985] AC 871 |
Consent and refusal of medical treatment by patients of sound mind. |
Supported the respect for patient autonomy in treatment decisions. |
| In re T. (Adult: Refusal of Treatment) [1993] Fam 95 |
Validity of advance refusals of treatment and their application in later circumstances. |
Considered in assessing the weight of PL's past expressed wishes despite no formal advance decision. |
Court's Reasoning and Analysis
The court carefully evaluated PL's medical condition, concluding she is severely disabled with profound cognitive and communicative impairments, lacking capacity to decide on CANH and unlikely to regain it. PL's condition does not fit neatly into recognized consciousness categories such as minimally conscious or vegetative state, but her cognitive deficits are profound and enduring.
The court gave significant weight to PL's clearly expressed past wishes against artificial life-sustaining treatment, as relayed reliably by family and friends, despite the absence of a formal advance decision. These wishes were consistent, unequivocal, and applicable to her current circumstances.
Evidence indicated that PL's current quality of life is minimal, with little consistent enjoyment and occasional distress, though she is well cared for and maintained with dignity. The prognosis with continued CANH is bleak, with no realistic prospect of meaningful recovery and risks of complications and further deterioration.
The court considered palliative care arrangements following withdrawal of CANH, including the recommendation that both nutrition and hydration be withdrawn together to minimize distress, as advised by the expert leading the palliative care unit. The family unanimously supported withdrawal as aligning with PL's wishes and best interests.
The court balanced the strong presumption in favour of preserving life, rooted in the sanctity of life principle, against PL's own values and expressed wishes, concluding that the presumption is rebutted in this case. The court emphasized that the best interests test is distinct from substituted judgment but incorporates the patient's values and preferences as a critical component.
Finally, the court addressed the issue of deprivation of liberty in the context of PL's anticipated move for end-of-life care, concluding that no deprivation of liberty authorization would be necessary given her clinical condition and treatment setting.
Holding and Implications
The court held that it is not in PL's best interests to continue Clinically Assisted Nutrition and Hydration (CANH), and therefore authorized its lawful discontinuance. This decision was based on a holistic assessment of PL's medical condition, capacity, previously expressed wishes, quality of life, prognosis, and the sanctity of life principle balanced against self-determination.
The direct consequence of this ruling was the withdrawal of CANH, followed by the provision of palliative care, leading to PL's peaceful death. The judgment sets no new legal precedent but reaffirms established principles concerning best interests decisions under the Mental Capacity Act 2005, particularly the weight to be accorded to an incapacitated person's past wishes in decisions about life-sustaining treatment.