Court of Protection Balances Best Interests and Autonomy in Nutrition and Hydration Case

Introduction

The case of East Suffolk and North Essex NHS Foundation Trust v DL & Anor [2023] EWCOP 47 presents the challenging intersection of mental capacity, healthcare treatment, and best interest decisions within the Court of Protection’s jurisdiction. The court was tasked with making a determination about the best course of action regarding the provision of nutrition and hydration to a woman, DL, who lacked the capacity to make such decisions for herself.

Key Facts

DL, a woman in her thirties with a range of psychiatric conditions and a history of aggressive behavior, was detained under section 3 of the Mental Health Act 1983. She had been refusing nutrition and hydration, resulting in a life-threatening condition. The court was presented with two options: to provide nutrition and hydration via nasogastric tube with restraint if necessary (the “Treatment Plan”), or under sedation in intensive care utilizing a peripherally inserted central catheter (PICC) line for feeding (the “Escalation Plan”).

The case was heard before Ms Justice Henke, who meticulously considered the medical evidence, DL’s expressed wishes and feelings, and submissions from legal representatives, including DL’s litigation friend, the Official Solicitor.

Legal Principles

Several legal principles from the Mental Capacity Act (MCA) 2005 and case law were applied:

Capacity

First and foremost, the court assessed DL’s capacity under the MCA 2005, finding she lacked the capacity to make decisions regarding her hydration and nutrition based on evidence from her psychiatrist, Dr A.

Best Interests

The heart of the case lay in determining DL’s best interests under section 4 of the MCA 2005, which involves a holistic assessment encompassing medical, social, and psychological welfare. This principle requires considering the patient’s wishes, feelings, beliefs, and values, where ascertainable, as well as the views of family and other interested parties.

Restraint

The potential use of restraint raised issues under section 6 of the MCA 2005, which permits acts in connection with care or treatment that are in the best interests of someone who lacks capacity. The necessity and proportionality of restraint were carefully scrutinized, especially given DL’s past trauma and the psychological impact.

The court also considered the principle of least restriction, aiming to choose the option that least infringed upon DL’s rights and freedoms.

Right to Life

Respect for the inherent value of human life was affirmed through reference to NHS Trust v Y [2018] UKSC 46, which emphasizes not relinquishing life easily.

Procedural Matters

The applicability of the MHA 1983 versus the MCA 2005, and jurisdictional questions concerning the court’s role, were informed by case law including JK v A Local Mental Health Board [2019] EWHC 679 (Fam).

Outcomes

Justice Henke concluded that the Treatment Plan was not a realistic option given DL’s history and likely psychological response to such measures. Instead, she determined that the Escalation Plan was in DL’s best interests, considering DL’s wishes to be sedated during treatment and the risks presented by the proposed treatment options.

The judgment mandated careful respect for DL’s privacy and dignity during transport and treatment and acknowledged the role of DL’s strong, supportive relationship with her siblings in the decision-making process.

Conclusion

In East Suffolk and North Essex NHS Foundation Trust v DL & Anor, the court balanced complex and competing considerations of life preservation, the patient’s autonomy, and the psychological impact of proposed medical interventions. The legal principles applied from the MCA 2005, particularly around capacity and best interest decisions, underpinned the court’s careful navigation of these issues. Ultimately, the decision prioritized DL’s expressed wishes within a framework of protecting her right to life and respecting her unique psychological makeup and history. The case underscores the critical role of the Court of Protection in safeguarding the rights and welfare of individuals who lack the capacity to make certain decisions about their care and treatment.