Court Declares Withholding CPR in Best Interests of Child with Severe Disabilities: Re NR (A Child) Case Analysis

Citation: [2024] EWHC 61 (Fam)
Judgment on

Introduction

The case of Re NR (A Child: Withholding CPR) [2024] EWHC 61 (Fam) raises critical ethical and legal questions regarding the withholding of life-sustaining medical treatment, specifically cardiopulmonary resuscitation (CPR), in the context of a child with severe disabilities and life-limiting health conditions. The judgment, delivered by Mr Justice Poole, carefully applies established legal principles to determine whether it would be in the child’s best interests to withhold CPR, amidst the differing views of the clinicians and the child’s parents.

Key Facts

NR, a child born with severe disabilities, suffers from multiple health conditions, including brain malformation and chronic respiratory failure, requiring extensive medical treatment and life support. NR’s health has deteriorated significantly, with a bleak prognosis. The Applicant Trust sought declarations to lawfully withhold certain medical treatments, including CPR, should NR’s condition deteriorate and lead to cardiac arrest. While NR’s parents opposed the declaration regarding CPR, all parties agreed on certain “ceilings of care”, except for the issue of administering inotropes outside of a planned procedure.

The court applied the following key legal principles in making its decision:

  1. Best Interests: The child’s best interests are the paramount concern. In Aintree v James [2013] UKSC 67, Baroness Hale emphasized focusing on whether treatment is in the patient’s best interests rather than on withholding or withdrawing it.

  2. Welfare in the Widest Sense: Decision-makers must look at the patient’s welfare broadly — not just medical but also social and psychological aspects.

  3. Presumption in Favor of Preserving Life: There is a strong presumption for life preservation which can be rebutted if other considerations carry greater weight (In Re J (A Minor) [1001] Fam 33).

  4. Views of Clinicians and Parents: The views of parents, clinicians, and others should be considered but are not determining (An NHS Trust v MB [2006] EWHC 507).

  5. Professional Guidance: The Royal College of Paediatrics and Child Health’s framework was referred to, which considers withholding or withdrawing life-sustaining treatment ethical under certain conditions.

  6. Article 8 of the European Convention on Human Rights (ECHR): The ECHR’s right to respect for private and family life underscores the need to respect and protect NR’s dignity and the family’s beliefs.

The court evaluated the facts of the case against these principles, which guided the focus on CPR following cardiac arrest and other treatments’ viability for NR.

Outcomes

Mr Justice Poole concluded that administering CPR would not be in the best interests of NR. This was based on several factors:

  • CPR’s potential to cause pain, distress, or harm;
  • The low likelihood of success and possibility of further complicating NR’s already grave condition;
  • The potential for CPR to result in a “traumatic and undignified” end for NR, as noted in the RCPCH guidelines.

The court determined the declaration sought by the Applicant Trust was justified and declared that withholding CPR in case of cardiac arrest would be lawful. This decision provides clarity for the healthcare professionals and the parents on the lawful courses of action, without suggesting prejudgment on any future applications regarding the withdrawal of life-sustaining treatment.

Conclusion

In Re NR (A Child: Withholding CPR), the court’s decision reflects a careful balance of legal principles, medical evidence, and the consideration of NR’s best interests, marked by respect for the views of the parents and the dignity of the child. The case reinforces the need for nuanced application of the law in complex medical and ethical scenarios, particularly where the withholding of life-supporting treatments is in question.