Re NR (A Child: Withholding CPR)

Adam Tear solicitor at Scott Moncrieff & Associates acted for the Parents of NR in a recent case relating to ceiling on treatment sought by King’s College Hospital, who are treating NR. The full judgment is here The parents were represented before the Court by Katie Gollop KC and Myles Jackson.
 
NR is a child with severe disabilities and life-limiting health conditions. NR requires mechanical ventilation and faces challenges such as interstitial lung disease, abdominal discomfort, and recurrent sepsis. Despite limitations in verbal communication, evidence suggests NR can experience pleasure and pain, with monitoring through a FLACC score.
 
The Trust sought court declarations to withhold three types of treatment. The first was various medical treatments (such as inotropes) in the event that his condition worsened, the second was restriction of access to ventilatory support in the event that he was extubated and then deteriorated, and the third was CPR in the event of a cardiac arrest.
 
A week before the hearing, the parents proposed adjournment of determination of the application for the withholding of ventilatory support declarations. The Trust agreed to that at the door of the court. There was significant agreement about the first group of treatments and therefore the Court’s focus was on the withholding of CPR in the event of a further cardiac arrest.

Despite disagreements among the parties, as to what is the best interests of NR the court emphasised the key legal principles, including the paramount consideration of the child's best interests and a presumption in favour of preserving life.

Professional guidance from the Royal College of Paediatrics and Child Health is considered, particularly in relation to CPR.

The court accepted valid concerns about signalling future decisions on withdrawing life-sustaining treatment, but rejected them, on the basis that the Judge would exclude this from his decision-making approach. The Court determined the CPR issue now, to provide clarity for clinicians, parents, and NR. The decision aims to balance justice, fairness, and the unique circumstances of NR's case.
 
Medical experts project a bleak prognosis, estimating a limited life expectancy. The parents, guided by their religious beliefs, emphasise NR's meaningful life and wish for continued extended care. The medical experts were unanimous that CPR was unlikely to be successful.

Despite the parents' opposition, the court decided that it would is not be in NR's best interests to receive CPR, emphasising the physical burden it poses and the unlikely prospects of successful resuscitation. The ceilings on treatment would however be lifted for any planned procedures, for the period leading up to and six hours post operation. The Court also emphasised that whilst its declarations permitted a ceiling of treatment, they did not prevent stop any clinician from providing such treatment if they considered it to be clinically justified.
 
The judgment acknowledges the parents' devotion and expresses gratitude for their collaborative approach, recognising the difficulty of the decisions they face. The court's decision aims to provide clarity to all parties while emphasizing the ongoing respect for NR's best interests and the legal principles outlined in the judgment.
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Adam Tear and the legal team will continue to advise and represent the parents between now and the final hearing listed for 3 days in April. Prior to that hearing, the Trust may pursue its application for a ceiling of ventilatory treatment, if NR meets the criteria for extubation, or it may apply for a declaration that it is lawful for ventilation to be withdrawn with the consequence that NR will die.