AC (A Minor) & Ward of Court
| Jurisdiction | Ireland |
| Judge | Mr. Justice Kelly |
| Judgment Date | 22 October 2019 |
| Neutral Citation | [2019] IEHC 691 |
| Docket Number | [WOC 10234] |
| Court | High Court |
| Date | 22 October 2019 |
[2019] IEHC 691
THE HIGH COURT
WARDS OF COURT
Kelly
[WOC 10234]
IN THE MATTER OF A.C., A MINOR AND A WARD OF COURT
Medical treatment – Curative intent treatment – Palliative intent management – Important treatment decisions needed to be taken in the best interests of the minor – Whether curative intent treatment or palliative intent management should be provided to the minor
Facts: The minor, a five-year-old boy, had a diagnosis of very high risk neuroblastoma. This application to the High Court arose in circumstances where important treatment decisions needed to be taken in his best interests in circumstances where his parents disagreed on whether curative intent treatment or palliative intent management should be provided to the minor.
Held by the High Court (Kelly P) that it was in the best interests of the minor that curative intent treatment should be proceeded with. Kelly P came to that conclusion for the following reasons: (1) there was a unanimous view of all relevant medical experts who had been consulted that, on balance, curative intent treatment should proceed; (2) the curative intent treatment was mainstream treatment and not experimental; (3) whilst the survival rate was as low as 10-20%, there was a realistic possibility of a cure; (4) the mother strongly supported the curative intent treatment and its immediate commencement; (5) the father had been rather more affected by emotion and sentiment than by reason; (6) the five-year-old had neither the maturity nor insight to understand his position; (7) the decision to commence curative treatment immediately was not final; (8) the first element of the treatment was of one month’s duration and if that started immediately it would be finished by the end of November and thus it was unlikely that there would be any treatment involved over the Christmas period.
Kelly P held that the minor should proceed to have the curative intent treatment as recommended by the consultant oncologist and that it should commence as soon as possible so as to minimise the risks of the tumour becoming active again.
Judgment approved.
This is a harrowing case. It involves a five-year-old boy A.C. (the minor) who has a diagnosis of very high risk neuroblastoma.
This application arises in circumstances where important treatment decisions need to be taken in his best interests in circumstances where his parents disagree on whether curative intent treatment or palliative intent management should be provided to the minor.
To borrow the words of Hayden J. in Manchester University Hospital v. M. [2019] EWHC 468 “It is difficult to imagine a more onerous question for a court to address” but address it I must where every effort to obtain agreement between the parents has failed.
The minor's mother L.T. (the mother) and his father M.C. (the father) are not married to each other. They have two other children who are aged eight and six respectively.
They cohabited together with their children until May 2019. They have been cohabitants with the minor for not less than 12 consecutive months since 18th January, 2016 and thus the father satisfies the cohabitation requirement under s.2 subs. 1 and 4A of the Guardianship of Infants Act 1964 as amended. He is therefore a legal guardian of the minor.
The father is a plumber by trade but has not worked in that capacity for many years. Instead he has been the principal carer for all three children looking after the domestic arrangements.
The mother is a bank official and her earnings provide the finances for the running of the household. The mother has an alcohol addiction for which she received inpatient treatment in April 2019 and is continuing to engage with post inpatient treatment supports. She is now well and fully functioning.
Up to the time of her alcohol addiction manifesting itself I am satisfied that both she and the father provided very good care for all of the children. When her alcohol addiction became very serious she failed to ensure the children's safety and wellbeing thus resulting in a referral to the Child and Family Agency in March 2019. The Agency completed its assessment at the end of April 2019 and has since closed its files.
I am satisfied that apart from that breakdown both parents provided good care to the minor and his siblings.
I heard evidence from both parents and I am satisfied that they love the minor as well as his siblings and wish to do the best for them. The mother wishes the minor to have curative intent treatment whilst the father wishes him to have palliative intent management. Despite efforts on the part of the hospital authorities who brought the wardship application no consensus could be arrived at between the parents.
There are clearly issues in the relationship between the parents but they and their legal teams are to be commended for resisting the temptation to ventilate them in the evidence before me. They confined themselves to the issue in hand namely what is to happen to the minor.
The minor is suffering from a neuroblastoma which is a paediatric cancer of the sympathetic nervous system namely the network of nerves that carry messages from the brain to the rest or the body. He was diagnosed with this condition in October 2018. Unfortunately, he had an inadequate response to induction chemotherapy which was carried out between 6th October and 20th December 2018. As a result, his diagnosis was reclassified as very high risk neuroblastoma.
High risk neuroblastoma has a five-year survival rate of approximately 50%. The survival rate for very high risk neuroblastoma is in the range of 10 – 20% five years’ survival.
There are international contemporary protocols for treating high risk neuroblastoma. Those treatments include induction chemotherapy, surgical resection of the primary tumour, high dose chemotherapy and stem cell rescue, radiotherapy and immunotherapy.
The diagnosis in October 2018 was confirmed when a tumour biopsy was carried out. The induction chemotherapy then took place. The minor's inadequate response to that chemotherapy gave rise to the later diagnosis of high risk neuroblastoma. As a result of this the consultant oncologist under whose care the minor is, continued to treat him with additional intensified chemotherapy in an attempt to reduce the tumour size so as to facilitate as best as possible its resection. It was not possible to achieve a complete resection because to do so the minor's left kidney would have to be removed. Accordingly, an operation to de-bulk the tumour took place. The father was reluctant to consider that surgery but ultimately agreed to it. That surgery took place on 28th June, 2019 and approximately 85% of the tumour was resected. The resected tumour contained viable anaplastic tumour cells denoting possible biological tumour aggressiveness.
The next phase of curative intent treatment is proposed in accordance with European protocols. It involves high dose chemotherapy and stem cell rescue. Because of the inadequate initial response to treatment the consultant oncologist proposes to further intensify the treatment with a tandem rather than a single high dose chemotherapy treatment. He has discussed this proposal with a fellow consultant oncologist at the hospital in question who completely agrees with this approach.
Following the necessity to institute these proceedings the view of Professor John Anderson, Honorary Consultant Paediatric Oncologist at Great Ormond Street Hospital for Children was sought. He provided a report which agreed with the approach of the Dublin consultant oncologists but suggested that certain further tests be carried out. These tests were carried out and a second report was provided by Professor Anderson just prior to the hearing before me on 16th October, 2019. He fully endorses the approach of the treating consultant in Dublin and says as follows in his report:
“I now in the light of the new evidence restate my opinion that with tandem transplant there is a realistic possibility of cure. I therefore continue to hold the opinion that I recommend proceeding to a tandem transplant treatment plan with careful disease re-evaluation between the two transplant components to avoid giving a second transplant conditioning procedure in the face of growing disease. Consideration should be given to a second surgical procedure after tandem transplant if he is in metastatic remission. Remission should therefore be consolidated with tumour bed radiotherapy, and immunotherapy with an anti GD2 antibody plus isotretinoin.”
This is the course of treatment recommended by the Dublin consultant and is fully endorsed by both his colleague and Professor Anderson.
It must be said however that even with treatment the minor's prognosis is predicted to be poor.
High dose chemotherapy and stem cell rescue is associated with significant treatment related morbidity and even a small mortality risk. The treating consultant, who gave evidence before me, put the mortality risk at 2-3%. The likely side effects are infection, hair loss, nausea/vomiting, mouth sores, abdominal pain, diarrhoea and a need for nutritional support either by naso-gastric tube or parenteral nutrition. Thus the treatment is very unpleasant. All of these side effects are likely. There are also possible side effects put at about 10% or less of veno occlusive disease of the liver and to a lesser extent the lung, seizures, allergic reactions, skin changes, central nervous system alterations such as behaviour changes or confusion.
The evidence is that curative intent treatment is likely to extend survival time. The quality of life...
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