Irish Hospital v R.F. and Another
| Jurisdiction | Ireland |
| Judge | Ms. Justice Iseult O'Malley |
| Judgment Date | 09 July 2015 |
| Neutral Citation | [2015] IEHC 608 |
| Docket Number | [2015 No. 5501P] |
| Court | High Court |
| Date | 09 July 2015 |
BETWEEN:
AND
[2015] IEHC 608
THE HIGH COURT
In these proceedings the plaintiff hospital seeks, in essence, a ruling from the court that it is in the best interests of the child R.F. that medical staff treating her may refrain from further aggressive treatment of her current acutely unwell condition, and that instead she should be provided with a programme of appropriate palliative care. The application is made on the basis that it is highly unlikely that she will recover from the current position, and that if she does she will have an extremely poor quality of life and will inevitably face another life-threatening event in the near future.
Specifically, the hospital wishes its clinical, medical and surgical staff to be permitted to follow their clinical judgment not to provide aggressive treatment as follows:
) resuscitation following cardiac or respiratory arrest, including by way of bag and mask ventilation, chest compression or the administration of medication;
) any artificial ventilation;
) any transfer or escalation to intensive care treatment;
) any form of surgery; and
) any procedure requiring general anaesthesia.
R. was born on the 16 th August, 2004. She was born with Turner's syndrome, a congenital heart condition, which is not in itself life-threatening or life-limiting.
When she was four months old she suffered serious and extensive brain damage as a result of non-accidental injury. She spent five months in hospital and has been in care since being discharged from that admission. As a result of her injuries she isprofoundly intellectually disabled. She suffers from severe spastic quadriplegia, epilepsy, scoliosis and recurrent life-threatening infections. She is wheelchair bound, cannot communicate verbally, cannot feed orally and lacks any capacity to look after herself.
R. has lived most of her life in a residential centre where she has been well-cared for and happy. She has enjoyed attending a special school and in particular she enjoyed music. Last year she made her first Holy Communion and went on a holiday. Although she does not have verbal communication she smiles when happy and cries when unhappy.
The evidence in the case has come mostly from Dr. B, consultant paediatrician with a special interest in neurodisability who has treated R. since 2008.
R's health has, unfortunately, been deteriorating since last year. She had pneumonia in early 2014 and has had 5 courses of antibiotics for respiratory tract infections in the past 6 months. In late 2014 she developed an infection at the base of the spinal rods inserted to deal with her scoliosis. She was treated for that infection with antibiotics which caused side effects of severe vomiting and diarrhoea. She was severely unwell during December, 2014 and the early part of January 2015, with multi-organ involvement.
On the 18 th June, 2015, she was admitted to hospital with a very severe pneumonia. This developed rapidly with acute clinical deterioration over the weekend of the 20 th and 21 st June. Despite a prolonged course of broad-spectrum antibiotics she has not made significant clinical improvement since then. She remains severely unwell with evidence of multi-organ involvement. Tests indicate impairment of her liver and kidneys.
She has gut failure. Feeds are poorly tolerated and she has almost continuous, profuse diarrhoea. She is not absorbing sufficient calories for her needs, but any increase in the volume of feeds merely increases the diarrhoea and gagging.
An alternative would be TPN (total parenteral nutrition). However, this would require R to stay permanently in hospital. Further, Dr B. says that it would not change R's situation, or alter her progression towards death.
Intravenous access has been described as very problematic and one person has said that R. is "black and blue" from attempts to insert needles. Drugs and fluids were being administered via a venous catheter in her femoral vein but the site became infected and it had to be removed on the 7 th July. She is currently receiving small amounts of fluid via her gastrostomy tube. The continued necessity for blood tests and insertion of femoral venous lines is painful and burdensome for her. Because of her intellectual disability she cannot understand why this is being inflicted on her.
However R. is not currently in pain, other than when procedures are being carried out. She responds to human voices. The guardian ad litem has stated that she visited heryesterday, the 8 th July. She says that R. was not in discomfort and reacted to the guardian's voice as a small baby would, was visibly relaxed and fell asleep.
According to the medical evidence it is absolutely inevitable that R will have another life-threatening illness in the near future. In that scenario there are two main possibilities. One is that she would have a sudden cessation of breathing, or her heart might stop. According to the medical evidence, children with disabilities have an extremely poor response to CPR. It is described as "burdensome, unpleasant and undignified" for a person at the end of life, and R. would probably die anyway.
The other possibility is a more gradual decline, probably with pneumonia. If R. were to be treated in intensive care, intubated and on a ventilator,...
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