Futile treatment in intensive care 2C06

When does intensive care become so futile that it is no longer in a patient’s best interests to prolong it? Say a patient has an indeterminate period of possibly months ahead in intensive care, but the doctors are certain that his prognosis is ultimately fatal and he will die there. Is the decision about future treatment options ultimately for doctors, patients or relatives? The question was recently discussed by the Supreme Court in James v Aintree NHS Foundation Trust.1 David James spent over eight months on the intensive care unit in Aintree Hospital. During this time, he suffered from multiple organ failure due to sepsis. He suffered a number of major complications including myocardial infarction, brain injury, and multiple septic episodes requiring inotropes. The clinical team was certain he was dying and the question arose about how many times multi-organ support should be re-introduced to prolong the process. We suspect that a reasonable body of ICU consultants would agree that further treatment would not be in the patient’s best interests in these circumstances, even though the patient’s life could be prolonged for an indefinite period. Taking a similar view, the clinical team proposed not reinstituting inotropic or renal support if Mr James had a further septic episode. The relatives disagreed, pointing to the interaction they continued to enjoy with him while he was being nursed on ICU. Mr James appeared to enjoy his family’s company, although formal neurological assessment showed that he was severely brain injured following a cardiac arrest. Relations between the doctors and family broke down and the hospital approached the Court of Protection, seeking a declaration that withholding inotropes, cardiopulmonary resuscitation and renal replacement therapy would be lawful. The Court of Protection declined to grant the declarations.2 The hospital appealed, and 15 days later the Court of Appeal3 overturned the decision of the junior court. The matter was then taken to the Supreme Court, which heard the case in July 2013 after Mr James had died, with the intention of bringing clarity to the law. Although it approved the conclusion of the Court of Appeal, it affirmed the reasoning of the Court of Protection. The Supreme Court allowed the conclusion of Court of Appeal decision to stand (ie that treatment could be withdrawn) because the patient’s condition had further deteriorated in the period immediately before the hearing. Nevertheless, it said the analysis of the Court of Protection was correct and the Court of Appeal wrong. What separates the Supreme Court and Court of Protection