Children’s best interests must prevail

The sad case of a 13-month-old child with end stage renal failure is illustrative of the very delicate balance between treatment which carries risks and following a palliative care plan.

In this case, Manchester University NHS Foundation Trust applied for an order authorising serious medical treatment for the child who was the subject of an interim care order and whose parents opposed treatment.

The case had been before the court previously regarding the removal of an infected peritoneal dialysis catheter and the insertion of a new one. However, it became clear during the insertion of the new catheter that the infection was rather more severe than had been anticipated and there was extensive scarring, impeding the insertion of a new catheter.

Whether haemodialysis was in the child’s best interests

In a report for the court, the child’s lead consultant paediatric nephrologist outlined the treatment options available – the first and primary option was performing haemodialysis. The consultant considered the ongoing risk of fatality in the child’s case was likely to be higher than for many receiving haemodialysis. However, he emphasised that it was the child’s “only real chance of survival” and the haemodialysis option represented, by the “narrowest of margins”, what was in the child’s best interests but pointed out that this was “only for now”.

The second option was a palliative care plan expressed as conservative care, with no further renal replacement therapy. The objective here would be to ensure the child was comfortable but recognising that she would die within a matter of weeks – this being a direct consequence of her renal failure.

A delicate balance: the decision

The court authorised haemodialysis but acknowledged the fragile balance between treatment and conservative care, commenting that it is “only marginally tipped” in the way the consultant contends.

The court came to the “clear conclusion” that the consultant’s assessment was correct, stating that it would be premature to confine treatment to palliative options, as the prospects of improving the child’s situation was “real, not illusory”.

The court also noted that the consultant had consulted widely with his colleagues and the approach within the profession was evenly balanced in favour of either of the contemplated options in this case. Similarly, an ethical committee would probably be split 50:50 as to which is the right course, reported the consultant.

The parents, who suffer from mental health issues, opposed the application having a deep and profound faith, believing entirely in the power of prayer. While the court noted the parents’ beliefs, it pointed to the role of the High Court under the inherent jurisdiction to act in the best interests of the child – and that must apply even to cases where parents have alternative views as we saw in the cases of Yates and Gard.

You can read the judgment: Manchester University Hospital NHS Foundation Trust v M & Anor here.

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