The decision of Mr Justice Jackson in Re W (Medical Treatment: Anorexia) 2016 to approve the care plan of a patient suffering from anorexia nervosa is another case where the Court of Protection has attached weight to the wishes of patients.
The Court of Protection approved the Health Board’s plan which was that W should now be discharged into the community with a detailed and well thought-out package of support for her and her family. The outcome is to some extent in accordance with the patient’s wishes and the least worst option from the patient’s point of view, according to Mr Justice Jackson.
W is aged 28 and has suffered from a severe and enduring form of anorexia for 20 years. She had been admitted to five specialist eating disorder units on six occasions for significant periods of time. Her current admission to a psychiatric unit had lasted for two and a half years. She was detained under section 3 of the Mental Health Act 1983. Despite the most intensive support, she was barely eating and losing weight at the rate of 500 grams – 1kg per week. At the time of the hearing, she weighed less than 30kg and her BMI was 12.6. She was at significant risk of death. She had an established pattern of short term engagement with services followed by her challenging boundaries and refusing treatment.
The judge found that W lacked capacity to make decisions about her care relating to her anorexia.
W’s Health Board made an urgent application to have their care plan approved. The Health Board had two proposals. The first was to render W unconscious for up to six months and feed her by tube until her BMI recovered. The judge outlined that in his opinion this was, quite rightly, not pursued.
The second option, preferred by the Health Board, involved a recognition that W’s condition was not currently treatable and that her remaining on the acute ward was not appropriate. This option required an immediate discharge into the community with a full community support programme for her and her family. There was a unanimous professional view that this option would be in W’s best interests and supported the Health Board’s application.
Mr Justice Jackson commented that “It will at first seem counterintuitive that someone so ill should be discharged from hospital. The conventional assumption is that hospital treatment is likely to bring benefits, but the evidence has persuaded me that in this case that is not so.” W had expressed a wish to live and felt she may be able to “turn it round” if she was at home. The doctors felt they had done what they could to enable her to gain and maintain her weight and the use of coercion or sedation would not work. Of interest, her responsible clinician had indicated they would seek to discharge W from detention, as while her condition warrants treatment, the team had found no way of treating it. The judge agreed that the present treatment, such as it was, was not beneficial and that it was not right for it to continue. In light of that he approved the care plan.
Mr Justice Jackson affirmed the principle that there is a strong but not absolute presumption that it is in a person’s best interests to receive treatment that helps maintain life. There may, however, be circumstances in which the treatment is not in the person’s best interests, including where it is futile or unduly burdensome. He also recapped on the Supreme Court’s decision in Aintree which highlighted the need to consider a patient’s welfare in the widest sense, not just medical but social and psychological, the nature of the proposed treatment and its prospect of success. Clinicians must try to put themselves in the place of the individual patient and ask what their attitude to the treatment is or would be likely to be and they must consult others about this.
He also commented that W’s situation was exceptionally worrying and her options limited. If any available option offered the prospect of a significant extension in her lifespan, he would naturally look at it with favour. However, that was not the case here.
Mr Justice Jackson also emphasised that the judgment related to the circumstances as they stood and that it was possible that W would require readmission to hospital if her condition deteriorates.
Readers will have noted that recent Court of Protection decisions have paid particular attention to the wishes of patients. In this case, the judge noted the very close and supportive relationship W had with her mother and sister and made a point of stating that he attached considerable weight to their points of view.