Withdrawal of treatment from minimally conscious patients

Clinical Ethics

Volumn 7, Issue 1, 2012, Pages 10-16

  Heywood, Rob ^a  

^a UNIVERSITY OF EAST ANGLIA   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 84862527264     PISSN: 14777509     EISSN: 1758101X     Source Type: Journal    
DOI: 10.1258/ce.2012.012m01     Document Type: Article

References (29)

1. Airedale NHS Trust v Bland [1993] AC 789
2. The condition known as the permanent vegetative state is now more commonly referred to as the vegetative state. For the purpose of this discussion, the familiar abbreviation of PVS is used
3. Jennett B, Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet 1972;1:734-7
4. Andrews K, Murphy L, Munday R, Littlewood C. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ 1996;313:13
5. W v M and Others [2011] EWHC 2443 (Fam)
6. Mental Capacity Act 2005, s 4 and 5
7. F v West Berkshire Health Authority [1990] 1 AC 1
8. Re A (Mental Patient: Sterilisation) [2000] 1 FLR 549 at 555
9. Re J (A Minor) (Wardship: Medical Treatment) [1991] Fam 33
10. Indeed there is some first instance authority to suggest that PVS patients not only have best interests, but ones that demand particular understandings of 'benefit' that have direct, practical implications not just for whether treatment should be given, but for the nature of its provision.
11. Ahsan v University Hospitals Leicester NHS Trust [2006] EWHC 2624 (QB)
12. The 'snoozeroom' is a small room which can accommodate one or two residents in which there is music and special lighting and other things to provide a sensory experience for the residents
13. The SMART assessment consists of both formal and informal components. The formal component requires an assessment by the SMART assessor over ten sessions within a three week period. There are two aspects to this; the SMART Behavioural Observation Assessment and the SMART Sensory Assessment. The informal component of SMART is completed by carers, family and friends and consists of a Communication Lifestyle History Questionnaire and a further assessment tool known as SMART Inform. The conclusion from the 2011 SMART assessment was that M's meaningful responses were less consistent than they were in 2007 during the formal assessment, but the observations by the team of carers were slightly more frequent during the informal assessment than they were in 2007. This led to the conclusion that M was still in a MCS in 2011
14. Bolam v Friern Hospital Management Committee [1957] 1 WLR 582. Best interests under the Bolam test meant that if a responsible body of medical opinion perceived the treatment to be in the patient's best interests, the courts would simply agree
15. In re Quinlan (1976) 355 A 2d 647
16. Cruzan v Director Missouri Department of Health (1990) 110 S Ct 2841 (USA Supreme Court)
17. Mental Capacity Act 2005, s 4 (6) (a) - (c)
18. Re G (TJ) [2010] EWHC 3005 (COP).
19. This naturally feeds into the bigger question of whether or not patients in a MCS have the 'right' to die. For a recent and interesting discussion see: Syd L, Johnson M. The right to die in the minimally conscious state. J Med Ethics 2011;37:175-8
20. For an interesting recent discussion, which calls into question the validity of advance decisions in MCS patients, see: Varelius J. Respect for autonomy, advance directives, and minimally conscious state. Bioethics 2011;25:505-15
21. Whilst to this author it is clear that M's earlier views should apply to her now, there is considerable theoretical debate about whether in fact a patient's former views should apply in the future.
22. See: Maclean AR. Advance directives and the rocky waters of anticipatory decision-making. Med Law Rev 2008;16:1-22.
23. Maclean AR. Advance directives, future selves and decision-making. Med Law Rev 2006;14:291-320
24. R v Inglis [2010] EWCA Crim 2637
25. Nakase-Richardson R, Yablon SA, Sherer M, Evans CC, Nick TG. Serial yes/no reliability after traumatic brain injury: implications regarding the operational criteria for emergence from the minimally conscious state. J Neurol Neurosurg Psychiatry 2008;79:216-8
26. Giacino JT, Aswal S, Childs N, et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002;58:349-53
27. For a recent and interesting discussion in respect of a breakthrough in assessing levels of consciousness in brain damaged patients using an electroencephalography technique (EEG) see: Cruse D, Chennu S, Chatelle C, et al. Bedside detection of awareness in the vegetative state: a cohort study. Lancet 2011;378:2088-94
28. B v An NHS Hospital Trust [2002] EWHC 429 (Fam). In this case a competent patient who was being maintained on a ventilator instructed the medical professionals to switch the ventilator off and discontinue her treatment. The court stated that the doctors had to comply with her request and that failure to do so would amount to tortious battery
29. One of the expert witnesses, Professor Turner-Stokes, initially gave evidence to the effect that M was at the lowest level of consciousness within the MCS. She then modified her view to suggest M was at a moderate level of consciousness within the MCS, but she still refused to agree with the other expert that M was actually at the higher end of consciousness