Judge may visit brain-injured man to decide case of ‘major importance’

A severely brain-injured young man is at the centre of an important High Court dispute between doctors and his parents over whether he should be resuscitated if his condition deteriorates.

The parents are opposing the HSE’s application for orders giving doctors discretion not to administer various treatments, including CPR, if his condition deteriorates further.

The president of the High Court, Mr Justice Peter Kelly, who described the case as "of major importance", may visit the man in hospital.

Because the man is a ward of court, the judge must decide whether the orders sought are in his best interests. The parents are in court for the case, which opened on Tuesday.

A senior doctor involved in the man's care said she discussed his situation on many occasions over years with his parents, in line with Medical Council guidelines. Those discussions were often difficult, and the parents did not agree the man was minimally conscious or did not communicate.

Because she considered the discussions had reached an “impasse”, she recommended an application be made last year to have the man made a ward of court.

She always worried about “a gulf” between families and doctors and believed the parents would find it easier to live with a court, rather than a medical, decision in this matter. “Somewhere along the way, they lost their trust in us.”

The fact the parents have separate legal proceedings alleging negligence in the man’s care and treatment “complicates the picture”, she said in response to the judge.

Minimally conscious

The man, who is in his 30s, has been hospitalised for about four years and his prognosis is poor. His treating team say he has irreversible brain injury and is in a minimally conscious state.

If his condition continues to deteriorate, further ventilator or other interventions will be futile and will only add to his suffering, it is argued.

The parents disagree about a number of issues, including their son’s ability to communicate and his future care. A medical expert for them has proposed the man could be cared for in a “more sympathetic” setting such as a nursing home or his own home.

The man walked into hospital some years ago but the treating team have been unable to restore him to that condition

In evidence on Tuesday, a specialist in intensive-care medicine, who is also involved in the man’s care, said a major difficulty was the absence of a “clear unifying diagnosis” of the cause of his brain injury.

The man walked into her hospital some years ago but the treating team have been unable to restore him to that condition, she said. He suffered an acute lung injury and a later brain injury and cannot now walk or feed himself.

She agreed he previously had given “thumbs up” signs but considered that had changed. She agreed others had different views on his communication abilities.

She expected his condition will continue to gradually disimprove and that he requires intensive nursing care. She agreed that could be provided at home or elsewhere, but that would require significant input and additional funding.

Organ failure

The experts on both sides all agree, at the end of life, he will suffer a fatal respiratory infection but don’t agree how that should be managed, she said.

Further infections might require the man to be aggressively ventilated, and he might also require dialysis and might suffer multiple organ failure. To aggressively ventilate him again would be an escalation she “could not support” and which she considered not in his best interests and “not fair”.

She disagreed life should be prolonged where there is structural lung damage and significant brain injury

The patient, not their family, has to tolerate the treatment, she said. She disagreed life should be prolonged where there is structural lung damage and significant brain injury.

She would be “not only unhappy” but “upset” if the orders were refused but, while against her better judgment, would adhere to what the court decided.

Earlier, Peter Finlay SC, for the HSE, said the case was not about withdrawing or scaling down existing services or supports for the man but allowing doctors to decline to intervene with respiratory or other interventions to a point not medically justified.

It was “inevitable” the parents would disagree and not wish to take a decision of this magnitude for their son. This was not about confrontation or distancing parents from the decision-making inquiry but an inquiry to assist the court in deciding this “extremely difficult and complex” case that posed medical, personal, ethical, technical and legal questions.

The case continues on Wednesday.