Comments from Professor Alastair Sutcliffe and Professor Dominic Wilkinson in response to news that the parents of Archie Battersbee have been given the right to appeal against the decision to allow his life-support treatment to end.
Prof Alastair Sutcliffe, Professor of General Paediatrics, UCL, said:
“This is not the first high profile case of a family of a very sick child and the medical staff treating them disagreeing as to the best course of treatment -or whether stopping treatment is appropriate- and perhaps these cases have become a more prominent aspect of care and prominence in our society.
“Such disagreements can happen to all of us who work at the NHS rock face even with the best will, sometimes due to unrealistic expectations for recovery, other times from broader miscommunications or driven by other types of expectation. Each case is different and nuanced.
“The appeal process will still be based on best medical evidence and advice. The appeal will involve reviewing evidence around the determination a diagnosis of ‘brain-stem death’ including any recent evidence that may be relevant. Even last year there has been published scientific advances and discussion¥ on determining brain death in adults.
“The NHS does not have infinite resources anymore than any other health care system, and thus keeping a child notionally alive whilst ‘brain dead’ is not an open ended situation. The practice of medicine is not black and white but shades of grey, and whatever the outcome of the court of appeal decision, this will affect future NHS care and allow clarity on current practice irrespective of the decision about this sad case.”
¥ Determination of Brain Death by David M. Greer N Engl J Med 2021; 385:2554-2561 DOI: 10.1056/NEJMcp2025326
Prof Dominic Wilkinson, Professor of Medical Ethics and Consultant Neonatologist, University of Oxford, said:
“In the UK, there are no laws that say what death is or how it should be determined. Instead, the diagnosis of death is made by doctors based on a code of practice. It defines death as the irreversible loss of both the capacity for consciousness and the capacity to breathe. Doctors can diagnose a patient as having died either where the patient’s heartbeat and breathing have stopped, or where there is evidence of irreversible cessation of brain stem functioning. There are strict medical criteria that are used for testing patients in intensive care suspected of being brain dead. Those involve careful testing of reflexes that arise from the brain stem as well as a series of rules and safeguards.
“It is devastating news for a family to learn that a patient has such severe brain damage that they have, in fact, legally died. It is understandable for family members to find that hard to believe or accept and to wish to hold on to hope.
“Usually, however, with careful compassionate communication, doctors are able to help the family to understand that sadly their loved one has gone, and that no further medical treatment could possibly help them.
“There have been other cases where parents or family members have not accepted a medical diagnosis of brain death. In the UK, courts have always concluded that treatment should stop. However, one difference in Archie’s case is that the standard tests for brain death were not possible. The judge relied in part on a test (an MRI brain scan) that is not usually used.
“In Archie’s case, standard testing was not possible, so doctors used several different brain scans including MRI scans. These are allowed by the UK code of practice to help in making a diagnosis of brain death. They showed that sadly there was no blood flowing to Archie’s brain, that his brain had no electric activity, and that there was permanent damage to the brain stem (an area at the junction of the brain and the spinal cord that contains crucial nerve centres for controlling basic functions, including those that control breathing and awareness.
“The legal appeal will focus on the question of whether the testing that has been done can confirm that Archie is indeed legally dead.
“However, even if the appeal court were to decide that Archie is technically still alive, that does not mean that treatment will continue as his parents wish.
“Where there is disagreement about medical treatment for living children (or adults) with severe brain injury, there is a legal process for making decisions in the court based on their best interests. In Archie’s case, the judge had carefully considered Archie’s wishes as well as his parents’ views and the evidence that they had obtained from other experts.
“The judge listened to evidence from several medical experts testifying to the devastating nature of his brain damage. She concluded that if he were alive, it would be in Archie’s best interests to stop the life support machines that are supporting him. Although he is no longer capable of feeling pain (or indeed anything), she found that his body was suffering physical harm from the treatments he was needing to receive, that “his prospects of recovery are nil”, and that the burdens outweighed the benefits of continued treatment. The courts have reached similar conclusions in other cases.
“The legal dispute over Archie’s care might continue for some time yet. However, just as experts on this case say that that there is no realistic prospect that he will recover, there is no likelihood that the appeal courts will reach a different decision. The conclusion for Archie, sadly, appears foregone.”
e.g. as reported in the BBC: https://www.bbc.co.uk/news/uk-england-essex-61869995
Prof Dominic Wilkinson: “No conflicts”
For all other experts, no reply to our request for DOIs was received.