Muslim man in right-to-life battle
The family of a Muslim man who is in a persistent vegetative state are fighting in the High Court for him to receive - against medical advice - life-saving treatment if his condition deteriorates.
A judge was told the family of patient "L", from the Greater Manchester area, believes that if the severely brain-damaged 55-year-old could express his wishes he would never agree, because of his faith, to an order that he should not be resuscitated or ventilated.
Pennine Acute Hospitals NHS Trust, which is responsible for his care, is seeking a court declaration that it would not be in his best interests to offer him ventilation or resuscitation if there was "a life-threatening event".
Claire Watson, appearing for the Trust, said it was the unanimous view of clinicians treating L, as well as independent experts, that the family man was in a persistent vegetative state "with minimal prospects of improving any neurological function and no meaningful prospect of further recovery".
"The consensus of opinion is that in the event of significant deterioration L should not be actively resuscitated or ventilated."
Ms Watson told Mr Justice Moylan, sitting in the Court of Protection in London: "Rather than there being the prolongation of life, there would be the prolongation of death and lack of dignity."
But the judge was told it was the family's view that "life is sacred and it would be contrary to the tenets of their religion not to provide life-supporting treatment".
One of L's sons told the court in a statement that, under Islam generally, "we believe that you prolong life as far as you can go and that you actively take every step to so do".
The son, referred to as Mr FL, added: "My father was very aware of these issues and often when we heard stories in the media about negligence and decisions to turn off life support, he would wince his face and give a look of disapproval.
"It was a solemn look of disapproval and sadness."
Mr FL also described the efforts L had made to ensure his own father's life was prolonged when he was seriously ill.
The family also believes L, who suffered a cardiac arrest in mid-July which resulted in severe brain damage, is not as "unresponsive" as the doctors suggest.
The judge was told that, since mother and son had signed their court statements, family members on daily visits to hospital had continued to observe "some degree of responsiveness" on L's part.
They are arguing that it is "simply too soon" to determine whether L is in a "permanent" vegetative state, or to conclude that his quality of life would be so limited or wretched - as one doctor had concluded - to make life-saving treatment futile.
The case has come before the Court of Protection because L, whose interests are being represented by the Official Solicitor, is a vulnerable adult whose condition means he lacks the capacity to make decisions about his medical treatment.
The judge is hearing oral evidence from both clinicians and family members, who have "a strong faith in God", before he decides whether to grant the Trust the order it is seeking.
Family lawyers have told the judge that, days after L suffered a cardiac arrest, a "Do not resuscitate" (DNR) notice was placed in his notes without consulting them in contravention of the Trust's own policy.
They say that when the family learned, they objected and the DNR notice was taken out of the notes.
L's wife has said in a written statement they are "a very close family". She describes her husband over the years as a "happy, loving person and a loving and caring father" notwithstanding his long-standing medical problems.
The couple have been married for more than 40 years, over 30 of them living in the UK, and have several adult children.
L suffered two cardiac arrests last March and spent two months in hospital before being discharged home in May.
He suffered the further cardiac arrest in mid-July which led to his present condition and him currently receiving treatment in a hospital's high dependency unit (HDU).
The Pennine NHS Trust argues that treatment should now be limited to what doctors consider is reasonable to maintain his dignity and to relieve any pain and discomfort he may be feeling - but it would not be in his best interests for active resuscitation or ventilation to be provided in the event of another cardiac arrest or other deterioration of his condition.
The Trust has indicated that nobody at present can be sure of L's life expectancy and it could be many months, or even longer.
The family want the judge to rule that "all steps" should be taken to preserve L's life.
Ms Watson, for the trust, described how L suffered hypoxic brain injury because of the severity of his last cardiac arrest.
A tracheostomy was performed to protect his airway and to allow him to be taken off a ventilator.
The clinical diagnosis from the intensive care team treating him was that a vegetative state resulted from severe brain damage, and that was confirmed by a consultant neurologist on July 25.
Two days later he was removed from the ventilator and was breathing independently. On August 3, he was moved from intensive care to the HDU and was currently in a stable condition, Ms Watson told the judge.
His clinical team considered he was in a persistent vegetative state with "a very poor prognosis".
An intensive care consultant agreed with the diagnosis and noted that he had not been able to elicit "any purposeful response" from L, and L would not "significantly improve".
Another consultant, specialising in anaesthetics and critical care, stated there was "less than 1% chance of meaningful recovery".
Any recovery would in any event be very limited and leave L "profoundly physically and mentally impaired".
The consultant noted that L's eyes opened spontaneously but neither focused nor followed movement.
He was tube-fed, had a urinary catheter and did not move his limbs spontaneously, or in response to verbal command or physical stimulus.
He was unable to respond to, or interact with, his surroundings and would always be totally dependent on others for all his basic needs, said Ms Watson.
He was also prone to respiratory deterioration, skin infections, urinary infections and the risk of pneumonia.
Ms Watson said his physical condition would deteriorate over time, with the developing of wasting, skin sores and limb contractures - tightening of muscles.
If he was capable of feeling pain on a basic level, which was difficult to know, he would suffer pain from his limbs and skin sores whenever moved.
An independent expert in intensive care jointly instructed by both parties stated that it was "absolutely unrealistic" to expect any further neurological recovery from such a "minimally conscious state".
The expert, said Ms Watson, supported the trust's position that, given L's profound brain injury, it would not be in L's best interests to resuscitate or ventilate if his condition significantly deteriorated.
An independent expert in neurology also jointly instructed accepted that prognosis was notoriously difficult in PVS cases but also supported the trust's position.
Ms Watson said it was well established that a doctor could not be forced to undertake medical treatment with which he or she did not agree.
The law required a doctor to provide treatment and care in the best interests of a patient like L incapable of making decisions for himself.
The trust accepted that, in assessing best interests, the court was not limited to considering "best medical interests" and had to take account of the beliefs and values likely to influence L if he could make his own decision.
The court also had to consider the views of family members.
But, whilst what might have been the patient's views, and the views of the family, were highly material they were "not the governing factors", argued Ms Watson.
In deciding L's best interests it was necessary to weigh the benefits and burdens of life-prolonging treatment.
Ms Watson submitted it would not improve his underlying condition and could only ever, at best, return him to his current state - prolonging his death and lack of dignity.
A senior doctor gave evidence at odds with family assertions that L had recently shown "some degree of responsiveness".
The doctor told the court that, between July 18 and today, he was not aware of any improvement.
He said: "Not a single member of staff has expressed that they have seen any purposeful movements."
The hearing continues tomorrow.
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