Thursday, May 11, 2023

High Court reporters

The High Court has given consent for doctors not to amputate a man’s leg against his wishes, even though he might die due to infection of the limb.

The man, who lacks the mental capacity to weigh the decision due to vascular dementia, has clearly and consistently objected to the proposed surgery and said he would rather die than have one leg.

The President of the High Court, Mr Justice David Barniville, said he would consent to the man’s discharge from hospital to his home where he will be supported by a palliative care team. The judge was also persuaded that there should be a provision that the man (70s) would not be resuscitated in the event of suffering a catastrophic bleed.

He had “absolutely no doubt” that the surgery was not in the patient’s best interests.

The judge said his decision was significantly informed by hearing directly from the man, through video link to the court. Despite lacking mental capacity, he is a “man who knows his mind” and who clearly has a good sense of humour, the judge said.

The man’s “strong objection” to the surgery was a significant factor in the judge’s decision. Mr Justice Barniville also considered that the amputation would significantly limit the man’s mobility and that he would have severe difficulties adapting to this.

The court already ruled last month that the above-knee amputation did not have to proceed. At that point all the medics agreed this was the appropriate approach.

Different views

The case came back before Mr Justice Barniville this week after a divergence of views emerged between treating doctors about the best course to take.

A consultant vascular surgeon believed the amputation should proceed as the man’s condition has changed and there was now a bigger risk of him bleeding to death.

The infection on his leg, caused by the man interfering with a post-surgical wound, could “rupture at any time” and he could die within 20 minutes if this occurs, he said.

The court also heard from a consultant geriatrician and a consultant psychiatrist who were against the procedure. They said the psychological impact of the surgery would give rise to severe psychological distress to the man.

His short-term memory loss would exacerbate the distress, as he would wake up “each morning to find that his leg is gone”, the geriatrician said.

The judge was satisfied all the doctors did their “very best” and acted in accordance with the “highest ethical and professional standards”.

He was struck by the surgeon’s submission that, despite advocating the benefits, there was a 50 per cent mortality rate associated with the surgery.

The Health Service Executive (HSE), represented by barrister Donal McGuinness, established that the man’s best interests were served by not conducting the surgery, the judge said.

A court-appointed guardian, represented by Barry O’Donnell SC, also came to the conclusion that palliative care was more appropriate than the amputation.

The judge commended the man’s “wonderful” family whose views evolved throughout the process, from being in favour of the surgery to welcoming the idea of the man returning home without having the amputation.

The man’s wife and son have always been motivated in serving his best interests, the judge said.

Before making his decision on Thursday afternoon, Mr Justice Barniville heard from a palliative care consultant who outlined a detailed plan for how the man’s family, or nursing home staff, could support him and provide him with pain relief medicines for whichever outcome the court decided.

She said his family met with her palliative care team and were happy to support him at home, in accordance with a detailed care plan, if the amputation does not proceed. They were aware his “two big wishes” are to keep his leg and to return home.

The family understood that if he suffers an acute event at home there should be no attempt to save his life. In such circumstances, one should “empower natural passing”, she said.

Mr McGuinness submitted that the family feels the man, who is fiercely independent and loves the outdoors, would not consent to the surgery even if he did have the mental capacity to do so. The barrister stressed the right to bodily integrity and to dignity in life and death.

Mr Justice Barniville said he will give a detailed written judgment at a later date.

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