“the fundamental principle is the principle of the sanctity of human life… But this principle, fundamental though it is, is not absolute … there is no absolute rule that the patient's life must be prolonged by such treatment or care, if available, regardless of the circumstances. First, it is established that the principle of self-determination requires that respect must be given to the wishes of the patient … and, for present purposes perhaps more important, the doctor's duty to act in the best interests of his patient must likewise be qualified. But in many cases not only may the patient be in no condition to be able to say whether or not he consents to the relevant treatment or care, but also he may have given no prior indication of his wishes with regard to it. … But the court cannot give its consent on behalf of an adult patient who is incapable of himself deciding whether or not to consent to treatment. I am of the opinion that there is nevertheless no absolute obligation upon the doctor who has the patient in his care to prolong his life, regardless of the circumstances. Indeed, it would be most startling, and could lead to the most adverse and cruel effects upon the patient, if any such absolute rule was held to exist. It is scarcely consistent with the primacy given to the principle of self-determination in those cases in which the patient of sound mind has declined to give his consent, that the law should provide no means of enabling treatment to be withheld in appropriate circumstances where the patient is in no condition to indicate, if that was his wish, that he did not consent to it.”
“It is axiomatic that people with disabilities, both mental and physical, have the same human rights as the rest of the human race. It may be that those rights have sometimes to be limited or restricted because of their disabilities, but the starting point should be the same as that for everyone else. This flows inexorably from the universal character of human rights, founded on the inherent dignity of all human beings, and is confirmed in the United Nations Convention on the Rights of Persons with Disabilities.”
“The most that can be said, therefore, is that in considering the best interests of this particular patient at this particular time, decision-makers must look at his welfare in the widest sense, not just medical but social and psychological; they must consider the nature of the medical treatment in question, what it involves and its prospects of success; they must consider what the outcome of that treatment for the patient is likely to be; they must try and put themselves in the place of the individual patient and ask what his attitude to the treatment is or would be likely to be; and they must consult others who are looking after him or interested in his welfare, in particular for their view of what his attitude would be.”
“In deciding what is best … the judge must have regard to … welfare as the paramount consideration. That embraces issues far wider than the medical. Indeed it would be undesirable and probably impossible to set bounds to what is relevant to a welfare determination.”
“there can be no doubt in my mind that the evaluation of best interests is akin to a welfare appraisal.…Pending the enactment of a checklist or other statutory direction it seems to me that the first instance judge with the responsibility to make an evaluation of the best interests of a claimant lacking capacity should draw up a balance sheet. The first entry should be of any factor or factors of actual benefit… Then on the other sheet the judge should write any counterbalancing dis-benefits to the applicant. An obvious instance in this case would be the apprehension, the risk and discomfort inherent in the operation. Then the judge should enter on each sheet the potential gains and losses in each instance making some estimate of the extent of the possibility that the gain or loss might accrue. At the end of that exercise the judge should be better placed to strike a balance between the sum of the certain and possible gains against the sum of certain and possible losses. Obviously, only if the account is in relatively significant credit will the judge conclude that the application is likely to advance the best interests of the claimant.”
“On mental status examination on19 May 2015 , Ms AB was very irritable, hostile and suspicious. Her mood was moderately depressed; she had delusional beliefs about the cause of her ulcer, being convinced it was due to the actions (positive actions, not negligence) of the surgeons who were treating her. She had no insight into her physical or psychological symptoms. She did appear confused at times but overall there was no clear evidence of any significant cognitive impairment warranting investigations for dementia. At that time, she did not cooperate with any formal cognitive assessment. As mentioned earlier, the treatment with a powerful antidepressant and anti-psychotic medication was successful in improving her mood but there was no real improvement in the psychotic symptoms and her delusional beliefs have continued. I diagnosed Ms AB as suffering from a moderate to severe depressive episode with psychotic symptoms. It is also possible that Ms AB was suffering from a delusional disorder prior to the emergence of the depressive episode.”
“It is possible that removing the source of infection could dramatically improve the functions of her brain and there could be a dramatic improvement in the cognitive functions as well as her mood. It is very unlikely that there will be a change in her psychotic symptoms, especially the entrenched delusional beliefs about her surgeons. It is also possible that she could, after the amputation, suffer from an acute stress reaction, making her more depressed with worsening psychotic symptoms. However, the acute stress reaction and any depressive or psychotic disorder can be treated with appropriate psychiatric medications. Given that she has responded well to these medications in the past, this suggests that she is likely to do so again in the future. It is likely that the depressive symptoms will respond better than the psychotic symptoms. According to the nursing staff Ms AB is now suffering from increasing physical problems including recurrent falls and episodes of altered consciousness and confusion. If the infection spreads further upwards and affects the nerves not damaged by diabetes, she is likely to suffer excruciating pain which is unlikely to respond to analgesics. In spite of her non-healing ulcer, Ms AB is able to walk with a frame at present. With the proposed treatment by above-knee amputation, she is likely to remain chair bound for a long period of time, if she receives rehabilitation. Given her history of non-cooperativeness with many of the medical staff, it is very unlikely that she will engage in rehabilitative efforts by the physiotherapist and occupational therapist. It is possible under those circumstances that she will need care in a highly specialist nursing home registered for caring for people with mental disorders for the rest of her life.”
“There are in my view two treatment options:- a) Amputation of the left leg above the knee would certainly be my preferred treatment measure, were it not for her psychiatric condition. She has told us that she does not want amputation; and it is plain that this would have a serious impact on her, just as feared by the IMCA. I have discussed the case with another Consultant Vascular Surgeon, Mr R, who is in agreement with me. Major amputation would remove the source of infection and the dead tissue, which would significantly improve the quality of her life. On the other hand, the risks of undergoing such surgery may be summarised as follows; the possibility of wound infection or dehiscence, a need for further surgery, and anaesthetic and cardiopulmonary risks associated with the procedure – risks which are augmented by non-compliance with treatment. It is anticipated that she may interfere with wound integrity and may not comply with antibiotic treatment, insulin administration and/or physiotherapy after the operation. There is, of course also a risk of deterioration in her mental health from undergoing amputation against her wishes. As far as the procedure is concerned, most patients undergoing such surgery will be given general anaesthesia. In view of the patient’s mental health state this is her only anaesthetic option. I have reviewed her case with my anaesthetist colleagues and am assured that there is no specific risk to her, over and above those just mentioned, from undergoing general anaesthesia. She is however likely to need more pre-operative sedation, within safe limits. In addition, there is a mortality rate for this procedure, at 30 days, of 10%-15% taking account of the extra post-operative risk for a non-compliant diabetic patient. She would require care on the high dependency unit after the surgery for approximately 3 days. It is recognised that she will be a very challenging patient to nurse, and I would expect sedation to be required, as well as intensive physical and psychiatric nursing. Similarly, it will be difficult to give her the physiotherapy she will need in order to learn to transfer safely; this may indeed prove impossible, confining her to a wheelchair. Thereafter she will need life-long care in a suitable care home, as she will no longer be able to cope in her own home. The general survival rate after major amputation is some 50% at 2 years (although this figure is taken from a population mainly of elderly males needing an amputation for vascular disease and suffering also considerable co-morbidities). Given the patient’s poorly controlled diabetes, her life expectancy may be set at between 5 and 10 years. Notwithstanding the risks I have just mentioned, on balance I consider that it is more in her interests to undergo surgery, to preserve her life; and that those risks may be managed, and the post-operative difficulties tackled, adequately, to that end. b) The alternative to surgery is to provide purely supportive care. I would expect it then to be a matter of time before she developed, and in view of her general physical condition succumbed to, an overwhelming antibiotic-resistant infection. I would estimate her life-expectancy in the absence of surgery as between 3 and 6 months. It is abundantly clear that the patient would undergo considerable distress if surgery were undertaken; however, I would expect her psychiatric team and her care home to do their best to keep this within bounds, with the aid of medication, psychological treatment, and familiarity. The urgency of surgery, in my view, has now increased because she is today showing signs of sepsis which may develop into septicaemia. There are practical difficulties in respect of performing surgery, as I conduct operations at the Hospital A only on Wednesdays. I am otherwise based at Hospital C. I consider it unlikely, however, that there would be the opportunity to transfer her to Hospital C if she needed surgery and could not undergo it on Wednesday 22 July; while in view of her current state I would regard Wednesday 29 July as likely to be too late, in that her condition may by then have deteriorated to the point where amputation would be unlikely to save her life.”
“Throughout the interview, which lasted approximately 20 minutes, Ms AB was in bed. She looked tired, but made good eye contact and clearly notices what was going on in the room. She did not appear anxious or distressed. She made very little spontaneous speech, and Miss F [a physiotherapist] had to repeat questions, in most instances several times, before Ms AB offered any answer. Her answers were brief.”
“From my interview with Ms AB, it was evident that she has the firm belief that her present health problems have been caused by the clinicians caring for her. In my opinion, there is little doubt that this belief is delusional, that is, it is firmly held despite available evidence to the contrary. Ms AB has another belief, associated with the first, that she could overcome her current health problems if she were allowed to go home and treat her foot as she sees appropriate. These beliefs were confirmed by the other informants I spoke to, and have also been noted consistently in the clinical records. In my opinion, the delusions just described are evidence of a disturbance in the functioning of Ms AB’s mind or brain. Regarding the specific decision that Ms AB is faced with (undergoing an above knee amputation), I note from the documents available to me that clinicians have considered that she is able to understand information relevant to the decision, and can retain that information. I was unable to elicit sufficient information during my interview with Ms AB to form my own opinion on this. However, I would note that Ms AB appears to be very aware (and consistently so) that she had been recommended to have an amputation. Because of the nature of her persistent delusions, I consider that Ms AB is unable to use or weigh information as part of the process of making a decision. Because she believes that her problems have been caused by those professionals looking after her, and she evidently does not trust the advice or treatment that she been recommended, in my opinion it is not possible for her to properly evaluate information that she has been given about her treatment, the consequences of not undergoing the amputation, and her prognosis. Because she has a disturbance in the functioning of her mind or brain, and she is unable to weigh information in the balance because of a mental disorder, my conclusion is that Ms AB lacks the capacity to make a decision about whether or not to have an amputation. For the same reason, in my opinion, Ms AB also lacks the capacity to participate in legal proceedings. I consider it very unlikely that she would understand, the significance of even the purpose of legal proceedings. In addition, she may become suspicious that such proceedings are part of the conspiracy against her. In this context, I note that some of her comments during my interview with her suggested that she was as suspicious that I was not independent of the clinical team treating her, despite my reassurances to the contrary.”
“Regarding the prognosis of her mental disorder, it would appear that she has responded to some extent to antidepressant medication. While she continues this medication, the risk of recurrence of depressive symptoms is minimised, although she may have further episodes of depression in the future. The prognosis of her psychotic symptoms (the delusions) is more uncertain. Some people, particularly those who develop delusions later in life, as Ms AB has, fail to show an adequate improvement with antipsychotic treatment. However, the discovery that Ms AB has been successfully hoarding medication that she should have been taking offers the possibility that she has had antipsychotic medication less consistently than expected, and at the lower dose than prescribed.”
“For some people with the combination of problems with which Ms AB presents with, successful treatment of physical symptoms will lead to improvement in the mental state. Poorly controlled diabetes can exacerbate or even give rise to mental state abnormalities. However, under such circumstances, the mental state abnormalities tend to fluctuate. This has not been the case with Ms AB. For this reason, in my opinion, it is unlikely that her delusions will lessen substantially if her diabetes, and the problems with her foot, were stabilised. If Ms AB undergoes the proposed amputation, I consider it likely that this will reinforce her beliefs about her illness being caused by those caring for her. This in turn may make it more difficult to provide her with appropriate nursing and medical care, if she becomes more paranoid and less cooperative. If she does not undergo the proposed amputation, I understand that this is likely to lead to death fairly soon. Commenting on this is outside my expertise, but assuming that this is the case, Ms AB would receive palliative care. I would not expect this to worsen her psychiatric symptoms, except perhaps to make her more frustrated that she is still not receiving what she considers to be appropriate treatment. If she accepts pain relief, then it should be possible to keep her mental state relatively stable.”
“Conclusions There are essentially two options. One do nothing there has been marked deterioration over the last five days and the patient is likely to die, probably within the next 5-10 days. Two major limb amputation. Amputation of foot: unlikely to be successfully as infection extending to lower leg, flaps required for reconstruction will almost certainly fail. Below knee amputation: may heal but only assuming the infection has not extended beyond the mid calf. Above knew amputation: if the preferred option, it is quick straight forward and even in a toxic patient relatively safe, with a high probability of healing. Recommendation Patient proceeds to an above knee amputation as soon as possible, I was impressed by the dedication and standard of nursing care on The Ward, a real tribute to the ward manager and nursing staff who are clearly managing a very difficult clinical problem.”