The matter related to P, a 28-year old woman who for many years had suffered from anorexia nervosa, first being diagnosed at the age of 13. Treatment had proved futile, with no lasting benefit. P’s weight was so low and her condition such that she was in serious danger of suffering a cardiac arrest and dying. The only treatment option left available was that of nasogastric feeding. It was determined P would be unlikely to tolerate this and would resist forcefully, exposing herself to risk of serious injury. There was also a risk P may suffer a cardiac arrest as a result of “refeeding syndrome”. If the treatment was to have any rate of success, P would need to be hospitalised over at least a six-month period and the procedure undertaken at least twice a day under sedation.
It was agreed the only purpose of the treatment would be to re-nourish P’s body to the point she was well enough to engage in psychiatric therapy, however the effects of her illness were now such that she would be unwilling/unable to engage in this therapy. In light of this and the physical and psychological trauma the treatment would inflict, P’s treating clinicians concluded it was not in her best interests to receive any further active treatment for her anorexia nervosa. As such, the Trust applied to the court for declaratory relief pursuant to ss 4 and 15 of MCA 2005 in the following terms;
- It was in P’s best interests not to receive any further active treatment for anorexia nervosa.
- P lacked capacity to make decisions about treatment relating to anorexia nervosa.
The Trust’s views were aligned with those of P and her family; P accepted her life was at risk, yet she was clear in her evidence that her quality of life was still such that there was meaning and purpose and her parents agreed that their daughter should not receive any further treatment; they did not want to watch her suffer further, despite the inevitability of the outcome. It was therefore agreed at the outset of the judgment that it was not in P’s best interests to receive any further treatment. As P was deemed to have capacity for the purpose of the proceedings the key remaining issue for the court to determine was whether P had capacity for the purpose of making decisions in relation to her own treatment.
Consideration was given to the application of the relevant sections of MCA 2005 in determining capacity in the context of the case and reference was made to the detailed history of the matter and P’s previous experiences of treatment. Mrs Justice Roberts addressed the issue that assessments of capacity should not be influenced by the fact that P is making an unwise decision, the outcome of the decision is irrelevant to whether the person lacks capacity.
Consideration was also given to the extent P’s anorexia affected her decision-making ability. Submissions were made on P’s behalf that her compulsive desire to avoid weight gain were not cited as reasons for her refusing nasogastric feeding and therefore could not be held to be the cause of her incapacity. The factors P relied on for her refusal of treatment related to her past experiences, the risks of nasogastric feeding, and her desire to be at home with her family.
Consideration was given to evidence from P’s treating psychiatrist, who stated that, as a result of her illness, P had an overvalued idea/fixation which overwhelmed her thought process, so as to prevent her being able to undertake a balancing exercise in relation to her decision making as required by MCA 2005. Whilst it was accepted that P was able to use and weigh information about many aspects of her life, this differed from her ability to rationally respond to advice about the need to gain weight to avoid death by starvation. Her judgement and decision-making ability were diminished by a severe irrational fear of weight gain.
The court ultimately relied on P’s desire to continue to go on living as the clearest manifestation of the extent to which her judgment had been impaired by her illness. The court reached a conclusion that P lacked capacity to decide whether or not she should be tube fed, it was determined it was not necessary to go beyond that in terms of wider definitions of potential treatment, on the basis that no other treatments were available or contemplated in P’s case. It was again iterated the finding in relation to P’s capacity would not have the result of requiring her to undergo nasogastric feeding, in light of the previous agreement between the parties that this was not in P’s best interests.
Mrs Justice Roberts highlighted that the declarations made in respect of P’s capacity should enable her to make autonomous decisions about her care as her illness progressed, for example in the event of a future emergency, her lack of capacity should not result in nasogastric feeding being imposed by a different hospital or Trust.
The full judgement can be read here
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