Guidelines are set for persistent vegetative state

BMJ 1994; 308 doi: (Published 23 April 1994) Cite this as: BMJ 1994;308:1060
  1. C Dyer

    The official solicitor, Peter Harris, has issued guidance for health authorities and NHS trusts in Britain, reminding them to seek the High Court's approval before withdrawing artificial feeding and hydration from patients in a persistent vegetative state. His practice note, issued last week, follows the second case in which the court has sanctioned the withdrawal of feeding for patients in the persistent vegetative state. The celebrated case of Tony Bland, the survivor of the Hillsborough football stadium disaster, went to the House of Lords last year and established that such patients need not be kept alive indefinitely. In the second case, last January, the High Court and Appeal Court at short notice sanctioned doctors' decision not to reattach a feeding tube that had become accidentally dislodged.

    In that case a 24 year old man, named only as S, had been diagnosed as being in a persistent vegetative state with no prospect of recovery after taking a massive overdose of drugs in June 1991. The official solicitor argued that the tube should be restored pending a full investigation into S's condition and a full court hearing, as in the Bland case. He wanted an independent expert to examine S and report on his prognosis. But the master of the rolls, Sir Thomas Bingham, said that S had been diagnosed as being in a persistent vegetative state by the consultant in charge of his case at Cossham Hospital, Bristol. It was a professional and thoughtful conclusion by a consultant of the highest standing.

    The practice note cites guidance from the British Medical Association that a diagnosis of persistent vegetative state should not be considered to be confirmed until the patient has been insentient for at least 12 months. Applications should be made to the High Court's family division by either the next of kin or the health authority or trust. If the next of kin makes the application the health authority or trust should be a party as well.

    The views of the next of kin “are very important and should be made known to the court in every case.” The patient may also have expressed views on treatment to prolong life in the past, either in writing or orally.

    There should be at least two neurological reports, including one commissioned by the official solicitor from an independent expert. The official solicitor, who will act as the patient's guardian for the court case, urges doctors to consult health authority lawyers without delay in any emergency in which consent is an issue. Recent cases have involved the refusal of consent for a caesarean section when the mother's and fetus's lives were said to be in danger and the apparent refusal of consent to a blood transfusion by an adult who had been injured in a road traffic accident.

    Lawyers in the official solicitor's office are willing to discuss cases informally with either doctors or health authority lawyers before proceedings are started.

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