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Covid-19: “Most complex patient in the world” should have ventilation withdrawn

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2193 (Published 07 September 2021) Cite this as: BMJ 2021;374:n2193

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  1. Clare Dyer
  1. The BMJ

A 56 year old woman described by doctors as “the most complex covid patient in the world” should have the ventilation keeping her alive withdrawn by the end of October, a High Court judge has ruled.1

Mr Justice Hayden, vice president of the Court of Protection, said it would be in her best interests to be moved from the intensive care unit to a quiet and private place where she could end her life surrounded by her close family members.

He said he had been told authoritatively that she was the most complex covid patient in the world, in terms of the neurological impact and complications of the disease. That conclusion had been arrived at following consideration of national and international case studies, he added.

The woman, referred to as AH, has been a patient at Addenbrooke’s Hospital in Cambridge since December 2020 and on a ventilator since January. Hayden said her clinical presentation was highly unusual and the impact of the illness had created “an invidious dilemma” both for her family and professionals.

AH has extensive brain damage and by March her peripheral motor nerves had little to no remaining function. She can communicate with her eyes and has some neck and lips movement, but no limb movement, and frequently exhibits distress.

She has four children and Hayden said some family members had been highly critical of the hospital. “At times, some of their behaviour has fallen below that which the nursing and medical staff should be expected to tolerate,” he added. He described the staff’s care of AH as “inspirational.”

Each family member had vacillated as to the right way forward, he said, and none of the available options were devoid of difficulty. Cambridge University Hospitals NHS Foundation Trust had applied to the court for a decision about AH’s best interests.

“It is an unusual feature of this case that while the way forward has been described as ‘finely balanced’ every single professional involved in AH’s care has reached the same conclusion—that continued ventilation is not in her best interests,” he said. During examinations, on every occasion, she has become distressed, cried, and appeared anguished.

As well as mechanical ventilation, she has a nasogastric tube, a urinary catheter, and a rectal tube to manage faeces. She requires frequent suctioning of her trachea to control respiratory secretions and is turned often to avoid pressure sores.

Hayden said the delicacy of the case arose from two important aspects. “AH is able to feel and show some degree of emotion. Predominantly, she now reveals pain and real distress. However, she plainly sustains comfort from the presence of her children who have been the focus of her life.”

He added, “The evidence, not least that given by the family, has identified a tentative plan which has crystallised, at least to some degree, during the hearing. As I have analysed, it is centred upon respecting AH’s dignity and promoting the best quality of life at this last stage. For it to be most effective it will require cooperation between the family and those caring for AH. This will require respect, each for the other. The time has come to give AH the peace that I consider she both wants and is entitled to.”

Continued ventilation had become burdensome and medically futile, he said, but it should be continued until all four children, including AH’s daughter in Australia, and other family members could be with her in a quiet place, which must be by the end of October.

“It provides an important opportunity for this close and loving family to be together at the end. The treating clinicians feel able to work with and perfect this plan and recognise that it is consistent with their own professional conclusions and reflective of the central importance of family in AH’s hierarchy of values and beliefs,” he concluded.

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