Young man who refused treatment for suspected type 1 diabetes died before palliative care plan was put in placeBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o787 (Published 24 March 2022) Cite this as: BMJ 2022;376:o787
A 23 year old man who refused hospital investigation for suspected type 1 diabetes later had a cardiac arrest, went into a vegetative or near vegetative state, and died before a treatment plan for palliative care only, approved by a High Court judge, could be put into effect.1
The man, referred to as M, was fit and well when he attended a clinic at the beginning of the covid-19 pandemic in March 2020 for a painful but apparently minor condition, said Mrs Justice Judd. He was found to have high levels of ketones and glucose in his urine and was told that he should be admitted to hospital for investigation and treatment.
The judge said that it was not clear why he refused, although his partner told the court that he was anxious about catching covid-19. Over the next few months his weight dropped to 39 kg, and in November 2021 he had a cardiac arrest.
After 45 minutes of CPR by an ambulance crew spontaneous cardiac output was restored, and M was taken to hospital. He was put into an induced coma, but when sedation was withdrawn after 12 days he was in a state of disordered consciousness.
He had type 1 diabetes diagnosed and was fed by nasogastric tube. CT and MRI scans showed hypoxic ischaemic damage to his brain and liver. He underwent a tracheostomy and had episodes of hospital acquired pneumonia, treated with intravenous antibiotics. He also experienced “storming”—increases in heart rate, blood pressure, temperature, and sweating.
After M was transferred to a hyperacute rehabilitation unit his condition deteriorated, and problems arose with providing nutrition after he developed an ileus. The clinicians treating him concluded that he should be given palliative care only, but his mother, father, and partner disagreed. London North West University Healthcare NHS Trust applied to the Court of Protection for a declaration that it would be in M’s best interests for life prolonging treatment to be discontinued.
Clinicians at Charing Cross Hospital, where he was originally admitted, supported the palliative care plan, and the judge said it became apparent that no other hospital or unit would be willing to give him active treatment.
Andrew Hanrahan, a consultant in neuro-rehabilitation at the Royal Hospital for Disability, based in Putney, told the court in a report that M was thin and wasted, restless and distressed, doubly incontinent, and paralysed in all four limbs, with contractures and deformities in his wrists and ankles as well as resting tachycardia. His life expectancy was days or weeks.
Judd said that all of the doctors who had been consulted agreed and that “none of them considered that there is any doubt about M’s terminal condition and the medical futility of any further active treatment.”
M’s family opposed the withdrawal of active treatment and accused clinicians of lying to them. But Judd said it was clear to her “'that they are simply not able to bring themselves to face the overwhelming nature of the medical evidence or to assess it in a rational way. “She added, “I do not criticise them for this because it is an utterly tragic and emotional situation for them all.”
She found the medical evidence “unanimous, compelling, and overwhelming” and declared that M should receive palliative care only. In a postscript to her judgment she revealed that he had died two days after she had delivered her draft judgment to the parties, so the palliative care plan was never put into action. “I understand the family was able to be by his side,” she added.