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SPOTLIGHT |
SPOTLIGHT |
A 34-year-old man’s refusal of dialysis was a manifestation of his mental disorder and so he should be ordered to undergo treatment at times when he does not consent to it, a Court of Protection judge has found.
The respondent (CC) in the case of A Healthcare B NHS Trust v CC [2020] EWHC 574 has psychiatric diagnoses of psychotic depression and a mixed personality disorder with marked dissocial and dependent traits. He is deaf and communicates via British Sign Language.
The judge, Mrs Justice Lieven, said CC was detained under section 3 of the Mental Health Act 1983 on X Ward which is the medium secure ward for deaf men within A Healthcare.
The issue in the case was whether CC should be ordered to undergo haemodialysis at times when he does not consent to it.
CC was diagnosed with type 1 diabetes mellitus at the age of 15 and he suffers from complex physical health issues caused by his chronically poor compliance with the required diabetic treatment.
His poor compliance had caused problems with his eyes, but more recently had resulted in renal failure requiring dialysis, and ultimately it was hoped a kidney transplant.
Mrs Justice Lieven said: “It is clear that there is a complex interaction between CC's mental disorder and his physical condition and thus physical health needs.”
CC's current non-compliance with dialysis treatment was thought by his responsible clinician, Dr H, to be a manifestation or symptom of his mental disorder. CC was described by Dr H as having 'at best' fluctuating capacity to make decisions about dialysis treatment.
The judge said that when CC was physically well, he understood that he needed dialysis and expressed a clear and consistent wish to live, but at times of crisis he would refuse dialysis and admission to Y General Hospital ('B NHS Trust') for such treatment to be provided to him.
CC's responsible clinician at A Healthcare and the nephrology team at B NHS Trust (who oversee CC's dialysis care), as joint applicants, sought clarification from the Court that dialysis could be provided to CC under section 63 MHA 1983 as medical treatment within the meaning of section 145(4) MHA 1983.
Mrs Justice Lieven made the order sought under the inherent jurisdiction given the urgency of CC's medical treatment, but has now issued a reasoned judgment.
She heard evidence, briefly, from Dr H, a consultant psychiatrist, and Dr I, a consultant nephrologist.
The judge said that the following issues arose in this case;
Mrs Justice Lieven said use of section 63 MHA 1983 to authorise dialysis was not straightforward. “Dialysis is a treatment for end stage renal failure and this would not normally be treatment to alleviate or prevent a worsening of, or to treat the consequences of, a mental disorder. However, Dr H considers that CC's need for dialysis is a consequence of his mental disorders,” she said.
A Healthcare and B NHS Trust brought the matter to Court because Dr H accepted this was not a straightforward case, both because of the issue of whether the dialysis was a treatment to alleviate CC's mental disorder, but also because of his fluctuating capacity. Dr H sought to ensure that he was acting lawfully and in CC's best interests due to the gravity of the decision.
The Applicants brought the matter to court in line with the guidance of Mr Justice Baker in A NHS Trust v A [2013] EWHC 2442 (Fam) at [80] that 'In cases of uncertainty where there is doubt as to whether the treatment falls within section 145 and section 63, the appropriate course is for an application to be made to the court'.
Mrs Justice Lieven found that: