On 7th April 2022, 12-year-old Archie Battersbee was found unconscious by his mother in their Southend-on-Sea home. Battersbee was found with a ligature around his neck and appeared to have suffered from several traumatic head injuries. It was believed this was the consequence of an attempt at a dangerous online challenge that went wrong. He was immediately taken to hospital and was placed on a mechanical vent. After several brain stem reflex tests, the doctors concluded that he had suffered from brain stem death and sought to withdraw his life support. His family objected to this, resulting in a series of legal proceedings. However, ultimately the High Court judge ruled that the treatment could be withdrawn, on 6th August 2022 Archie’s life support was turned off and he passed away as a result of the injuries he suffered from in April.
Within the first few weeks of Archie being admitted into hospital, the doctors had concluded that it was ‘very likely’ Archie was brain stem dead after carrying out various tests and scans. It was stated that all of Archie’s bodily functions were being sustained artificially. Based on this evidence, judges ruled on several occasions to withdraw Battersbee’s life support however, each time it was appealed and asked to be reconsidered. At one of the final appeal hearings, Sir Andrew McFarlane, the president of the High Court Family Division, stated: ‘"In short his system, his organs and, ultimately, his heart are in the process of closing down." On 5th August 2022, after Archie’s family requested for him to be moved to hospice care and remain on the mechanical vent, opposing the hospital’s views, Mrs Justice Theis ruled that this would not be in the best interests of the patient. As a result, life support was withdrawn the following day.
Throughout the period spanning from April to August, Hollie Dance and Paul Battersbee, the parents of Archie, advocated for his life support to be sustained. They believed that because his heart was beating when the judges ruled to withdraw life support on 13th June, Archie deserved to have his treatment continued. They appealed decisions that the court was making as they believed that Archie was a ‘natural-born fighter’ and could recover from this, despite the fact that the chances of recovering from brain stem injury are very slim. Archie’s parents were supported by the Christian Legal centre during their appeals and the parents wished for Archie’s religious beliefs to also be taken into account. His mother said: ‘"We disagree with the idea of dignity in death. Enforcing it on us and hastening his death for that purpose is profoundly cruel. It is for God to decide what should happen to Archie, including if, when and how he should die.” Despite appealing for the UN to intervene and support their decision to move Archie to a hospice, the judges ruled against the parents’ wishes as they believed it would be prolonging the inevitable.
In the UK, there is no legal definition of death. Death is determined using a set list of neurological criteria however, generally in medical practice, a doctor will make the final call whether a patient has passed away or not and this is what will be accepted. The Academy of Medical Royal Colleges has stated that generally, the accepted standard for death is: ‘the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe…and therefore irreversible cessation of the integrative function of the brainstem.’
Brain death is usually considered to be the death of the brain stem and the loss of all brain function. This is when a person will be on an artificial life support machine with damage to the brain that is irreversible. The person will remain comatose and unable to breathe for themselves. If all brain function ceases, technically the person can be considered to be legally dead.
Cardiac death is generally described as sudden cardiac death. This is when death occurs due to a cardiovascular problem that leads to a stop in the heart beating within an hour of the beginning of any related symptoms. If the heart is not beating, life cannot be sustained so the person will be considered to have passed away immediately. Typically, they do not attempt to keep people who suffer from sudden cardiac death alive using artificial life support as it is considered to be ineffective.
Both brain death and cardiac death are linked but there are some differences between them. A person can be considered as brain dead but may not have technically suffered from cardiac death as their heart will still be beating. However, a person cannot have suffered from cardiac death and still have brain function. Once a person has suffered from cardiac death, there is very little that can be done to help them or sustain their life.
Within the NHS, when someone has been declared brain dead, they are essentially legally dead and therefore, there is very little that can be done to revive them. However, because they are usually on life support, their life can be prolonged even though they are not going to recover from their injuries.
In the Journal of Pain and Symptom Management, an article was written discussing the ethics of keeping those who are brain dead on life support. The article discusses how not pronouncing the patient as dead can lead to a whole host of issues including financial, ethical and legal complications. It can also lead to decreased acceptance of death when the patient is eventually taken off life support. The article continues to discuss how important it is for clinicians to weigh out the consequences of taking the patient off life support and whether it does more harm than good if the inevitable is prolonged. In the article, it states: ‘Declaration of brain death should not be delayed to wait for families or to justify hospital care. Instead, appropriate family care should be provided after the death declaration’.
The GMC has guidance on how a patient should be treated towards the end of their life and once their life has ended. Here is one of the key points that is made:
‘It is now widely agreed that high-quality treatment and care towards the end of life includes palliative care that focuses on managing pain and other distressing symptoms; providing psychological, social and spiritual support to patients; and supporting those close to the patient. However, it is not always recognised that palliative care can be provided at any stage in the progression of a patient’s illness, not only in the last few days of their life.’
In terms of withdrawing life support in itself, dignity should be maintained by ensuring that this is what the patient or the patient’s family wants and making sure you discuss everything with them, provide them with any information they need and most importantly, provide them with access to counselling and welfare services so that they can be supported throughout the process. It is essential to make sure the situation is dealt with sensitively but also honestly so as not to lead to any misconceptions or misinformation.
In the British Journal of Anaesthesia, an article about the withdrawal of end-of-life care perfectly summarises the main factors that should be considered. It states:
'The clinician must:
Besides this, as mentioned earlier, it is important that the patient’s family are well supported throughout the process and after life support is withdrawn, as many families have difficulties accepting that their family member has passed away and will therefore require further support.
If the patient did not have an advanced directive or stated their wishes when they still had mental capacity, the decision falls to their family members. They need to consider whether withdrawing life support would be something that would honour the patient’s wishes. The clinicians will work alongside the family to help determine what decision would be in the best interest of the patient.
In a BMJ article written by an ethicist surrounding the case of Archie Battersbee, the discussion of the reputation and public opinion of the NHS truly encompasses everything that went through my mind when reading about this case. The article states:
‘The NHS trust, treading on eggshells while trying to avoid offence and reputational damage, must look back on this episode with a mixture of relief that the case is over and dread of another similar one. The legal costs alone must have reached hundreds of thousands of pounds. The increased levels of security have added to the bill: at one point there were reportedly eight security guards around Archie’s room. In the future, that dread of another case could translate into a tactical decision by the NHS to respect the views of relatives even when these are harmful to the patient. The practical consequences of this case, aside from the psychological toll on the parents and staff, the loss of trust, the financial cost, and the dangerous precedent, meant that Archie’s death was drawn out by weeks.’
Having such a publicised case has increased awareness of issues with withdrawing life support and it has provided the NHS with a learning opportunity, helping them understand how they can handle similar cases in the future and what they should consider before litigation.
https://www.bbc.co.uk/news/uk-england-essex-61829522
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14568
https://www.nhs.uk/conditions/brain-death/
https://www.ncbi.nlm.nih.gov/books/NBK507854/
https://academic.oup.com/bjaed/article/17/12/396/4107857
https://www.nhs.uk/conditions/end-of-life-care/withdrawing-treatment/
https://www.bmj.com/content/378/bmj.o1980
https://www.jpsmjournal.com/article/S0885-3924(10)00454-9/fulltext
Author: Fateha Khawaja
Editor: Allegra Wisking
