Question: The Alfie Evans case

AUDub

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Dec 4, 2013
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Give me ambiguity or give me something else.
This could be an interesting topic.

Some background reading:

https://www.judiciary.gov.uk/wp-content/uploads/2018/02/alder-hey-v-evans.pdf

Alfie was born seemingly healthy but was noted to have developmental delays fairly early on. At 6 months of age, he was MRId and a neurological disorder was indicated. Two weeks after the MRI he was admitted to the hospital with a respiratory virus and what was believed to be febrile convulsions (fever induced seizures). His seizures worsened. The seizures were epileptic in nature, not febrile. Neurology was consulted. EEG monitoring was ordered and he was put on anti-convulsive drugs. His condition worsened. He had pneumonia and severe encephalopathy. He coded. His care team prepared his parents for the worst. Extraordinary work by the care team saved his life.

He fought off the infection. However, his EEG exams did not show improvement and remained the same since that time. He was in a coma.

An external review of his charts was ordered. His EEGs showed no activity except when was seizing since January of 2017. His MRIs revealed a progressive degenerative neurological disorder. His brain was, at the time of his passing, mostly CSF and water where his brain should have been. To put it bluntly, the seizures liquified much of his brain, and that continued every time he had a seizure, which was his only response to stimuli. Even had it been possible to stop the seizures, and he did not respond well to a variety of top drugs meant to do just that, he would not recover. He had already lost too much. All experts who had seen his charts in depth agreed his condition was "catastrophic and untreatable." His doctors decided it was no longer in Alfie's best interests to continue care.

Alfie's parents, in their understandable distress, did not accept this. They sought avenues to have him remain on life support. Their appeals resulted in a lot of public outcry. Bambino Gesu, a Vatican run hospital, offered to take him.

The courts in the UK weighed Alfie's interests against those of his parents, and decided it was to his benefit to remain in the UK to die comfortably.

Read the link I posted above. They'll tell you all you need to know about how the judge reached his decision. I had a hard time finding fault with his reasoning.

The question I want to discuss is, in cases like this, how far does parental authority stretch when weighed against the interests of the patient? After looking into the case in depth, I personally find my self with the state on this one.

Anyone need anything cleared up? If not, what say you?
 
As a physician, I cannot fault his physicians.
As a parent, I cannot fault his parents.

It's heartbreaking. I'm just glad the boy is now at peace.
 
As a physician, I cannot fault his physicians.
As a parent, I cannot fault his parents.

It's heartbreaking. I'm just glad the boy is now at peace.

Agreed. I am, however, extremely frustrated with the idiots that gathered outside - harassing the hospital's employees and being a general annoyance (setting off fireworks at night, for instance) for the other patients and their families - and with the pundits and commentators that tried to turn this into a cause célèbre against socialized medicine/abortion/euthanasia.
 
I understand the emotion of the parents, especially in the moment. And I understand the immediate decision to keep him on life support.

But keeping that poor child alive after they had a chance to come to terms with the situation was incredibly selfish.

There is some solace in the fact that his brain was so completely destroyed that he would have been unaware of anything, including the seizures.

After watching that for several months, I just don't know how parents could not conclude that the poor little fellow needed God's peace more than anything in the world, including a parent's love.

To answer Dub's question, I don't know how to draw an objectively-determined line between a parent's authority and a child's welfare. I am, however, reminded of Potter Stewart's famous line on another topic....I know it when I see parents cross it, and in this instance, they unfortunately did.
 
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There is some solace in the fact that his brain was so completely destroyed that he would have been unaware of anything, including the seizures.

He certainly wouldn’t process it the same way, but one of the considerations the judge took into account was whether or not what was left of Alfie could experience pain.

Page 9:

https://www.judiciary.gov.uk/wp-content/uploads/2018/02/alder-hey-v-evans.pdf

24. Dr Samuels filed a report which was, as I have said, solicited by the parents. F required him to attend to give oral evidence. If I may say so I thought that was a proper course for F to take. However, Dr Samuels is very clear that Alfie’s prognosis is futile. He notes that BG describes him as being in a “semi-vegetative state” (my emphasis). For Dr Samuels the greatest concern was the possibility of any potential suffering that Alfie may be experiencing. He considered that the high quality intensive care that Alfie is receiving at Alder Hey could “sustain him for a long time”. He noted that there is the “potential for acute infection e.g. sepsis, or hypoxia relating to seizure to cause sudden deterioration and death”. Dr Samuels stressed, both in his report of 10 December 2017 an d in his oral evidence, that movement, light and sound can produce physiological change in Alfie for which he posited three potential explanations: basic reflex; seizure related activity; association with discomfort.Whichever was most likely Dr Samuels considered that the appropriate course was to offer palliative care to Alfie. This he considered would best be served by symptom management i.e. keeping Alfie comfortable and withdrawal of ventilation and intensive care. In his thinking the combination of the futility of Alfie’s life (i.e. the absence of any prospect of recovery) and the uncertainty of knowing whether Alfie is suffering were key factors.


25. Dr M in her report, dated 20 December 2017 (see para 5 above), sets out her conclusions and opinion. Though she amplified these in her oral evidence they remained essentially the same:

"My opinion, based on Alfie’s presentation, clinical deterioration and progression of his MRI scan appearances and the expert opinion of a number of paediatric neurologists is that Alfie has a progressive neuro-degenerative disorder from which there is no hope of recovery. This opinion is supported by clinical experts both within Alder Hey Children’s Hospital and from independent national and international experts who have reviewed Alfie. It also the consensus opinion held by the entire medical consultant body on the Paediatric Intensive Care Unit at Alder Hey.
It is my opinion (and that of my intensive care consultant colleagues), that Alfie has a poor quality of life. He is completely dependent on mechanical ventilation to preserve his life. He has no spontaneous movements, cannot communicate and continues to have frequent seizures. I believe that is it unlikely that Alfie feels pain or has sensation of discomfort but I cannot be completely certain of this since Alfie has no way of communicating if he is in pain or discomfort. I believe that given Alfie’s very poor prognosis with no possible curative treatment and no prospect of recovery the continuation of active intensive care treatment is futile and may well be causing him distress and suffering. It is therefore my opinion that it is not in Alfie’s best interests to further prolong the current invasive treatment. It would, in my opinion, be appropriate to withdraw intensive care support and provide palliative care for Alfie for the remainder of his life."

Pain is, in fact, one of the lowest level brain functions.
 
It seems a nightmare to me that a judge (ie, the government), and against the parents wishes, has "authority" to pull the plug and let the child die.

It's a bit of dark humor that they would not release him to go to Italy to seek other treatment, stating that they did not wish him to die in transit. Instead, they pull the plug.

My best friend and husband of my sister-in-law faced the terrible decision to let his wife go about a year ago. I just thank God that he alone was able to make the decision, rather some government official decreeing it was her time.
 
It seems a nightmare to me that a judge (ie, the government), and against the parents wishes, has "authority" to pull the plug and let the child die.

It was decided via independent arbitration in the UK high court of family justice. The judge is not bound by the views of the physicians any more than those of the parents.

Not all cases of this nature are as widely publicized as this, but it would be in error to say similar things don't happen here.

It's a bit of dark humor that they would not release him to go to Italy to seek other treatment, stating that they did not wish him to die in transit. Instead, they pull the plug.

Alfie presented a difficult case. The court had to balance what seemed reasonable against what his parents’ wishes were. What was proposed - insofar as they had a plan, consisted of “fly him somewhere to continue treatment”- was a course of action that would not have changed the outcome but possibly introduced extended pain and suffering. The state is saying, “Wait. Alfie is a UK citizen, and we can’t stand by and subject him to futile efforts that will won’t change the outcome and might cause him further harm.”


So the court weighed the possible outcomes:


1. Alfie remains in the UK and receives appropriate palliative care. This includes drugs for his convulsions, pain and the death rattle that occurs naturally as carbon dioxide levels build, and also food and water. (This is how it was when my brother passed. I’ll never forget being in that room.)


2. During transport, he suffers continual seizures due to the stress of transport, as this was his only response to stimuli, and suffers an unpleasant death in transit.


3. Alfie remains on life support, either in Italy or Merseyside. Infection, such as sepsis creeps in. He develops painful ulcers and abscesses, as many folks on long term care do. Google sepsis if you want to see just how awful it can be. As his convulsions continue, and the host of drugs he was on did not manage them well, the deterioration of his brain continues.


Yes, Alfie’s death was a forgone conclusion, but there is value in choosing the course that resulted in the least pain. And some deaths are less pleasant than others.


My best friend and husband of my sister-in-law faced the terrible decision to let his wife go about a year ago. I just thank God that he alone was able to make the decision, rather some government official decreeing it was her time.

His doctors, many international experts, the doctors in both Italy and Germany at hospitals willing to take him, all agreed his condition was "catastrophic and unsurvivable." His time had already come, and his parents, bless them, could not come to terms with that.

At some point, it just becomes grotesque.
 
I go back and forth on this but one thing I can say for certain - I'm thankful I wasn't the one having to make the choice.

Sometimes there's just no winning answer.
 
For me, this is like giving an infinity stone to Thanos. I would rather not give either doctors or bureaucrats that kind of power over my family. When the family is making an ethical judgement, it will be contained mostly to their family. Where as the state has much greater capacity to do harm to a larger population.
 
For me, this is like giving an infinity stone to Thanos. I would rather not give either doctors or bureaucrats that kind of power over my family. When the family is making an ethical judgement, it will be contained mostly to their family. Where as the state has much greater capacity to do harm to a larger population.

You could apply that logic to just about any child welfare law, really.
 

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