ASSISTED DECISION-MAKING - The Legality of ‘Ceiling of Care’ by Medical Professionals

A case was brought by the HSE to the High Court to determine the legality of medical professionals in refraining giving life-prolonging interventions against the will of a patient who has refused treatment despite his reduced capacity.

The patient was aged 78 who had a history of severe depressive illness with psychotic features. Over the previous two years, the patient had become frail, sustained multiple serious fractures and serious weight loss.

During this time, the patient had refused psychiatric medication and treatment and had a course of involuntary electroconvulsive therapy authorised under the Mental Health Act 2001, which resulted in only brief and limited improvement.

The patient frequently stated that the quality of his life was poor, that he did not want to live in a nursing home and that his death was inevitable while not accepting that he was depressed.

In February 2025, the patient’s psychiatrist, placed a ‘ceiling of care’ letter on his chart recording the respondent’s wish that medical treatment would be offered but not forced and that there should be no coercive feeding, treatment, and no CPR.

The doctor was of the opinion that the patient lacked the capacity to make independent decisions.

The patient was moved to an approved centre where he continued to refuse meals, decline investigations and medication and supportive interventions.

The question before the court was whether clinicians may lawfully refrain from performing invasive and coercive interventions on the respondent which they regard as futile, harmful, and disproportionate, in circumstances where the proposed “ceiling of care” would likely result in the respondent’s premature death.

The court heard evidence from the patient’s psychiatrist said that the patient could understand information, retain it, and communicate a choice, but could not use or weigh that information in a meaningful evaluative way.

An independent witness supported the evidence of the patient’s psychiatrist, adding that he lacked capacity in respect of complex decisions relating to his care and treatment.

The judge considered that the starting point was the presumption of capacity arising by virtue of s.8(2) of the Assisted Decision-Making (Capacity) Act 2015 and at common law.

The judge had regard to the submission of the respondent’s guardian ad litem that the respondent’s refusal to engage with a capacity assessment ought not to be interpreted as evidence of lack of capacity.

The judge said: “The respondent has a right to refuse to engage with his medical attendants and with the Guardian ad litem. I must determine whether, aside entirely from this non-engagement, the respondent’s decision to decline all medical treatment is capacitous or whether, on the other hand, the presumption of capacity has been rebutted.”

The judge was satisfied that the presumption of capacity had been rebutted where the patient did not accept or believe the advice concerning the likely impact of his choices on his health and life stating: “I am satisfied that the respondent’s longstanding and trenchant refusals of treatment do not represent capacitous, evaluative decision-making, but rather decisions made in the absence of an ability to weigh the consequences thereof. I am also satisfied that the respondent also lacks capacity to consent to palliative medical treatment and to make decisions in relation to his accommodation.”

In dealing with the lawfulness of the ‘ceiling of care’ the judge considered the Supreme Court decision of JJ [2022] 3 IR 1.

In considering caselaw, the judge stated that the authorities highlighted ‘‘consistently confirm that the Court’s function is not to direct clinical care, but to determine whether the course proposed by clinicians is legally permissible.”

 The judge found that the relief sought engaged the right to life insofar as non-intervention may shorten life, the court considered that it was appropriate to authorise the patient’s clinicians to refrain from taking steps to prolong his life and that “Such authorisation respects the respondent’s longstanding will and preference to refuse medical treatment, even if his life is in jeopardy and, to that extent, reflects his longstanding values.”

The judge was further satisfied that it would be ethically unacceptable to permit the patient, when he enters the active stage of dying, to suffer unmanaged pain or distress and authorised the provision of non-coercive palliative care where appropriate

The judge was also satisfied that whilst the respondent’s personal liberty would be restricted, his continued detention in an approved centre was necessary and proportionate to protect his right to bodily integrity in light of his lack of capacity, frailty, and inability to appreciate risk.

In conclusion, the judge granted the declaration.

The judge was further satisfied that it would be ethically unacceptable to permit the patient, when he enters the active stage of dying, to suffer unmanaged pain or distress and authorised the provision of non-coercive palliative care where appropriate.

In conclusion, the judge granted the declaration of lawfulness as to the ceiling of care and the remaining orders sought.

Health Service Executive v P.J. [2026] IEHC 291