## Facts

- K.I., a two-year-old child, had severe, permanent medical and neurological impairments, with virtually no cognitive functioning and no prospect of improvement.
- Medical testimony indicated K.I. could not hear or see, but could experience pain, including pain caused by invasive resuscitation efforts.
- K.I. lived with her mother, B.I., who was found to have alcohol-abuse problems and to have repeatedly failed to follow medical instructions for K.I.’s treatment.
- D.M., the putative father, initiated neglect proceedings in the Superior Court.
- During the neglect case, K.I. fell into a coma, prompting the court to hold a hearing on whether physicians should attempt resuscitation if K.I. suffered cardiopulmonary arrest.
- Experts (including medical and ethics witnesses) testified that attempted resuscitation would provide no therapeutic benefit and would only prolong pain and suffering.
- B.I. opposed a do-not-resuscitate (DNR) order and sought full resuscitation; D.M. supported a DNR.
- After adjudicating K.I. neglected and assuming protective jurisdiction, the Family Division entered a DNR order based on K.I.’s best interests.

## Issues

1. Whether an end-of-life medical decision for a profoundly disabled, never-competent minor should be governed by a best-interests standard or substituted judgment.
2. Whether a court’s DNR order for a neglected child impermissibly infringes constitutionally protected parental autonomy and privacy in medical decision-making.
3. Whether the evidence supported the trial court’s determination that a DNR was in the child’s best interests, or whether the court abused its discretion.

## Decision

- The District of Columbia Court of Appeals affirmed the neglect adjudication and the DNR order.
- The court held that the best-interests standard governed because substituted judgment was not feasible for a child who had never possessed meaningful cognitive capacity.
- The court rejected constitutional challenges based on parental autonomy, holding that the state, acting as parens patriae after a neglect adjudication, may override parental preferences to protect the child’s welfare.
- The court found sufficient evidence that resuscitation would impose significant pain without corresponding medical benefit, supporting the trial court’s best-interests determination and showing no abuse of discretion.

## Legal Principles

- For a child who has never had meaningful cognitive capacity, courts should apply an objective best-interests standard rather than substituted judgment when deciding whether to forgo aggressive resuscitation.
- Substituted judgment presupposes some ability to form preferences or a record of values; where none exists, attempting to reconstruct wishes is speculative.
- After a neglect adjudication, the court has parens patriae authority and responsibility to decide medical questions affecting the child’s welfare, including resolving disputes between parents.
- Parental autonomy and privacy interests in directing a child’s medical care are substantial but not absolute; they may be limited when treatment would impose serious burdens without benefit to the child.
- A DNR determination must be supported by competent evidence and reached through procedures allowing parents to participate meaningfully (e.g., counsel, presentation of evidence, cross-examination, and findings).

## Conclusion

The court upheld a DNR order for a neglected, profoundly impaired, never-competent child, holding that best interests—not substituted judgment—controls and that parens patriae authority may override parental preferences when aggressive resuscitation would only prolong suffering without medical benefit.


In re K.I., 735 A.2d 448 (D.C. 1999)