A High Court judge has allowed a hospital trust's request to withhold life-saving treatment from a severely brain-damaged Muslim patient if his condition significantly deteriorates.
The family of the 55-year-old man, from Greater Manchester, who is in a "minimally conscious" state, argue that their religious faith requires everything to be done to prolong life "until God takes it away".
Mr L's wife and two of his adult sons say his condition is continuing to improve and it would be wrong for clinicians of the Pennine Acute Hospitals NHS Trust to withhold ventilation or resuscitation treatment in the event of a cardiac or respiratory arrest.
But Mr Justice Moylan, sitting at the Court of Protection in London, ruled that the balance was "firmly in favour" of a declaration that it would be lawful to withhold treatment.
The judge said it sounded "harsh" but treatment would "prolong Mr L's death" and would not prolong his life "in any meaningful way."
The judge said: "It would result in death being characterised by a series of harmful interventions without any realistic prospect of such treatment producing any benefit."
He refused the family permission to appeal, but they can still ask the Court of Appeal itself to intervene.
Doctors diagnosed Mr L as being in a "persistent vegetative state" (PVS) after he suffered a second cardiac arrest in mid-July which resulted in devastating brain damage. Later they agreed he had entered a minimally conscious state.
But they still said Mr L would have "minimal prospects of improving neurological function" and no "meaningful quality of life" if life-prolonging treatment were given.
The Trust argued that improvements seen in his condition by the family remained so minimal that active resuscitation would be futile and could lead to an "undignified and traumatic death".
Treating clinicians suggested that such action would conflict with the medical principle "do no harm", and might even be "cruel".
Mr L, who has been married for more than 40 years and has eight children, was rediagnosed as not being in a vegetative state after his family insisted they had seen signs that he was improving.
In August video evidence, including film of Mr L closing his eyes and "grimacing" when his eyes were cleaned, led doctors to conclude that he was now "most likely in a minimally conscious state".
The court case in London was adjourned so that further assessments could be made.
But Trust lawyers later returned to court, saying it would still not be in Mr L's best interests to receive active resuscitation.
They argued that his treatment should be limited to what doctors consider is reasonably required "to maintain his dignity and relieve such pain and discomfort as he may feel".
Family lawyers disagreed and said he was showing increased awareness of his environment and responding to family members and the smell of a perfume from Mecca when they visited him in hospital.
They also said he went quiet when listening to readings from the Koran.
Solicitor Julianne Moore, who represented Mr L's family, said after Monday's hearing: "The hearing has given the family the opportunity to put across their views in terms of what they believe L would have wanted on the grounds of how he lived his life and, in particular, his religious beliefs.
"However, they are devastated at the outcome of the hearing and remain of the view that all attempts should be made to prolong L's life, particularly in view of his uncertain prognosis.
"They consider that it was inappropriate to place a Do Not Resuscitate order in L's notes without informing or consulting his family and that, in view of the uncertainty in relation to his condition, it was premature to do so.
"The family are also concerned that there were failures in the care provided to L whilst a patient at the hospital which may have caused or contributed to his condition and we will be advising the family in respect of allegations of medical negligence."
Moore, a partner at law firm Pannone, said relatives were considering attempting to appeal against Monday's ruling.
Lawyers representing the family unsuccessfully asked the judge for permission to appeal.
Moore said relatives were considering renewing their application in the Court of Appeal.
Relatives argued that the judge failed to give sufficient weight to their religious views and those of Mr L, a devout Muslim.
Mr L's adult son, "FL", said his father believed his faith required him to seek to live - no matter the suffering that it might entail.
In his two-hour judgment, the judge said he rejected the argument that life-sustaining treatment had to be provided "regardless of the likely consequences".
He emphasised that, although religion and family views had to be put in the balance, his decision must be based on "the best interests" of the patient.
In the course of his ruling, the judge referred to the fact that a "do not resuscitate" notice had been put on Mr L's medical notes "without prior consultation in breach of the Trust's own policy".
The judge said a Trust consultant had apologised and accepted proper procedures had not been followed and frankly admitted what had happened was "grossly wrong".
He also apologised because no member of the family had been asked by any member of the treating staff to participate in the assessment of Mr L's level of awareness.
The court heard that Mr L had suffered from a number of medical conditions for many years, including: complications caused by obesity, diabetes, hypertension, heart disease plus sleep apnoea and pulmonary disease - which cause breathing difficulties.