New South Wales

When will a substitute decision-maker be needed to make health care decisions and medical treatment decisions for another person at the end of life?

In New South Wales there are two types of medical decisions which can be made: health care decisions and medical treatment decisions.

A person is presumed to have capacity to make both health care decisions and medical treatment decisions. If a person has impaired capacity and can no long make those decisions, a substitute decision-maker will need to make those decisions on the person’s behalf. This situation often arises as a person nears the end of their life.

For more information about capacity and consent to medical treatment in New South Wales click here.

Who can be a substitute decision-maker?

If a person with impaired capacity has made a common law Advance Care Directive giving a direction about their health care or medical treatment, that direction must be followed. A substitute decision-maker is not needed as the decision has been made, but they may be consulted to help understand the Advance Care Directive.

If the person does not have an Advance Care Directive, a default decision-maker, known as a person responsible, can make the decision. This will be the first person from the following list (aged 18 years or over) who is available and willing to make the decision (in order of priority):

• The person’s guardian, if they have been given authority to consent to medical treatment. This may be either:
  • a guardian appointed by the New South Wales Civil and Administrative Tribunal (NCAT); or
  • an Enduring Guardian appointed by the person under an Enduring Guardian document (see below for further information about these guardians).
• The person’s spouse or partner if the relationship is close and continuing.
• An unpaid carer of the person.
• A relative or friend of the person who maintains a close personal relationship with them through frequent personal contact and a personal interest in their welfare. They must not receive remuneration from the person (including payment for the person’s care).

The NCAT may provide consent if there is no person responsible. Where a person objects to treatment, NCAT may authorise a guardian to give consent, so long as is satisfied the person's objection is due to them not understanding the nature of or reason for the treatment.

Click here for more information about a person responsible and here for further information substitute decision-makers.

In New South Wales a power of attorney can only be used to make financial decisions and cannot make decisions about health care or medical treatment.

Information about guardians

In order for an Enduring Guardian to act:

• The person must ‘be in need of a guardian’ because the person, due to disability, is totally or partially incapable of managing his or her own affairs, and is restricted in major life activities to the extent that the person requires supervision or social habilitation; and
• The Enduring Guardian document must specifically grant the Enduring Guardian powers to make medical, dental and/or health care decisions.

Further information about Enduring Guardians is available from the NSW Trustee & Guardian.

For a person to be appointed a guardian the NCAT must be satisfied:

• the personalities of the proposed guardian and the person with impaired capacity are generally compatible;
• the proposed guardian’s interests will not conflict with the person's interests; and
• the proposed guardian is willing and able to exercise the powers of a guardian.

The NCAT can appoint either a plenary guardian (with all the powers the person would have if they had capacity) or a limited guardian (with specific powers only). In practice, it is rare for the NCAT to appoint a plenary guardian because it cannot make an order for a plenary guardian if a limited guardian is all that is needed.

If there is no one available or appropriate who can act as a guardian, NCAT may appoint the Public Guardian. More information about guardians is available at the NSW Trustee & Guardian.

What is the role of the New South Wales Civil and Administrative Tribunal (NCAT) in relation to decision-making at the end of life?

At the end of life, the NCAT has power to consent to medical treatment for a person who has lost capacity. It may do so if no person responsible is available or willing to provide consent, or if the person objects to the proposed treatment and there is no guardian authorised by NCAT to override those objections. The NCAT may also:

• appoint a guardian (who may withhold or withdraw life-sustaining treatment so long as the NCAT grants them power to make health care decisions);

• vary or revoke an Enduring Guardian or guardian’s appointment; and

• provide advice or directions to guardians about how their powers should be exercised.

Major medical treatment

The NCAT can make decisions regarding major medical treatment for a person with impaired capacity. Examples of major treatment include treatment that involves a substantial risk of death or serious harm to the person, or in some cases the administration of a general anaesthetic.

Major treatment does not include withholding or withdrawing life-sustaining treatment. Decisions in cases have determined that the NCAT does not have power to refuse or withdraw consent to life-sustaining treatment. However, the NCAT may withhold consent to treatment, which would have a similar effect as refusing treatment.

Considerations when consenting to treatment

In consenting to medical treatment, the NCAT must consider:

• the views of the person with impaired capacity, the person (i.e. the health professional) proposing the treatment and the person responsible;
• the person’s condition, alternative treatments available, the nature and effect of treatments, significant risks of the treatment, and reasons for the proposed treatment; and
• the need to ensure the adult is not deprived of necessary medical treatment.

The NCAT must not consent to treatment unless it is the most appropriate form of treatment to promote and maintain the person’s health and wellbeing.

Further information about the NCAT’s role is available from the NCAT.

What is the role of the Public Guardian in relation to decision-making at the end of life?

The Public Guardian is an independent office created under the legislation. It has a number of functions relating to substitute decision-making at the end of life. The Public Guardian can:

• be appointed as a guardian if no one else is available to make a decision about medical treatment and health care for a person who has lost capacity; and

• make a decision, as guardian, if the appointed guardian dies and there are no surviving or alternative guardians.

The Public Guardian does not have power to intervene and make a decision to resolve a disagreement about treatment e.g. within a family, or between family and health professionals, or where decisions are being made inappropriately. It can however provide information and advice to the community about end of life decision-making and the State's guardianship regime. For more information visit the NSW Trustee & Guardian.

What health care and medical treatment decisions can a substitute decision-maker make?

Whether or not a substitute decision-maker can consent to or refuse life-sustaining treatment depends on the type of decision-maker and the appointment made:

• An Enduring Guardian document can grant an Enduring Guardian the power to consent to one or both of the following:
  • Health care. This includes the power to refuse life-sustaining treatment.
  • Medical or dental treatment decisions. In this situation the Enduring Guardian cannot refuse treatment and require that life-sustaining treatment be withheld or withdrawn. They can, however, decide not to consent to that treatment, which could lead to it not being provided.

• The power of a guardian (including the Public Guardian, if appointed) to consent to health care will depend on whether the NCAT makes a plenary or ‘full’ appointment (granting the person all the powers of a guardian), or a ‘limited’ appointment (which grants specific powers only):
  • If there is a plenary appointment, the guardian can make all the decisions that the person could have made if they had capacity, including power to consent to or refuse health care (including life-sustaining treatment).
  • If there is a limited appointment and the NCAT has granted that guardian power to make decisions about health care, then that will include the power to consent to or refuse life-sustaining treatment. However, if the ‘limited’ guardian is only able to consent to medical or dental treatment, they will not be able to refuse life-sustaining treatment. Despite this, the guardian could choose to withhold his or her consent to treatment, which may result in life-sustaining treatment not being given, and would have a similar effect as refusing treatment.
• A person responsible may consent to medical treatment, but does not have the power to refuse or withdraw consent to treatment, including life-sustaining treatment. A person responsible can however withhold consent to that treatment, which may result in life-sustaining treatment not being given (and may have a similar effect as refusing treatment).

How do substitute decision-makers make decisions?

All substitute decision-makers must follow the general principles set out in the Guardianship Act when making decisions to consent to health care or medical treatment for a person at the end of life. These principles include:

• the welfare and interests of the person without capacity (this is the paramount consideration);
• the person’s freedom of decision and action should be restricted as little as possible;
• the person should be encouraged to live normally in the community as far as possible;
• the person’s views should be taken into consideration;
• consideration should be given to the importance of preserving the person’s family relationships, culture and linguistic environment;
• the person should be encouraged as far as possible to be self-reliant in matters relating to personal, domestic and financial affairs;
• the person should be protected from neglect, abuse and exploitation; and
• the community should be encouraged to apply and promote these principles.

The substitute decision-maker must also consider the:

• views of the person with impaired capacity;
• person’s condition;
• alternative courses of treatment;
• risks of each course of treatment; and
• reasons why a particular course of treatment should be carried out.

Where the Public Guardian is appointed guardian, the Guardianship Standards, position statements and decision-making guidelines must also be followed when making a health care decision.

The NCAT is also bound to follow the above general principles. However, if asked to consent to medical treatment for a person with impaired capacity, the NCAT must only agree if it is the most appropriate form of treatment available for the person’s health and well-being.

Can a substitute decision-maker's decision be overridden?

Yes. A substitute decision-maker's consent will not have effect where:

• a health professional carrying out or supervising the treatment is aware or ought to be aware that the person objects to the treatment, or
• the proposed treatment is to be carried out for a purpose other than promoting or maintaining the person’s health or wellbeing.

However, a person’s objection to treatment may be disregarded in two situations:

• If a guardian has been authorised by the NCAT to override the person's objection and provide consent OR
• the person has minimal or no understanding of what the treatment entails, and the treatment will cause the person no distress, or only some distress that is likely to be reasonably tolerable and only transitory.

In those situations the consent will operate and treatment can proceed despite the person's objection.

Can health professionals provide, withhold or withdraw treatment without the consent of a person’s substitute decision-maker?

A health professional is under no duty to treat a person (even if requested by a substitute decision-maker) if the treatment would be of no benefit, not in the person’s best interests, or futile. In this situation there is no obligation for a health professional to obtain consent to the withholding or withdrawing of such treatment (though, as a matter of practice they may wish to do so).

For further information about the law relating to futile or non-beneficial treatment visit the Adults Treatment Decisions page.

A health professional can carry out major medical treatment (which does not include withholding or withdrawing life-sustaining treatment) without consent if they believe the treatment is necessary and urgent to save the person’s life or prevent serious damage to the person’s health. Minor treatment can also be carried out on a person without consent if there is no person responsible for the person, or if the person responsible is unavailable or unwilling to make the decision.

When can emergency treatment be provided, and is consent required?

In an emergency situation, a substitute decision-maker’s consent is not required by the law. Medical treatment can be provided without consent to a person without capacity if the person’s health practitioner believes the treatment is urgent and necessary to:

• save the person’s life,
• prevent serious damage to health, or
• prevent the adult from suffering significant pain and distress.

Though not required by the law, it is still good practice for health professionals to obtain a substitute decision-maker’s consent to the urgent treatment if possible.

The NSW guardianship law does not address whether or not a medical practitioner can withhold or withdraw treatment in an emergency without consent. However, if the medical practitioner believes treatment would be futile, he or she does not have to provide such treatment, and the treatment can be lawfully withheld or withdrawn without obtaining consent.

For further information on emergency treatment visit the Capacity and consent to treatment webpage.