End-of-life planning for medical practitioners
Planning ahead for managing end-of-life decisions is complex and can take time.
Your patient, their guardian and other important people in their life should be included in discussions about withdrawing treatment and care plans.
What is the role of a guardian in end-of-life planning?
Guardians need detailed information to provide consent to any end-of-life medical treatment, including:
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whether the person has made an Advance Care Directive
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the person’s current or previous views
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the views of family, friends and carers
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clinical views from treating practitioners
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risks and benefits (including side effects) of any proposed treatment.
What happens if the Public Guardian is appointed?
When we are appointed either solely or jointly as the person’s guardian, and have been appointed with the appropriate decision-making functions or authorities, decisions will be made as soon as possible (including after-hours for urgent matters).
We can also help if information is required from medical professionals and involvement from significant others.
Advance Care Directives
What is an Advance Care Directive?
An Advance Care Directive (ACD) outlines a person’s wishes for their future medical treatment in case they are unable to make or communicate their decisions. It includes their:
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medical history and current condition
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preferences, values and beliefs.
Who can make an Advance Care Directive?
An Advance Care Directive (ACD) can only be made by the person themselves when they have decision-making capacity.
A guardian or another person cannot write, direct or consent to an ACD on the person’s behalf.
How is an Advance Care Directive made?
An ACD is usually made in writing but can be verbally presented.
It is not required to be witnessed or registered, but as the person’s health practitioner, it’s important for you to:
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sign it and keep a copy as an ACD is legally binding
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ensure that it is current and specific to the circumstances.
If the guardian has the authority to make healthcare decisions, they can consent to you making an ACD at your request.
If you have concerns about the validity of your patient’s ACD, it’s important to seek legal advice.
What do I need to know about end-of-life care for someone under guardianship?
As the patient’s healthcare provider, you should work with their guardian to ascertain consent to any end-of-life medical treatment. It is important to understand the following:
- Doctors do not have to offer non-clinically necessary treatment
Doctors may propose treatment limitations or withdrawal, but the values and wishes of the patient should be central to health and end-of-life discussions and given as much consideration as possible.
The guardian can consent to treatment withdrawal but if they disagree with your proposed treatment plan, they can advocate for treatment reinstatement or a second opinion.
- Consent is not required for urgent medical treatment
This includes treatment to save a person’s life, prevent serious damage to health or prevent suffering. If the patient has already directed that they do not consent to urgent, (including lifesaving) treatment through a valid Advance Care Directive, or they have communicated their wishes in an appropriately endorsed and valid NSW Ambulance Authorised Adult Palliative Care Plan, the treatment cannot be given.
- The Public Guardian require a Resuscitation Plan to consider use/withholding of resuscitation measures
A Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures. It also outlines other aspects of end-of-life treatment.
You should discuss the plan with your patient, the Public Guardian and family members.
- A Resuscitation Plan must be informed by any valid Advance Care Directive (ACD) or previously prepared plan
The Public Guardian will not consent to the withholding of resuscitation without a Resuscitation Plan.
If cardio-respiratory arrest is not anticipated and there is no Resuscitation Plan in place, we expect that the doctor uses clinical judgement and follow any valid ACDs.
- Euthanasia is illegal
A person’s Advance Care Directive cannot direct euthanasia.