IJU [2019] NSWCATGD 21

Judgment (9 paragraphs)

[1]

Background

IJU is a 78-year-old woman who lives at an aged care facility. It is reported that she has advanced dementia and is bed-bound.
IJU was admitted to a public hospital on 25 May 2002 following a stroke resulting in a dense left hemiparesis and cognitive deficits. Her admission was complicated by major depression. Prior to her hospital admission she was working part-time as a cook at a childcare centre. She had no relatives residing in Australia.
On 24 September 2002, applications were lodged by a social worker at the public hospital for the appointment of a guardian and financial manager for IJU.
In early October 2002, IJU was discharged to a nursing home.
On 20 November 2002 the Tribunal made guardianship and financial management orders for IJU. The estate of IJU was committed to the then Protective Commissioner (now the NSW Trustee and Guardian) and the Public Guardian was appointed as IJU's guardian for one year to make decisions about her accommodation.
The guardianship order was reviewed on 12 November 2003 and lapsed.
Around 2008, IJU was moved from the nursing home to the aged care facility. It is unclear how this decision was made.
On 6 May 2008, IJU was the subject of an application for consent to medical treatment while she was at another public hospital. Consent was provided for IJU to have a diagnostic thoracentesis to sample effusion under local anaesthetic and any necessary treatment normally provided in association with or consequential to that treatment.
On 24 September 2019 the Tribunal received an application for the appointment of a guardian for IJU from SZE, General Manager and Director of Nursing at the aged care facility.
We agreed to ZAC, Acting Director of Nursing at the aged care facility, acting as substitute applicant during the hearing.

[2]

Is IJU someone for whom the Tribunal could make an order because she has a disability which prevents her from being able to make important life decisions?

Section 14 of the Guardianship Act 1987 (NSW) ("the Act") provides that the Tribunal may make a guardianship order for a person if it is satisfied that he/she is "a person in need of a guardian". A person in need of a guardian is "a person who because of a disability is totally or partially incapable of managing his or her person": s 3(1) of the Act. A person with a disability is a person who is: 1. intellectually, physically, psychologically or sensorily disabled; 2. of advanced age; 3. a mentally ill person within the meaning of the Mental Health Act 2007 (NSW); or 4. otherwise disabled; and by virtue of that fact is restricted in one or more major life activities to such an extent that he or she requires supervision or social habilitation: s 3(2) of the Act.
We note that IJU has been the subject of previous orders of this Tribunal in 2002 and 2008 when the Tribunal accepted evidence that she was unable to make decisions or provide informed consent because of her cognitive impairment.
The Tribunal received a copy of a document dated 14 June 2019 signed by Dr Z, IJU's general practitioner, in which it is stated that IJU has advanced dementia and severe cognitive impairment. Dr Z also states that IJU is unable to make any decisions due to her severe impairments.
We had before us a report from Dr Y, Geriatric Advanced Trainee at the Department of Geriatric Medicine at the public hospital, dated 8 November 2019. Dr Y states that: [IJU] has a background of advanced dementia, with previous cerebrovascular accidents. As a result she has poor baseline functioning, is bed bound and dependent of (sic) all activities of daily living. She is non-verbal, often mumbling quietly. She is resistive to nursing care. She is malnourished with a bodyweight of 21kg… … [IJU] was found to have developed bruising over her left hip with plain film imaging demonstrating an intertrochanteric femur fracture. It is unclear the mechanism of this injury or how it occurred. Staff deny trauma or fall however it is noted she was being transferred with a hoist. [Dr Y] concludes that: She ([IJU] likely has severe osteoporosis and is very frail; a non-operative approach to managing the fracture is not unreasonable given her pain is well managed. Mortality and complication rates following a fractured neck of femur are high, and her prognosis following this event is very guarded.
ZAC told us that she has known IJU for four years. In addition to having advanced dementia, IJU has an affective mood disorder. ZAC confirmed that IJU is unable to communicate and cannot make important life decisions
We are satisfied that IJU has disabilities, including advanced dementia, which prevents her making important life decisions. She is a person for whom the Tribunal could make a guardianship order.

Should the Tribunal make a guardianship order and what order should be made?

The Tribunal must consider all of the following matters set out in s 14(2) of the Act before exercising its discretion to make a guardianship order: 1. the views (if any) of: 1. the person, and 2. the person's spouse, and 3. the person's carer and 1. the importance of preserving the person's existing family relationships, and 2. the importance of preserving the person's particular cultural and linguistic environments, and 3. the practicability of services being provided to the person without the need for the making of such an order.
These matters have no hierarchy or weighting and each is a mandatory consideration. However, the Tribunal must undertake a balancing exercise for its consideration of the matters in s 14(2) of the Act. When undertaking this task the Tribunal may be guided by the principles that are set out in s 4 of the Act (see IF v IG [2004] NSWADTAP 3).
In the application for the appointment of a guardian for IJU it is stated that a guardian should be appointed for her because she: …doesn't have the capacity to make decisions especially when clinical decisions are needed to be made. It is very important to have an authorised representative to make those decisions in (sic) behalf of [IJU].
We accepted the evidence before us that IJU was not able to present her views about the guardianship application as a result of the severity of her cognitive impairment.
During the hearing ZAC told us that IJU developed bruising on her left hip following which it was determined that she had a fracture. IJU was previously on antipsychotic medication but this is no longer the case. She is now only being administered medications for pain relief, however these include major medications.
ZAC said that decisions need to be made about IJU's funeral arrangements; her health care; palliative care and end of life decisions. She submitted that a guardian is required because IJU is incapable of making decisions and has no family.
We asked ZAC whether decisions will need to be made about any other aspects of IJU's life, such as her accommodation. She responded that it is intended that IJU will be cared for at the facility until she dies.
We were provided with a copy of a NSW Health Advance Care Directive (ACD) purporting to relate to IJU, although not signed by her. The document was 'witnessed by' Dr Z and ZAC on 3 August 2019.
In light of Dr Z's document dated 14 June 2019 referred to above, in which he states that IJU is unable to make any decisions due to her severe impairments, it is extraordinary that Dr Z has confirmed in the ACD on 3 August 2019 that he 'had no reason to doubt the capacity of the person ([IJU])'.
We had a lengthy discussion with ZAC during the hearing about the lack of validity of the ACD relating to IJU.
ZAC told us that she has been instructed by management of the facility that an ACD must be prepared for every resident of and that, if the resident is unable to complete an ACD as a result of their impairment, a family member is asked to complete one on their behalf. If there is no family member, it appears that the person's general practitioner may be asked to complete one.
The information provided to IJU is legally incorrect.
In order to be valid, an ACD must be signed by the person to whom it relates after being informed of the purpose and effect of an ACD at a time when that person is able to understand the facts and choices involved and the consequences of their decisions. An ACD cannot be signed by any other person.
In Hunter and New England Area Health Services v A [2009] NSWSC 761, McDougall J summarises the principles relating to emergency care decisions, including ACDs. His Honour states [at 40]: (6) A person may make an "advance care directive": a statement that the person does not wish to receive medical treatment, or medical treatment of specified kinds. If an advance care directive is made by a capable adult, and is clear and ambiguous, and extends to the situation at hand, it must be respected. … (11) What appears to be a valid consent given by a capable adult may be ineffective if it does not represent the independent exercise of persons (sic) volition: if, by some means, the person's will has been overborne or the decision is the result of undue influence, or of some other vitiating circumstance.
The apparent lack of understanding of the facility, Dr Z and ZAC about what is required for an ACD, a very significant legal document, to be valid is of great concern as it leaves IJU with a legally invalid form of decision making at a critical time in her life.
As the purported ACD made in relation to IJU is invalid we had to consider whether or not to make a guardianship order for IJU.
There is a regime set out in Pt 5 of the Act for a 'person responsible' to provide lawful substitute consent for the carrying out of certain medical or dental treatment, without being appointed by the Tribunal as a guardian. This regime, however, relates only to proactive medical interventions (FI v Public Guardian [2008] NSW ADT 263, at [40]). A person responsible is not authorised to make decisions about the withdrawal, cessation or non-provision of life-sustaining treatment.
In circumstances in which a guardian is appointed under the Act with a medical and dental consent function, unless they also have a health care function, they do not have the authority to decide to withdraw life-sustaining treatment for the person under guardianship. However, a guardian appointed with a health care function does have the authority to make decisions in connection with health care that include decisions to withdraw life-sustaining treatment (FI v Public Guardian [2008] NSW ADT 263, at [51]).
After considering the oral and written evidence presented, we are satisfied that a guardianship order should be made for IJU and that the guardian should have authority to make decisions about her healthcare and to consent to medical and dental treatment on her behalf. This will enable the guardian to make decisions about palliative care for IJU and, if necessary, to make decisions about the withdrawal or withholding of life-sustaining treatment (for example, by way of a 'not for resuscitation' order) provided this is in her best interests.
We informed ZAC that a guardian is unable to make funeral arrangements for IJU but that, given her estate is under the management of the NSW Trustee and Guardian, they can be approached for guidance at the appropriate time.
We noted that IJU was transferred from the nursing home to the aged care facility around 2008 without the involvement of a guardian, but at a time when she had been deemed incapable of consenting to medical treatment. ZAC was unable to advise us how this accommodation decision was made because it occurred prior to the aged care facility commencing to use electronic records and she did not have access to older paper records.

At a glance

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Judgment (9 paragraphs)

Legislation Cited (3)

Cases Cited (1)

Cited By (1)