No 199 September 2017

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Take control

ALEX COOMBS

Alex Coombs is Social Worker – Haemophilia & Other Inherited Bleeding Disorders at the Ronald Sawers Haemophilia Treatment Centre, The Alfred hospital, Melbourne

The right documentation can give you some power over your future medical care and treatment.

THE UNEXPECTED

As some of you may recall the 10th March 2011 was a day my life and world changed for me. Until that date I had been living my life fairly carefree, travelling and working as a social worker at the Alfred hospital Infectious Diseases Team and Ronald Sawers Haemophilia Treatment Centre for three years.  I had relocated from Perth, where I had lived all my life to start in a new social work clinical area and enjoy the many great lifestyle options Melbourne had to offer.

You never know what is waiting ahead and the changes that can occur in an instant. I still remain unable to explain why I went from planning to head off to work one morning as I stood on my third floor balcony to now being reliant upon an electric wheelchair and personal carers every morning 7 days a week six years later.

Like many people I hadn’t given much thought about the “what if’s. I had a unit I planned to hold onto, and had dutifully done my will that made provisions for my estate and any remaining extended family in Perth. Being single and away on the other side of Australia from my family, who would be responsible to make medical or financial/lifestyle decisions on my behalf if I wasn’t in a position to do so one day? Even if I was partnered too, it is not as clear-cut as you or even best friends know.

ADVANCE CARE PLANNING

I recently attended a workshop on Advance Care Planning, which is a way to ensure your thoughts and wishes about your medical care and treatment can be recorded and known by your GP, treating team and hospital and your family/significant others. I add that the guidance and input of the medical team is still highly sought and not to be ignored in any aspect of this. As we age our body keeps changing, no matter how healthy we think we are or attempt to be. For those with existing medical conditions this can add more complexity and risk.

I am not trying to sound alarmist but to bring to your attention that there are a few ways that we all can ensure that our wishes for medical intervention can be communicated to your medical team, treating hospital or if you find yourself in another hospital not familiar with your medical history.

SUBSTITUTE DECISION MAKERS

Who should know your wishes regarding your health and medical decision making if you can’t communicate them yourself? Well let’s start with your significant other(s). Whether you are married, de-facto or single it can become essential someone has recollection of what you want regarding treatment or level of intervention to either restore your health or keep you comfortable and pain free.  The person who makes these decisions on your behalf when you cannot is known as a “substitute decision-maker”. I would recommend people appoint a substitute decision-maker and potentially an Advance Care Plan to capture your wishes to their fullest degree and avoid the potential for conflicts to arise between family and significant others.

The timing of having a conversation with your chosen confidante about your wishes, in my opinion, would be best when you are at your healthiest and competent. You may have recently had an event that began to make you think ‘what if’. We can all make assumptions about who takes over, even I did as a social worker after almost 20 years in health.

WHO WILL DOCTORS TURN TO FOR MEDICAL DECISIONS?

When a treatment decision has to be made and you do not have the capacity to make it, the medical team will turn to a specific hierarchy of decision makers based on the level of connection to you as the patient. Whilst all relationships will be respected generally in the health care system, the powers to make decisions about medical treatment for you when you cannot are considered to be very important under the law. In all Australian states and territories except NT, the medical team must use a legislated hierarchy for the substitute decision maker that follows legally recognised relationships and blood family connections. Depending on which state or territory you live in, this person might be known as the “person responsible” or the “[statutory] health attorney”.

Who is this person? The first person the medical team will turn to is someone you have appointed legally. If you have not appointed anyone, then depending on which state or territory you live in, they will be required to turn to your spouse, or if you don’t have one, your nearest relative or unpaid caregiver.

WHO WOULD YOU CHOOSE?

Usually when we are admitted to hospital, we, or someone on our behalf might fill in a registration form with the words: “next of kin”, “Emergency Contact”, “person responsible” requiring name and contact details. Whilst helpful, do this person know what we want to happen to us from the medical treatment point of view? What if our personal, religious, spiritual or cultural beliefs influence our thinking? Would the person whom the treating team talk to know how important that is to us?

If you would choose someone different to the “person responsible” or “health attorney” or “next of kin” or you don’t have anyone who fits the criteria, your next option is to appoint someone you trust as your substitute decision-maker. If no one fits that criteria for you, you can ask for a publically appointed person to be applied for. The person you have appointed will have the powers to make decisions on your behalf when you are unable to do so due to an accident or illness. This is one area that can give power to those who are in a same sex attracted relationship, those without close family ties living or close by or due to family dysfunction.  Bear in mind that if you are in a same-sex relationship, this is usually not recognised under the law in your state/territory, and you may need to appoint your partner legally as your substitute decision-maker to have them as the first person to turn to in the legal hierarchy of medical decision-makers.

HOW DO YOU DOCUMENT YOUR DECISION-MAKER AND WISHES?
 

Each state and territory has legal documents you can use to appoint someone as your preferred substitute decision-maker and legal documents to record your wishes.

See ROLES AND DOCUMENTS for more information.

Before you go ahead and document your wishes and sign it off, PLEASE inform the appointed person that you intend to do so and discuss your wishes with them. They don’t need another sudden surprise during a traumatic hospital situation to be told they have a significant level of responsibility on your behalf.

ROLES AND DOCUMENTS

 

  • Next Of Kin – the closest living relative such as wife, husband, domestic partner, sibling with whom your medical team will discuss your medical situation with but may not be the person legally deemed to be the substitute decision maker, if that applies in your state or territory - see below.
  • Emergency contact – similar to the above but a person who can be nominated to go between you, your medical team and the outside world of family and friends
  • Guardian – legally appointed person to make decisions if you have no one else capable or willing to do so
  • Person responsible/statutory health attorney/health attorney – is the first person in a legislated list of relationships who is available, willing and able to make decisions about your medical treatment. In all Australian states and territories except NT, the relationships in the list will include the following, although their place in the hierarchy varies from state to state:

Person appointed legally to undertake medical decisions on behalf of the patient

Spouse or domestic partner

Primary unpaid caregiver

Nearest relative aged 18 and over, which may mean the oldest.

In some states, a close friend

                       

  • Legally appointed substitute decision-maker - is a person given legal authority by you to make medical decisions when your own capacity is diminished.

Depending on which state or territory you live in, this person might be known as:

An enduring guardian

An enduring power of attorney (Medical treatment/Healthcare matters/ Personal matters)

An agent

A decision-maker.

You will need to complete an official form provided by your state/territory government to appoint someone as your substitute decision-maker. See www.advancecareplanning.org.au for the appropriate forms in your state/territory.

There are other substitute decision-maker roles where you can appoint someone else to manage your financial and lifestyle affairs, such as an Enduring Power of Attorney (Financial matters). If you have any of these forms completed, please ensure your GP, hospital, medical team, case manager, social worker, family and significant friends are aware of their existence. A copy should be noted as a true and sighted copy to be held in your medical records. If you attend other hospitals ensure they each similarly have a copy.

  • Advance care plan - records your wishes in regard to the types and level of medical intervention you wish to be carried out in emergency and life threatening events. If you have recorded your wishes in one of these documents, I would recommend that you can arrange for another copy to be held by in any hospital where you already have a medical record and are likely to be admitted.

The name of the advance care plan document varies from state to state. See www.advancecareplanning.org.au for the appropriate forms in your state/territory.

The documents for your substitute decision-maker and advance care plan are very important to ensure that your appointed decision-maker is consulted and can work together with your medical team to be guided by your documented wishes. You may wish to consider the advantage of these documents being on file in your medical records.

By writing this, as a social worker I hope it will give rise to more careful documentation of our client’s wishes and decision-making. These documents enable us to have conversations with our clients to ensure their health beliefs are recognised and followed by those often left to make hard decisions at difficult times.

MORE INFORMATION

Advance Care Planning Australia – www.advancecareplanning.org.au

Includes information about substitute decision makers and advance care planning documents and forms for each Australian state and territory

Australian Dept of Health - LGBTI Advance Care Planning by State and Territory - https://agedcare.health.gov.au/support-services/my-aged-care/lgbti-advance-care-planning-by-state-and-territory-0

MyAgedCare – Advance Care Planning - https://www.myagedcare.gov.au/end-life-care/advance-care-planning

 

Carter RZ, Detering KM, Silvester W et al. Advance care planning in Australia: what does the law say? Australian Health Review 2016;40:405–414. http://dx.doi.org/10.1071/AH15120.

 

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Date last reviewed: 21 September 2017