Consent to withhold or withdraw life-sustaining measures
Acute Resuscitation Plan and consent
An Acute Resuscitation Plan (ARP) is a medical order initiated and completed by a medical officer. It provides clinical authority for attending clinical teams to act in acute emergency situations. ARPs involve decisions about life-sustaining measures designed to save the life and health of a patient who has impaired capacity.
Different laws apply to:
- discussing life-sustaining measures that may or may not be provided, and
- acting on prior decisions made about life-sustaining medical treatment.
There are very stringent legal requirements that involve obtaining consent to withhold or withdraw life-sustaining measures from a patient who lacks capacity and documenting the decisions made.
It is important to note that consent to withhold or withdraw life-sustaining measures from a patient who lacks decisional capacity is not required in all circumstances, for example in some acute emergency situations.
Consent during an acute emergency
Guardianship laws distinguish between the consent required in routine healthcare versus acute emergency situations.
Because the need for cardiopulmonary resuscitation is considered an acute emergency, consent is not generally required—provided the medical officer responsible for care of the patient is not aware they had objected to the withholding of cardiopulmonary resuscitation. In other words, if the patient expresses to the doctor they want CPR in the event capacity is lost, this represents an 'objection' to the withholding or withdrawing of life-sustaining measures.
In these cases, which are considered relatively rare in practice, consent will be required from the patient's substitute decision-maker to withhold or stop providing cardiopulmonary resuscitation.
Consent is always required to withhold or withdraw artificial nutrition and/or hydration, even in an acute emergency.
Read more about obtaining consent:
- substitute decision-making
- informed decision-making in healthcare
- End-of-life care: Guidelines for decision-making about withholding and withdrawing life-sustaining measures from adult patients
ARPs and advance health directives
An ARP does not replace an advance health directive.
The ARP form is a medical order or clinical tool completed in a hospital setting (including in a residential aged care facility) by a medical officer.
An advance health directive is a formal document given legal status under the powers of the guardianship laws. It is prepared by a person at or over the age of 18, and allows them to direct what medical treatment and healthcare they would like in the event they cannot make decisions for themselves. As a formal legal document, advance health directives also require compliance with signing and witnessing provisions for them to be valid.
Sometimes a patient will have both documents. If a patient has a valid advance health directive, this should be noted on page two of the ARP form. Any inconsistencies between a person's valid advance health directive and their ARP should be resolved as soon as it becomes known.
In the patient deteriorates and does not have an ARP or advance health directive, the attending team must exercise clinical judgement based on the standards of good medical practice. In these cases, the doctor will also need to factor into their decision-making any known objections to the provision or withholding or withdrawing of healthcare while the person had capacity.
Disagreements can arise when the patient and/or their substitute decision-maker(s) misinterpret or disagree with:
- the healthcare team on medical treatment proposed
- the prognosis of the patient's condition, and
- whether or not the medical treatment is in the best interests of the patient.
Potential disagreement can usually be overcome through sensitive and considered communication between interested parties by focusing upon the known wishes of the patient and their best interests. If the patient has formally documented their wishes in an advance health directive before loss of decision-making capacity then, legally, these wishes prevail over the demands of the family.
In managing potential conflict situations, the standards of good medical practice will guide decision-making to uphold the patient's best interests. It may be helpful to involve a social worker, or other staff with whom the family have formed a relationship with.
More information about resolving disputes at the end of life can be found in End-of-life care: Guidelines for decision-making about withholding and withdrawing life-sustaining measures from adult patients.
Read information about legal considerations, targeted towards patients, carers and families. It covers:
- substitute decision-makers
From a clinical perspective, more information about legal considerations can be found in the End-of-life care: Guidelines for decision-making about withholding and withdrawing life-sustaining measures from adult patients.
The information provided on these pages is general in nature and is not intended as legal advice. Resuscitation planning issues will often be complex—you need to consider individual circumstances, and sometimes the level of detail will mean further advice is required. If you are in any doubt please seek legal advice.