⚖️ Substitute Decision-Making: Meaning and Use in Aged Care
Substitute decision-making (SDM) is a concept that becomes relevant when an individual loses the capacity to make important decisions about their own personal care, medical treatment, or finances. In the context of aged care, this situation frequently arises due to conditions that affect cognitive ability, such as advanced Alzheimer's disease, dementia, or following a severe medical event.
When a person is determined to be incapable of making specific decisions, a designated individual or entity steps in to make those choices on their behalf. This person is commonly called a substitute decision-maker. The SDM's role is governed by law and generally means making decisions that have the same legal force as if the person had capacity and made the decision themselves.
The Role of the Substitute Decision-Maker
The SDM is generally responsible for making choices concerning the incapacitated person’s wellbeing and interests. These responsibilities often cover two main areas: personal care and health care.
Health Care and Medical Treatment Decisions
The most significant aspect of the SDM’s duties often involves consent to or refusal of health care and medical treatment. This can range from routine medical procedures to life-sustaining treatment decisions, especially toward the end of life. The SDM must be capable of making the decision, meaning they must grasp the information relevant to the decision and weigh the reasonably foreseeable consequences.
In many jurisdictions, the SDM is legally obligated to base their decision on the known wishes and past conduct of the person when they had capacity. If those wishes are not known or clear, the SDM must then act in the person’s best interests, considering factors like potential risks, burdens, and benefits of any proposed treatment.
Personal Care and Living Arrangements
In aged care settings, particularly long-term care, the SDM’s responsibilities extend beyond medical choices. They may be tasked with decisions regarding:
- Nutrition and Diet: Determining appropriate meals and dietary restrictions.
- Living Arrangements: Deciding where the person will reside, such as moving them into a residential aged care facility or choosing specific home care services.
- Hygiene and Safety: Making choices about daily personal routines, clothing, and overall safety within their environment.
The substitute decision-maker must work closely with aged care providers and health professionals to make sure the loved one is receiving appropriate and person-centered care.
Who Can Be a Substitute Decision-Maker?
The authority to act as an SDM is established through legal frameworks, which vary by location. Generally, the legal hierarchy for who can be an SDM includes:
- Court-Appointed Guardians or Representatives: A person formally appointed by a court or specialized board to make decisions.
- Attorneys for Personal Care: A person named by the individual while they still had capacity, typically through a legal document like a power of attorney for personal care.
- Default Statutory List: If no formal appointment has been made, the law typically sets out a default list of family members who can act, often starting with a spouse or partner, followed by adult children, parents, or siblings.
The SDM must meet certain legal requirements, such as often being 16 years of age or older and available to make the decision when needed.
Substitute Decision-Making vs. Supported Decision-Making
It is important to distinguish substitute decision-making from supported decision-making.
Supported decision-making happens when a person retains capacity but requires assistance to understand information and communicate their choices. Examples of support include presenting information in an understandable format, adjusting language, or giving the person more time to talk through options. The person still makes their own decision; the supporter simply helps the process.
Substitute decision-making, conversely, occurs when the person has lost capacity, and the SDM is legally taking their place to make the choice.
Advance Care Directives and the SDM
In many regions, if a person has a valid Advance Care Directive (or similar legal instruction) that applies to a specific situation, the SDM's authority may be limited or superseded by that written directive. An Advance Care Directive allows a person to express their preferences for future care while they still have capacity, acting as a direct instruction to health professionals and the SDM.
Understanding the laws regarding substitute decision-making is essential for families navigating the aged care system to uphold the wishes and wellbeing of their loved ones when they are no longer able to speak for themselves.
❓ Frequently Asked Questions (FAQs)
- What determines if someone needs a substitute decision-maker?
A person needs an SDM when they are assessed by a qualified professional as being incapable of making important decisions about their personal care or medical treatment. Incapacity means the person cannot understand the information relevant to the decision or appreciate the foreseeable consequences of making or not making that decision. - Can I choose my own substitute decision-maker in advance?
Yes, in most legal systems, you can formally appoint someone to be your substitute decision-maker for personal care or health care while you still have legal capacity. This is commonly done through documents such as a Power of Attorney for Personal Care. - What is the substitute decision-maker’s primary goal?
The primary goal of the SDM is to make decisions based on what they genuinely believe the incapacitated person would have chosen, based on the person's views, wishes, and conduct when they had capacity. If the person's wishes are unknown, the SDM must make the choice that is in the person's best interests.
