LL (Guardianship)

[2012] TASGAB 15

GUARDIANSHIP AND ADMINISTRATION BOARD
HOBART

LL – Application for Appointment of a Guardian by Department of Health and Human Services

Neutral citation: LL (Guardianship) [2012] TASGAB 15

REASONS FOR DECISION

Anita Smith (President)

Date of hearing: 19 June 2012

Guardianship – Limits of a guardian’s powers with respect to forensic patients – restraint of forensic patients – sufficiency of Forensic Tribunal Guidelines and Chief Forensic Psychiatrist’s Standing Orders regarding restraint – sources of substitute consent for medical treatment for forensic patients – persons responsible

Guardianship and Administration Act 1995 s. 4, 6, 19, 20, 21, 27, 28, 31, 65
Mental Health Act 1996 s. 72G, 72I, 72J, 72L

1. LL is a forensic patient within the meaning of the Mental Health Act 1996 (MHA) and is detained on a restriction order at the Secure Mental Health Unit. The treating team at the Unit applied pursuant to section 19 of the Guardianship and Administration Act 1995 (GAA) for the appointment of a guardian for him primarily for the purpose of being able to evaluate and consent to or refuse medical treatment on LL’s behalf. 

2. Before granting the order, the Board must be satisfied that LL has a disability which makes him unable to make reasonable judgments about medical treatment and that he is in need of a guardian. 

3. The application was heard at the Secure Mental Health Unit on 19 June 2012.  Present at the hearing were the following persons:

   LL
   Ms Sarah Campbell – LL’s legal representative
   Dr David McDougall - Applicant
   NL - LL’s mother
   BD – Friend of NL and LL
   Ms Lisa Warner – Public Guardian
   Annerie – Social Worker, Secure Mental Health Unit

   At the conclusion of that hearing, the Board adjourned to obtain copies of orders of the Forensic Tribunal related to LL’s medical treatment.  Upon receipt of those orders, they were circulated to the parties with an invitation to make further submissions, before the Board would make a decision.  That invitation was taken up by the Public Guardian and LL’s representative but not by the applicant.

Other proceedings:

1. The Forensic Tribunal gave authorisation pursuant to section 72I of the MHA for medical treatment of LL with respect to administration antipsychotic drugs on 6 July 2011. That authority revoked all previous authorities given by that tribunal and will expire on 5 July 2012.

2. On 27 April 2012, Dr David McDougall from the Unit applied for an emergency order pursuant to section 65 GAA. On 4 May 2012 after making enquiries, the Board appointed the Public Guardian as LL’s guardian for 28 days with powers and duties of the guardian limited to decisions concerning consent to any health care that is in the best interests of the represented person and to refuse or withdraw consent to any such treatment.

3. On 11 May 2012, the Public Guardian sought amendment of the order using the advice and direction powers of the Board pursuant to section 31 of the GAA. The extension sought was the inclusion of powers pursuant to section 28 of the GAA to physically restrain LL for the purpose of taking blood tests. That extension was granted on 14 May 2012.

4. The emergency order, including the extension, was renewed for a further 28 days on 1 June 2012; such order will expire on 29 June 2012. 

Elements in section 20(1) GAA:

1. Although LL rejects a long-standing diagnosis of schizophrenia, evidence from the applicant about LL’s disability and resultant incapacity for making reasonable decisions was not contested at the hearing.  Accordingly, the Board was satisfied that LL is a person with schizophrenia. 

2. According to the applicant, as a result of his schizophrenia, LL believes that all attempts to treat him arise from a desire by his medical team to trick or harm him.  The applicant states that he is unable to evaluate medical treatment because he views all offers of medical treatment from within this paranoid frame of reference.  Counsel for LL noted in particular that the Forensic Tribunal had, on 6 July 2011, found that LL had capacity for general medical treatment (as opposed to psychiatric treatment) and refused to make orders in this regard.  However, the Board is not bound by previous decisions of the Forensic Tribunal and capacity to understand medical treatment varies over time and according to the treatment.  The Board was satisfied that, as a result of his schizophrenia, LL is incapable of making reasonable judgments about accepting or rejecting medical treatment. 

3. The applicant asserts a need for a guardian only in the context of the guardian giving consent to medical treatment (i.e. acting as a person responsible) and supporting arrangements for that treatment such as periodic blood testing.  The applicant stated at the hearing that it is likely that LL will routinely require restraint for medical treatment to be administered.

4. The possible need for a guardian arises in the context that LL is demonstrating minimal response to antipsychotic treatment. So long as his mental condition fails to improve, the treating team will endeavor to find the treatment or combination of treatments that may break through his resistance to treatment. An improvement in his condition is particularly important as it relates directly to whether he eventually becomes fit to stand trial and, therefore, his future as a forensic patient under a restriction order. A restriction order is extremely limiting upon LL’s freedom of decision and action, therefore a course of action that may contribute to that order being reviewed and revoked is a serious consideration for the Board pursuant to sections 6, and 20(2) GAA.

5. The Public Guardian and LL’s representative argued that an order of the Forensic Tribunal consenting to medical treatment would be a less restrictive alternative to a guardianship order which would meet the same ends and, on that basis, where a Forensic Order exists there is no need for a guardian. 

6. Whether a guardian can consent to restraint is a matter of legal interpretation. Whether LL is in need of a guardian is a matter of legal consideration as to what alternative forms of authorisation might exist. As part of the consideration of the need for a guardian (as required in section 20(1)(c) GAA), these points will now be considered.

Can a guardian authorise restraint of a forensic patient?

1. Section 28 of the GAA empowers the Board to specify in a guardianship order that the guardian or some other specified person is empowered to take such measures or actions as are specified in the order to ensure that the represented person complies with any decision of the guardian in the exercise of the powers and duties conferred by the order. Often, as in the emergency order in this matter, the measures or actions specified relate to physical restraint to ensure that treatment can be administered to a person under guardianship. That section also provides immunity from liability from false imprisonment or assault actions where the guardian takes such measures or actions in the reasonable belief that the measure or action is in the best interests of the represented person and it is necessary or desirable to take that measure or action in the circumstances.

1. However, the relevant parts of section 72L(1) of the MHA provide:

   72L. Physical restraint

   (1) A forensic patient may be placed under bodily restraint only as permitted under this section.

   (2) A forensic patient may be placed under bodily restraint if the restraint –

   (a) is necessary –

   (i) for medical treatment of the patient; or

   (ii) …

   (vi) for any other purpose specified in guidelines issued by the Forensic Tribunal; and

   (b) is authorised –

   (i) by a medical practitioner or an approved psychiatric nurse for a period of less than 4 hours; or

   (ii) by guidelines issued by the Forensic Tribunal; or

   (iii) by standing orders issued by the Chief Forensic Psychiatrist; and

   (c) is applied for no longer than authorised as specified by the medical practitioner or approved psychiatric nurse referred to in paragraph (b) or as otherwise authorised by guidelines issued by the Forensic Tribunal or standing orders issued by the Chief Forensic Psychiatrist; and

   (d) is applied in accordance with any guidelines issued by the Forensic Tribunal. (emphasis added)

   From this provision, the Board interprets that the guardian’s usual source of authority arising from section 28 GAA is not applicable to a forensic patient. Therefore, the extension of the emergency order on 14 May 2012 was in error, as such authority cannot vest in a guardian in respect of a forensic patient.

2. This exclusion of a guardian’s powers only relates to circumstances where the represented person is also a forensic patient and only in relation to bodily restraint.  It means that the treating team of the Secure Mental Health Unit can obtain substitute consent to medical treatment from a guardian, but if they need to restrain a person to administer that treatment, the authority for restraint comes from the MHA, the Guidelines and the Standing Orders. 

The Guidelines of the Forensic Tribunal:

1. The Board made a request of the Forensic Tribunal on 19 June 2012 for a copy of the relevant Guidelines which have become detached from the website link on that Tribunal’s website.  That link is named “Guidelines in respect of restraint and seclusion” and the text states: “Standard for the Use of Restraint for Nurses and Midwives. The Forensic Tribunal has adopted these standards, developed and updated by the Nursing Board of Tasmania.”  However, although Chair and the Executive Officer of the Tribunal acknowledged the request and the problem with the website, they were unable to furnish the Board with a copy of the Guidelines before the writing of this decision (29 June 2012).   Because the Guidelines cannot be found, the Board cannot take them into account. 

The Chief Forensic Psychiatrist’s Standing Orders:

1. On 28 June 2012, the Acting Chief Forensic Psychiatrist supplied the Board with a copy of the Standing Orders issued by former Chief Forensic Psychiatrist, Dr John Crawshaw and the Wilfred Lopes Centre, Safe Practice and Environment policy on Bodily Restraint written by Acting Manager of the Centre Susan Styles together with the Audit Instructions and Pro Forma. (These were forwarded to the parties.) Order 12 of the Chief Forensic Psychiatrist’s Standing Orders relates to restraint pursuant to section 72L. Clause 12.2 emphasises that restraint should be used as a last resort and establishes processes for internal monitoring of the use of restraint.

2. The Board accepts that the Chief Forensic Psychiatrist is not fettered in the manner in which Standing Orders are issued and the Board has no authority to comment on the sufficiency or otherwise of this Order.  However, given the gravity of the subject matter, it seems surprising that the Order lacks any reference to:

   a)Informing the patient of his or her rights before or after the restraint,

   b)A grievance mechanism for patients,

   c)Notification to the ‘person responsible’, legal representative or significant others outside the Unit of the occurrence of restraint,

   d)Practical steps (other than de-escalation) which might avoid moving to restraint as a last resort,

   e)Avenues for external review of the decision of Unit staff,

   f)The frequency with which restraint might be used pursuant to section 72L(2)(a) and whether such use can be periodic, and

   g)The additional documents governing the use of restraint provided to the Board by the Acting Chief Forensic Psychiatrist.

1. The additional documents supplied by the Acting Chief Forensic Psychiatrist have slightly more detail, but still lack a focus upon patient’s rights to the same degree as the Standing Orders.  What is clear from the documents supplied by the Chief Forensic Psychiatrist is that bodily restraint in the Unit occurs entirely in a ‘closed loop’.  There is no acknowledgement of the value of notification or evaluation of the use of restraint, either individually or systemically, by a person outside of the control of the Chief Forensic Psychiatrist.  The Board’s view is that the legislative potential of the Guidelines and the Standing Orders to offer human rights protection to persons in the Secure Mental Health Unit has not been realised and that, for a person like LL for whom it is possible that restraint will be systematically used to advance medical treatment, additional protection is required. 

What alternative forms of authorisation might exist for consent to LL’s treatment?

1. Section 72G of the MHA provides that medical treatment may be administered to a forensic patient who is incapable of giving informed consent by reason of a disability, regardless of the age of the forensic patient, in any of the following situations:

   (a) a person responsible for the forensic patient under the Guardianship and Administration Act 1995 has consented to the treatment;

   (b) the administration of the treatment is otherwise authorised by or under Part 6 of that Act; (not applicable in this case)

   (c) the administration of the treatment to the forensic patient is authorised under section 72H, 72I or 72J.

2. During the currency of the emergency guardianship order, the Public Guardian as guardian for LL, is also his ‘person responsible’ as determined by section 4(1)(c)(i) of the GAA. If there was not an emergency guardianship order, NL would qualify as his person responsible pursuant to section 4 of the GAA, as she meets the criteria of being either the ‘person having the care of’ LL (section (4)(1)(c)(iii)) or ‘a close friend or relative’ of LL (section (4)(1)(c)(iv)).

3. At the hearing, NL said that if she was making a decision about whether or not her son required treatment, and a consequence of consenting on his behalf to having that treatment would be that he might be restrained, she would err on the side of refusing treatment. She indicated that her primary concern would be the avoidance of restraint of her son, regardless of the concerns of the treating team about the need for continuity of treatment. If the Board does not make an ongoing order, NL will remain the person responsible and therefore have authority under Part 6 of the GAA and section 72G to give consent or refusal on LL’s behalf while he is incapable of doing so. While the Board is concerned that there should be monitoring of restraint to ensure that it is kept to a minimum, the Board does not support the eradication of restraint if it means that LL is denied treatment, or continuity of treatment, as a result. Given her reservations and the need to preserve her important relationship with her son, the Board did not think it appropriate to leave NL in the position of being ‘person responsible’ with respect to treatment that may require restraint to be administered. Appointment of a guardian, other than NL, would supplant her role as person responsible.

1. The Forensic Tribunal is also a source of authority to treat LL. An order made on 6 July 2011 remains in force to 5 July 2012. It is possible for the Tribunal to alter and continue that authorization by issuing an interim order pursuant to section 72J MHA in the short term without a hearing and in the longer term following a hearing of an application pursuant to section 72I MHA.

2. During the period of the emergency order, the Public Guardian consented to administration of antipsychotic medication and a one-off blood test.  At the same time the existing order of the Forensic Tribunal also provided consent to administration of antipsychotic medication being Olanzapine, Clonazepam, Risperidone, Risperidone Consta and Zuclopenthixol acetate (some being as alternatives).  As the Board understands it, the treatments subject to both consents were similar, but the Guardian consented to an additional antipsychotic treatment, Amisulpride.  Dr McDougall submitted that any break in the ability to administer the full range of these treatments, even for one week, will be a serious set-back for LL’s recovery and mental health. 

3. With regard to section 72G, the Board considers that it is preferable that there only be one source of authority to treat of the options set out in subsection (4) of that section. Although the provision refers to “any of the following situations” it is unlikely that Parliament intended that it would be possible for there to be competing or even conflicting authorities. The Board agreed with LL’s counsel that there should not be two sources of authority for the same treatments.

4. Counsel for LL indicated that because the situation that had prompted the application for emergency guardianship related to possible testing and treatment for some emerging concerns about LL’s physical health, whereas the Forensic Tribunal order related to treatment of his mental illness with antipsychotic drugs, the appointment of a guardian for those emergency concerns was appropriate.  However, it is apparent from the Public Guardian’s report that the guardian consented to treatments which duplicated or competed with the consent by the Forensic Tribunal.  This is a matter to which the Public Guardian and the Secure Mental Health Unit staff need to be alert in future situations. 

5. Had the authority provided by the Forensic Tribunal been of longer duration, the Board would have determined that there was no need for the appointment of a guardian. However, given that the Tribunal’s authorisation expires only one week following the expiry of the emergency guardianship order, the Board considers it appropriate to address the issue of consent to medical treatment within the framework of the GAA as there will possibly be a vacuum of authority looming in a very short time which may have the effect of breaking the continuity of treatment for LL. It is also better to give consideration to this in the context of a guardianship hearing where LL has the benefit of representation, than for consideration to be given pursuant to section 72J MHA on an interim basis with no hearing and no representation.

Which of the alternative sources of authorisation is most appropriate for LL?

1. The Tribunal assesses consent to medical treatment according to the following tests:

   MHA Section 72I - Authorisation of medical treatment by Forensic Tribunal

   “(4) If after conducting the hearing the Forensic Tribunal is satisfied that –

   (a) the forensic patient has a mental illness that is amenable to medical treatment; and

   (b) an approved medical practitioner has recommended medical treatment for the illness but –

   (i) the forensic patient is incapable of giving informed consent to the administration of the treatment by reason of a disability; or

   (ii) the forensic patient has refused or failed to consent, is likely to refuse or fail to consent or has withdrawn consent to the administration of the treatment; and

   (c) the treatment should be administered to the forensic patient in the best interests of the forensic patient or for the protection of other persons –

   the Forensic Tribunal may authorise the administration of the medical treatment to the forensic patient during the period, and subject to any conditions, specified in the authorisation.”

   A person responsible, as a guardian would be, assesses consent to medical treatment according to the following tests:

   GAA Section 43 - Consent by persons responsible
   “(1) A person responsible for a person to whom this Part applies may consent to the carrying out of medical or dental treatment which is not special treatment if he or she is satisfied that –

   (a) the relevant person is incapable of giving consent; and

   (b) the medical or dental treatment would be in the best interests of that person.

   (2) For the purposes of determining whether any medical or dental treatment would be in the best interests of a person to whom this Part applies, matters to be taken into account by the person responsible include –

   (a) the wishes of that person, so far as they can be ascertained; and

   (b) the consequences to that person if the proposed treatment is not carried out; and

   (c) any alternative treatment available to that person; and

   (d) the nature and degree of any significant risks associated with the proposed treatment or any alternative treatment; and

   (e) that the treatment is to be carried out only to promote and maintain the health and wellbeing of that person; and

   (f) any other matters prescribed by the regulations.”

1. There are stark differences in the two provisions regarding the issue of capacity and the observance of the wishes of the person.  The person responsible has to weigh up risks associated with the proposed treatment to the person, which would presumably include risks associated with restraint for the purpose of treatment.  Generally the test applied by a person responsible provides for more compassionate, person-centred grounds of assessment than the test applied by the Tribunal.  The ‘person responsible test’ is arguably less restrictive than the ‘Forensic Tribunal test,’ as a person responsible cannot override the will of a person with capacity, but the Forensic Tribunal can.  However, in the factual circumstances of this case, it is most likely that either form of substitute decision will be equally restrictive upon LL. 

2. At the hearing, Dr McDougall presented some convincing arguments to the Board about the greater level of flexibility and responsiveness of the appointment of a guardian in making decisions about medical treatment as opposed to the application-by-application process of Tribunal authorisation.  The Public Guardian appeared to agree with those arguments at the hearing, but her written submissions following the hearing conflict.  Counsel for LL argued that the applicant’s concerns may relate mostly to administrative convenience.

3. A tribunal may be differently constituted from time to time and makes its decision based on the particular evidence before it and the relevant legislative tests.  A guardian or person responsible, however, can make that decision based upon the development of a longer term relationship and a personal database of information gathered over time as well as the application of the test in section 43 of the GAA.   Where treatments recommended by a treating team are subject to continual monitoring and adaptation to conditions, the appointment of a guardian presents advantages for a patient over the approval of a tribunal, which remains fixed over time.  For a patient whose treatment regime is unlikely to change, approval by the Tribunal may be less restrictive than the appointment of a guardian.  The Board was satisfied that the ability for the treating team, the guardian and LL to develop a history and a rapport meant that decisions about LL’s treatment under guardianship would be made with greater consistency and therefore better meet his best interests. 

1. Ultimately, however, despite the submissions of the Public Guardian and counsel for LL, consideration whether one order is more or less restrictive than another is futile in the context of this application.  The order of the Forensic Tribunal will expire on 5 July 2012.  The Board is advised that no application has been made to the Tribunal at the time of writing. 

2. The only possible applicants for an order pursuant to section 72G are an approved medical practitioner, the Chief Forensic Psychiatrist or the controlling authority of the Secure Mental Health Unit. Dr McDougall, on behalf of the Unit, has stated his preference for the appointment of a guardian; meaning that it is unlikely that there will be an application for the Tribunal to consent to medical treatment, at least while this application is current. They have a right to choose their forum and they have chosen the facility of an application for guardianship. The Board must determine the application accordingly.

1. In assessing the alternative that is least restrictive of LL’s freedom of decision and action, the Board must assess actual alternatives and consider those alternatives against LL’s best interests.  His best interests are served by ensuring continuity of treatment.  Approval by the Tribunal for continuity of all current treatments is not an existing alternative or an expected alternative beyond 5 July 2012.

Is LL in need of a guardian? – Section 20(1)(c) GAA

1. Unless the Board appoints a guardian, NL will be LL’s person responsible.  When the Forensic Tribunal order expires in one week, it is likely that she will refrain from consenting to any treatment where there is a possibility of restraint for the purposes of treatment.  Such restraint is a feature of the present treating relationship, so effectively he may be without antipsychotic treatment.  Without treatment, LL will most likely remain on a restriction order indefinitely.  The appointment of a guardian, with the capacity for fine-tuning dosages and prescriptions on an as-needs basis, will be the most effective mechanism for overcoming LL’s treatment resistance with a view to him becoming fit to plead and ending the restriction order.  For this purpose, LL is in need of a guardian.

2. Additionally, an examination of the legislation, guidelines and order surrounding restraint has revealed that there is very little guidance to staff of the Unit about how, when and how often to restrain a patient to administer medical treatment and that there is no obligation to notify external parties who might monitor the use of restraint on behalf of the patient. 

3. The Board concludes that until 5 July 2012, there is a need for a guardian to consent to treatments not included in the Forensic Order.  Following that date, there will be a need for a guardian to consent to the full range of treatment on LL’s behalf.  In addition, there is a need for a person with authority who is external to the Unit to monitor the use of restraint to administer medical treatment to LL. 

Least restrictive alternative - Section 20(2) GAA

1. For reasons set out in paragraphs 30 to 36 above, the Board is satisfied that LL’s needs could not be met by other means less restrictive of his freedom of decision and action. 

Best interests - Section 20(3) GAA

1. Following the hearing, the Public Guardian submitted: 

   “LL does not appear to be an individual who would benefit from a guardianship order, in that he has completely rejected the opportunity to meet with or even speak to his guardian about his wishes.  He has left a highly abusive phone message communicating his anger about the order to his guardian and then when we attempted to subsequently contact him to determine his wishes about the medication decisions we needed to make he stated he had nothing to say and wanted no further contact and hung up on the guardian.  Indeed, his treating doctor indicated that pursuing contact with him would only cause him further agitation and distress.  Given these circumstances, it would seem that another Forensic Order might be a way to cause less distress to LL and we would support the making of such an order.”

2. The Board has carefully considered this submission. The Board believes this view of the role of a guardian is too narrow. Firstly, it concentrates only on being able to establish and communicate LL’s wishes. This is a central requirement of a person responsible, but it neglects the wider advocacy and protection role of a guardian set out in section 27(2)(b) and (e). Secondly, it assumes that contact for the purposes of establishing his wishes must be either in person or by telephone. There is no evidence to suggest that LL is illiterate, so presumably the guardian could attempt to establish rapport with LL in writing or at the very least communicate actions taken on his behalf in writing. A guardian might offer facilities for him to respond in writing, for instance a simple questionnaire. Additionally, the guardian could establish NL or trusted staff at the Unit as a conduit for written or oral communication to assist in establishing rapport with the guardian over time.

3. Establishing LL’s wishes might require a modicum of resourcefulness on the part of the guardian but it is not impossible, nor is it the limit of a guardian’s responsibilities. LL is a resident of a highly secure facility, the subject of a restriction order, subject to restraint and forced treatment and a person with a serious psychiatric disability which is presently resistant to treatment.  The Board does not accept that the present refusal of LL to communicate directly with the guardian or the present advice of the doctor means that there is no benefit to LL in having a guardian appointed to consent to treatment on his behalf and to monitor the use of restraint upon him. 

Limitations upon the order – section 20(4) and (5) GAA

1. As set out in the preceding paragraphs, the need for a guardian is limited to giving substitute consent to treatment on his behalf and to monitor the use of restraint upon him.  The need is also limited in time.  That is: until 5 July 2012, the guardian need not and should not duplicate consent to treatment already given by the Forensic Tribunal.  Following 5 July 2012, the need for consent to medical treatment is wider and the order will reflect that.

Eligible persons for appointment as a guardian – section 21 GAA

1. NL did not offer consent to appointment as a guardian.  The Public Guardian noted in a report dated 24 May 2012:

   “The Public Guardian remains suitable as guardian for LL under the emergency guardianship order.  As to the possibility of a longer term guardianship order the Public Guardian would remain suitable absent a suitable private guardian.  LL’s mother has filled the role of person responsible in the past but feels conflicted by this position as she fears consenting to health care measures against her son’s wishes may place their relationship at risk.  Further, NL herself is diagnosed with schizophrenia which doctors believe can at times compromise her ability to act objectively in her sons best interests when it comes to weighing up medical treatment for him.”

2. The Board considers this report constitutes consent to appointment as a guardian for the purposes of section 21(1) GAA and also presents issues to the Board relating to section 21(2)(b) GAA to the effect that appointing the Public Guardian will best preserve the relationship between LL and NL.

Conclusion:

After hearing an application by Dr David McDougall in respect of LL (hereinafter called the ‘represented person’)

The Board was satisfied that the represented person

• is a person with a disability, and

• is unable by reason of the disability to make reasonable judgements in respect of his person and circumstances; and

• is in need of limited guardian.

THE BOARD ORDERS

1.  That the Public Guardian be appointed as guardian of the represented person.

2.  That the powers and duties of the guardian are limited to:

(i)the authority to obtain records and review documentation relating to the represented person with a view to monitoring the use of bodily restraint upon him and advocating on his behalf with regard to the use of restraint.

(ii)until 5 July 2012, decisions concerning consent to any health care that is in the best interests of the represented person and to refuse or withdraw consent to any such treatment, except where the particular treatment is currently the subject of an order by the Forensic Tribunal.

(iii) following 5 July 2012, decisions concerning consent to any health care that is in the best interests of the represented person and to refuse or withdraw consent to any such treatment.

3.  That this order remains in effect to 27 June 2015.

Anita Smith
PRESIDENT