UDQ

[2015] NSWCATGD 12

NSW Civil and Administrative Tribunal

New South Wales

Medium Neutral Citation:	UDQ [2015] NSWCATGD 12
Hearing dates:	23 June 2015
Date of orders:	23 June 2015
Decision date:	23 June 2015
Jurisdiction:	Guardianship Division
Before:	B Tearle, Senior Member (Legal) S Stone, Senior Member (Professional) D Crowley, General Member (Community)
Decision:	Consent to the administration of Androcur for a period of two years
Catchwords:	MEDICAL CONSENT – special medical treatment – considerations
Legislation Cited:	Guardianship Act 1987 (NSW)
Category:	Principal judgment
Parties:	Mr UDQ (the subject person) Mr EMD (the applicant)
File Number(s):	57466
Publication restriction:	Decisions of the Guardianship Division of the NSW Civil and Administrative Tribunal have been anonymised to remove any information that may identify any person involved in the Tribunal’s proceedings (s 65, Civil and Administrative Tribunal Act 2013 (NSW)).

REASONS FOR DECISION

1. These Reasons for Decision are for the orders of the Tribunal made on 23 June 2015 relating to special medical treatment for Mr UDQ.

Application details

2. This was an application by Mr EMD, Geriatrician, for consent to special medical treatment for Mr UDQ under section 44 of the Guardianship Act 1987 (NSW).

3. The proposed special medical treatment is the administration of Cyproterone, up to 100 mg daily.

What the Tribunal decided

4. The Tribunal consented to special medical treatment for Mr UDQ in the terms set out in the order of 23 June 2015.

THE EVIDENCE AND THE TRIBUNAL'S REASONING

Background to this application

5. Mr UDQ, who is 92 years old and of Macedonian heritage, is a resident an aged care facility at South-Western Sydney. Mr UDQ had previously been living in his family home at West Sydney, and he was recently an inpatient of Public Hospital A and Public Hospital B. Mr UDQ is reported to have moderate dementia.

6. On 15 June 2012, Mr UDQ appointed one of his grandsons, Mr TAQ, to be his attorney under an enduring power of attorney.

7. Mr UDQ has been under guardianship since 16 December 2014, when the Tribunal appointed the Public Guardian to be his guardian for a period of 12 months. The Tribunal then gave the Public Guardian the authority to make decisions concerning Mr UDQ's accommodation, health care, medical and dental treatment, services, and access arrangements.

8. On 13 February 2015, the Tribunal made a financial management order, and appointed Mr UDQ's grandsons, Mr TAQ and Mr QFR, to be his joint private financial managers.

Reasons for proposed treatment

9. On 19 March 2015, the Tribunal received an application from Mr EMD, a Geriatrician at Public Hospital A, for consent to the administration of Cyproterone (Androcur), up to 100 mg daily. Mr EMD indicated in his application that the proposed special medical treatment was intended to treat Mr UDQ's sexually inappropriate behaviour, and also his benign prostatic hypertrophy.

10. Mr EMD informed the Tribunal that Mr UDQ had been assaulting women in his aged care facility. Mr EMD stated that the administration of Cyproterone had been commenced while Mr UDQ remained an inpatient in hospital. Mr EMD understands that the administration of Cyproterone has continued since Mr UDQ's discharge from hospital.

What did the Tribunal have to decide?

11. If a person is incapable of giving informed consent to special medical treatment, then only the Tribunal may provide consent.

12. Before the Tribunal may give consent to the special treatment proposed for Mr UDQ, it must be satisfied that:

• Mr UDQ is incapable of giving consent to the proposed special treatment; and

• The proposed special treatment is the most appropriate form of treatment for promoting and maintaining Mr UDQ's health and well-being; and

• The proposed special treatment is the only or most appropriate way of treating Mr UDQ and is manifestly in his best interests; and

• Any and all prescribed guidelines of the National Health and Medical Research Council that are relevant to the carrying out of the proposed special treatment have been or will be complied with.

Conduct of the hearing

13. The hearing on 23 June 2015 took place at the Tribunal's Balmain premises. An interpreter in the Macedonian language was present at the Tribunal's premises, and assisted the participants throughout the hearing.

14. Mr UDQ experiences very significant hearing loss. Mr UDQ attended the hearing in person, but, even with the assistance of a hearing device, he was quite unable to hear the proceedings. The extent of Mr UDQ's disabilities was such that he was unable to express any view the Tribunal. Accordingly, it was not possible for the Tribunal to take account of his views.

15. At the end of these Reasons for Decision is a list of the witnesses at the hearing [appendix removed from publication].

Is Mr UDQ able to consent to this treatment?

16. Mr UDQ's Aged Care Client Record, prepared on 24 April 2014, noted that he had dementia (Alzheimer's Disease), with challenging behaviours. Mr UDQ had scored 13/30 on a RUDAS assessment.

17. In his application, Mr EMD advised that Mr UDQ is not capable of giving consent to the administration of Cyproterone, because of his advanced mixed Alzheimer's/vascular dementia. During the hearing, Mr EMD confirmed that:

• Mr UDQ has moderate dementia; and

• Mr UDQ is unable to provide own consent to treatment, given his widespread cognitive deficits.

18. Dr Z, a Psychiatrist at Public Hospital B, recorded in a Discharge Summary prepared on 12 May 2015 that Mr UDQ has cognitive deficits that are consistent with mixed Alzheimer's/vascular dementia. Dr Z reported that Mr UDQ had been admitted to hospital following sexually inappropriate behaviours.

19. Ms TGN, the Deputy Director of Nursing of the aged care facility, confirmed that Mr UDQ does not understand his Cyproterone treatment, and would not be able to provide his own consent.

20. The Tribunal accepted the above evidence, and found that Mr UDQ is not able to consent to the proposed treatment.

Is the treatment the most appropriate form of treatment to promote and maintain Mr UDQ's health and well-being?

21. As was noted above, Mr EMD indicated in his application that the proposed special medical treatment was intended to treat Mr UDQ's sexually inappropriate behaviour, and also his benign prostatic hypertrophy.

22. During the hearing, Mr EMD confirmed that Mr UDQ displays symptoms of prostatism, with an elevated PSA, suggesting the presence of prostate cancer. Mr EMD reported that the administration of Cyproterone had been commenced, in order to treat Mr UDQ's prostatic symptoms.

23. Mr EMD advised that Mr UDQ had been trialled on antipsychotic medications to treat his sexually inappropriate behaviour. However, in Mr EMD's view, Cyproterone is now only option for the treatment of that behaviour. Mr EMD expressed the very clear view that Cyproterone is now the safest and the best medication for Mr UDQ. In Mr EMD's opinion, Cyproterone is the only medication that could treat both Mr UDQ's prostatic symptoms and his behavioural issues.

24. The Tribunal asked Mr EMD whether there might be side-effects from the administration of Cyproterone. Mr EMD replied that tiredness can be a side-effect, and, very rarely, liver dysfunction.

25. The Director of Care of the aged care facility, advised in a report prepared on 15 April 2015 that Mr UDQ had engaged in sexually inappropriate behaviour towards the residents in that facility.

26. During the hearing, Ms TGN, confirmed that the aged care facility was currently administering Cyproterone to Mr UDQ, at 100 mg daily. Ms TGN gave evidence that the administration of Cyproterone has produced a very definite change, as a result of which Mr UDQ is not now touching other female residents of that facility. However, before the treatment was commenced, Mr UDQ's behaviours were very different, and he used to try to undress the female residents. Ms TGN expressed the view that the treatment has very considerably improved Mr UDQ's quality of life. Ms TGN also reported that she has not seen any side-effects from the administration of Cyproterone to Mr UDQ.

27. Mr TAQ, a grandson of Mr UDQ, confirmed that the administration of Cyproterone had reduced his grandfather's symptoms. Mr TAQ expressed his full support for the ongoing administration of Cyproterone to his grandfather. Mr QFR, another grandson, expressed a similar view.

28. On the other hand, Mr UDQ's son, Mr AMQ, stated very emphatically that he did not support the administration of Cyproterone to his father. Nevertheless, Mr AMQ was not able to articulate a clear reason for his opposition to the treatment.

29. A representative from the Office of the Public Guardian, observed that the administration of Cyproterone has been beneficial for Mr UDQ. Accordingly, the Public Guardian supported the application lodged by Mr EMD.

30. After taking account of the evidence available at the hearing, the Tribunal concluded that the proposed treatment is the most appropriate form of treatment to promote and maintain Mr UDQ's health and well-being.

Is the treatment the only, or most appropriate, way of treating Mr UDQ, and is it manifestly in his best interests?

31. Mr EMD assured the Tribunal that, in his view, the administration of Cyproterone is manifestly in Mr UDQ's best interests.

32. The Tribunal again accepted the evidence of Mr EMD and Ms TGN on this issue. The Tribunal was satisfied that the proposed treatment is the only, or the most appropriate, way of treating Mr UDQ, and is manifestly in his best interests.

Consent

33. The Tribunal consented to the administration of Cyproterone, up to 100 mg daily. The Tribunal's consent is effective for a period of two years from the date of the order, given the need for ongoing treatment for Mr UDQ.

34. In the closing stages of the hearing, the Tribunal asked the representative from the Office of the Public Guardian, whether the Public Guardian sought the authority under section 45A of the Guardianship Act:

• to consent to the continuation of this special medical treatment for Mr UDQ; or

• to carry out further special treatment of a similar nature on him.

35. The representative from the Public Guardian indicated that Public Guardian did not request the Tribunal to confer that additional authority. In these circumstances, the Tribunal did not confer that additional authority on the Public Guardian.

FORMAL FINDINGS

36. The Tribunal made the following formal findings:

• Mr UDQ is incapable of giving consent to the proposed special treatment; and

• The proposed special treatment is the most appropriate form of treatment for promoting and maintaining Mr UDQ's health and well-being; and

• The proposed special treatment is the only or most appropriate way of treating Mr UDQ, and is manifestly in his best interests; and

• The Tribunal records its understanding that there are no prescribed guidelines of the National Health and Medical Research Council that are relevant to the carrying out of the proposed special treatment.

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I hereby certify that this is a true and accurate record of the reasons for decision of the Civil and Administrative Tribunal of New South Wales.

Registrar

Decision last updated: 13 July 2015