Victorian Consolidated Legislation

Medical Treatment Act 1988 - SCHEDULE 3

Sections 3, 5B REFUSAL OF TREATMENT CERTIFICATE AGENT OR GUARDIAN OF
INCOMPETENT PERSON I ............. [name] .............. [address] certify
that I am empowered to act in relation to decisions about medical treatment of
............. [name of patient] ("the patient"). I have been appointed to act
by-

* an enduring power of attorney (medical treatment) issued under the
Medical Treatment Act 1988.

* an appropriate guardianship order of the Victorian Civil and Administrative
Tribunal under the Guardianship and Administration Act 1986 that provides for
decisions about medical treatment. I certify that- (a) the patient has
attained the age of 18 years; (b) I have been informed about and understand
the nature of the patient's current condition to an extent that would be
reasonably sufficient to enable the patient, if he/she were competent, to make
a decision about whether or not to refuse medical treatment generally or of a
particular kind for that condition. I believe that the patient would request
that no medical treatment, or no medical treatment of the particular kind
mentioned below, be administered to him/her. On behalf of the patient, in
relation to his/her current condition, I refuse-

* medical treatment generally.

* medical treatment, being
............................................................... (specify
particular kind of medical treatment). Dated: Signed: .....................
(Agent/Guardian for ..................... [Name of patient])

*Delete whichever is not applicable



Verification We each certify as follows: (a) I am satisfied that
.................... [name of agent or guardian] has been informed about the
nature of the patient's current condition to an extent that would be
reasonably sufficient to enable the patient, if he/she were competent, to make
a decision about whether or not to refuse medical treatment generally or of a
particular kind for that condition and that the agent/guardian understands
that information; (b) I was not a witness to the enduring power of attorney
(medical treatment) under which .........................................
(name of agent) was appointed. Dated:
Signed: ............................................   Signed: .........................................
(Registered Medical Practitioner) (Another Person) Patient's current condition
The patient's current condition is ................................ (describe
condition) The patient is incompetent. Dated: Signed: (To be signed by the
same registered medical practitioner) NOTICE OF CANCELLATION (For completion
where patient agent or guardian cancels the certificate under section 7 of the
Medical Treatment Act 1988) I cancel this certificate Dated: Signed
........................................ (Patient, agent or guardian) or The
patient, agent or guardian clearly expressed or indicated a decision to cancel
this certificate on (Date) Signed
............................................... (Person witnessing patient's
agent's or guardian's decision)



NOTES: 1. "Medical treatment" means the carrying out of- (a) an operation; or
(b) the administration of a drug or other like substance; or (c) any other
medical procedure- but does not include palliative care. "Palliative care"
includes- (a) the provision of reasonable medical procedures for the relief of
pain, suffering and discomfort; or (b) the reasonable provision of food and
water. The refusal of palliative care is not covered by the
Medical Treatment Act 1988. 2. An alternate agent can only make a decision
about a patient's medical treatment if the alternate agent first produces to
each medical practitioner who is to verify this certificate a statutory
declaration that meets the requirements of section 5AA(1) of the
Medical Treatment Act 1988. 3. If this certificate is to be completed by an
alternate agent, a medical practitioner must refuse to verify this certificate
if the alternate agent does not produce to him or her a statutory declaration
that meets the requirements of section 5AA(1) of the
Medical Treatment Act 1988 or if the medical practitioner reasonably believes
that the original agent can be contacted and is not incompetent. 4. If a
medical practitioner is asked to sign the verification part of this
certificate and has doubts about any of the following matters, an application
may be made to the Victorian Civil and Administrative Tribunal to review the
case-

   (a)  whether the patient is incompetent;

   (b)  in the case of an alternate agent, whether the medical practitioner or
        other person should decline to be satisfied of the matters referred to
        in paragraph (a) of the verification, in accordance with
        section 5AA(2) of the Medical Treatment Act 1988;

   (c)  whether the agent or guardian is competent to act and is acting in
        good faith in refusing medical treatment on behalf of the patient.
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