Advance Care Directive Disputes in South Australia: SACAT, the OPA, and Family Disagreements

When Families Fight Over an Advance Care Directive

The point of an Advance Care Directive is to prevent disputes by documenting your wishes clearly while you still have capacity. But ACDs don't eliminate conflict — they sometimes become the focus of it.

Family disagreements about an ACD in South Australia typically fall into one of three patterns:

• The SDM's decisions are challenged. Adult children disagree with the SDM's refusal or consent to treatment, arguing the SDM isn't following the person's wishes.
• The ACD's validity is questioned. A family member claims the person lacked capacity when they signed, was coerced, or was unduly influenced.
• The ACD's instructions are ambiguous. Different family members interpret vague provisions differently, and the clinical team doesn't know whose interpretation to follow.

South Australia has a structured two-tier system for resolving these disputes: informal mediation through the Office of the Public Advocate (OPA), and formal tribunal proceedings through SACAT.

Step 1: Contact the Office of the Public Advocate

The OPA is a first point of contact for ACD-related disputes. It provides information, advocacy, and dispute resolution services for people with impaired decision-making capacity and their families.

The OPA's Dispute Resolution Service offers:

• Information and guidance — helping families understand what the ACD says, what the SDM's authority is, and what the legislation requires
• Mediation — bringing family members, SDMs, and healthcare providers together to discuss the situation and reach a consensus
• Support and referral — if there's a suspicion of elder abuse, coercion, or misuse of decision-making authority, the OPA can explain available next steps

Mediation through the OPA is voluntary. It can resolve many disputes without the formality, cost, and emotional toll of a tribunal hearing. The OPA's mediators are experienced in the specific dynamics of ACD conflicts — the guilt, the grief, the family politics, the medical complexity.

However, the OPA cannot make binding legal determinations. If mediation fails and the parties can't agree, the dispute escalates to SACAT.

Step 2: Apply to SACAT

The South Australian Civil and Administrative Tribunal has broad powers to resolve ACD disputes. If mediation fails and a formal determination is needed, the parties can apply to SACAT.

SACAT can:

• Declare whether an ACD is valid — confirming or denying that the person had capacity at execution, was acting voluntarily, and followed the correct execution procedures
• Determine whether the ACD has been activated — confirming that the person has lost capacity and the ACD's provisions now apply
• Consider disputes about the ACD — SACAT can make binding declarations about its validity and whether it has been activated; unresolved questions about its provisions can be raised in that process
• Vary or revoke the ACD — modifying or cancelling the directive if SACAT is satisfied that it no longer reflects the person's genuine wishes or is inappropriate in the circumstances
• Make guardianship or administration orders — where the ACD or SDM arrangements do not resolve the dispute, SACAT can issue the relevant order
• Appoint a guardian — if the ACD is revoked and no SDM is available, SACAT can issue a guardianship order to appoint someone with decision-making authority

SACAT hearings are relatively informal compared to Supreme Court proceedings, but they're still a legal process. Parties can represent themselves or be represented by a lawyer. Medical evidence is typically required, including capacity assessments and treating clinician reports.

Common Dispute Scenarios

"The SDM Is Refusing Treatment We Want"

A son is the first preferred SDM. His mother's ACD contains a binding refusal of mechanical ventilation if she has an irreversible terminal condition. She's now in hospital with end-stage lung disease, and the clinical team has confirmed the condition is irreversible. The son is enforcing the refusal. His siblings want ventilation to continue.

Under the Act, the SDM is doing exactly what they're legally required to do: following the binding provision. The siblings' preferences don't override a valid binding refusal, and the clinical team must follow the ACD. If the siblings believe the SDM is misinterpreting the directive — perhaps they argue the condition isn't truly "irreversible" — they can apply to SACAT for a determination.

"She Was Coerced Into Signing"

A daughter suspects her mother was pressured by her second husband into appointing him as sole SDM and including provisions that benefit him. She alleges undue influence.

This is a validity challenge. The daughter should contact the OPA first, then apply to SACAT if mediation doesn't resolve it. SACAT can consider evidence about whether the person was acting voluntarily and whether the execution requirements were met, then make orders about the ACD if the challenge is established.

"The SDM Isn't Available"

The first preferred SDM has moved overseas and isn't responding to calls. The clinical team needs consent for treatment, but the ACD doesn't contain a specific binding provision covering this situation.

If the first preferred SDM is unavailable, the clinical team should contact the second preferred SDM (if one was appointed). If no backup SDM is available, the team can apply to SACAT for directions, or fall back to the "Person Responsible" hierarchy under the Consent to Medical Treatment and Palliative Care Act 1995 for urgent decisions.

Prevention Is Better Than Litigation

Most ACD disputes are preventable. The common thread is ambiguity — either in the document itself or in the family's understanding of it.

• Draft clear, specific instructions. Vague language creates interpretation disputes. Binding provisions should name specific treatments and specific clinical circumstances.
• Talk to your family. Your SDM knows your wishes, but do your other children? Does your spouse understand why you chose a particular SDM? Unaddressed feelings of exclusion or disagreement surface as disputes after you lose capacity.
• Document your reasoning. Keep a separate letter explaining why you made specific choices. "I appointed my daughter Sarah as SDM because she has medical training and understands my values about quality of life" is harder to challenge than an unexplained appointment.
• Choose SDMs who can handle pressure. The SDM's role often means enforcing decisions that other family members oppose. Select someone who can hold firm under emotional pressure without fracturing family relationships.

Our South Australia Advance Directive & Living Will Kit includes a family conversation planner and an SDM appointment worksheet — designed to surface and resolve family disagreements during the planning process, when they can be discussed calmly, rather than at the bedside.

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