Palliative Care Directives in NSW: Refusing Treatment, Stopping Life Support, and Comfort Care
Your Right to Refuse Treatment in NSW
Under NSW common law, every adult with decision-making capacity has the right to refuse any medical treatment — including life-sustaining treatment — for any reason. This right extends beyond the point of capacity through a valid Advance Care Directive.
The legal foundation is straightforward: treating a patient without consent constitutes a common law battery. If your ACD clearly refuses specific treatments and the directive is valid (made with capacity, voluntarily, and applicable to the clinical situation), clinicians are legally bound to respect those refusals.
This includes the right to refuse cardiopulmonary resuscitation, mechanical ventilation, dialysis, blood transfusion, artificial nutrition and hydration, and any other medical intervention — even if refusing that treatment will result in your death.
What your ACD cannot do is demand treatment that your medical team considers clinically futile or inappropriate. A doctor has no legal obligation to provide treatment that, in their professional judgement, offers no therapeutic benefit. But they must respect your refusal.
Comfort Care: What It Means Clinically
Comfort care — sometimes called palliative care, supportive care, or comfort measures only — is not the absence of medical treatment. It is a specific clinical approach focused on managing pain, symptoms, and distress rather than attempting to cure the underlying condition or prolong life.
In your ACD, requesting comfort care means:
Pain management. Administration of analgesics (including opioids) at doses sufficient to control pain, even if those doses carry a secondary risk of hastening death. This is legally protected in NSW under the principle of double effect — the intent is to relieve suffering, not to cause death.
Symptom control. Management of breathlessness, nausea, agitation, and other distressing symptoms through appropriate medication and clinical interventions.
Palliative sedation. In cases of refractory suffering — pain or distress that cannot be controlled by any other means — continuous palliative sedation can be administered. This involves sedating the patient to unconsciousness for the remainder of their life, while withholding artificial nutrition and hydration.
Exclusion of life-prolonging interventions. No CPR, no mechanical ventilation, no dialysis, no artificial feeding — unless those interventions are specifically directed at symptom relief rather than extending life.
How to Document Treatment Refusals Effectively
The NSW Supreme Court's standard from Hunter and New England Area Health Service v A requires your refusals to be clear, specific, and applicable. Generic statements about comfort care alone are not enough.
Structure your treatment refusal section by addressing each major intervention category:
Cardiopulmonary resuscitation. "I refuse CPR in all circumstances" or "I refuse CPR if I have been diagnosed with a terminal illness with a prognosis of less than 12 months." Be explicit about whether this is absolute or conditional.
Mechanical ventilation. "I refuse endotracheal intubation and mechanical ventilation for life-prolonging purposes. I consent to short-term ventilation only for post-operative recovery from planned surgery or for the purpose of maintaining organ viability for donation."
Artificial nutrition and hydration. "If I lose the ability to swallow safely, I refuse insertion of a nasogastric tube or PEG tube for artificial nutrition. I consent to comfort-focused oral care and ice chips for comfort only."
Dialysis. "If my kidney function declines to the point of requiring renal replacement therapy, I refuse haemodialysis and peritoneal dialysis."
Antibiotics and blood products. "I consent to antibiotics solely for infection-related comfort (e.g., treating a urinary tract infection causing pain) but refuse antibiotics administered to prolong life in the setting of terminal organ failure."
Free Download
Get the New South Wales — Advance Directive Quick-Start
Everything in this article as a printable checklist — plus action plans and reference guides you can start using today.
The Resuscitation Plan: PD2014_030
In NSW public hospitals, your ACD's treatment refusals are translated into a clinical order called a Resuscitation Plan under NSW Health Policy Directive PD2014_030. This plan sits at the front of your hospital chart and provides immediate instructions to treating staff.
The Resuscitation Plan is not a separate legal document you draft yourself. It is a clinical tool completed by your treating doctor, ideally in consultation with you or your Enduring Guardian, that translates your ACD's language into hospital-specific clinical orders.
If you are admitted to hospital with a valid ACD, request that the admitting doctor complete a Resuscitation Plan that reflects your directive's instructions. This ensures your refusals are visible to every nurse, registrar, and code team member — not buried in your patient file.
Stopping Life Support: What Actually Happens
If you are already on life support and your ACD contains instructions to withdraw treatment, or if your Enduring Guardian makes that decision consistent with your documented wishes, the treating team follows a structured withdrawal protocol.
The process is not instantaneous. The clinical team will:
- Confirm the legal authority — either your ACD's instructions or your Enduring Guardian's consent
- Complete a Resuscitation Plan documenting the withdrawal decision
- Transition to comfort measures — pain relief, anti-anxiety medication, respiratory secretion management
- Withdraw the life-sustaining intervention — extubation, removal of vasopressors, cessation of dialysis
- Provide ongoing symptom management until death occurs
Family members are typically invited to be present. Chaplaincy and social work support are available. The process is designed to be as dignified and controlled as the clinical setting allows.
If family members disagree with the withdrawal, and you have no Enduring Guardian or your ACD is ambiguous, the clinical team will not proceed until the dispute is resolved — potentially through an emergency application to NCAT's Guardianship Division.
Voluntary Assisted Dying Is Separate
NSW enacted the Voluntary Assisted Dying Act 2022, which permits eligible persons to access voluntary assisted dying under strict conditions. This is an entirely separate process from advance care planning — it requires active capacity, a terminal diagnosis with a prognosis of 6 months (or 12 months for neurodegenerative disease), and multiple assessments by independent doctors.
Your ACD cannot request voluntary assisted dying. The legislation explicitly requires that the person maintain decision-making capacity throughout the request and assessment process. An ACD operates when capacity is lost — the opposite scenario.
If you are interested in both palliative care planning and voluntary assisted dying eligibility, discuss both with your GP as separate clinical pathways.
The New South Wales Advance Directive & Living Will Kit includes treatment-specific refusal templates, comfort care instructions that align with NSW Health's Resuscitation Plan framework, and clinical scenario guides that ensure your palliative care preferences are documented with the precision NSW common law requires.
Get Your Free New South Wales — Advance Directive Quick-Start
Download the New South Wales — Advance Directive Quick-Start — a printable guide with checklists, scripts, and action plans you can start using today.