To the Editor: End-of-life issues: Case 11 illustrates an increasingly common scenario confronting physicians caring for older patients. The case example of a nursing home resident with stroke, dementia and the onset of pneumonia highlights the importance of encouraging patients to prepare for future medical decision-making. This can be done through the use of enduring guardianship, medical powers-of-attorney or advance care directives ("living wills"). Documenting these matters allows people to appoint others to make healthcare decisions on their behalf, and to indicate what treatment they would want in various clinical circumstances, should they no longer be competent to do so. If "Mrs W" had appointed an enduring guardian to deal with issues of healthcare and medical consent, or had indicated in an advance care directive what her wishes would be if she were to become seriously ill, the decision-making process may well have been clearer.

The other issue this scenario raises is the need to check whether Mrs W's daughter could have made medical decisions for her mother. In New South Wales, if the daughter had been in a caring role for her mother before nursing-home placement, she could be considered the "person responsible" (similar to the old concept of "next of kin"). Under the Guardianship Act 1987 (NSW), the "person responsible" is able to act as a substitute decision-maker for healthcare and medical treatment. While it would clearly still be good, sensible medical practice to involve other family members in discussion about Mrs W's future, it would ultimately be the daughter, as the "person responsible", who would be able to make those decisions.