🧠 Cognitive Impairment & Legal Orders

A guide for Australian nursing students — understanding cognitive impairment, assessing decision-making capacity, legal documentation, SACAT Section 32 Special Powers, and keeping wandering patients safe.

🇦🇺 Australia Year 2 & 3 SA Focus Clinical Practice Legal Orders
🎓 Educational Resource Only: This page supports nursing student learning. Legal and clinical processes vary between health services and jurisdictions. Always follow your facility's policies, seek guidance from senior staff, and refer legal questions to social work or your legal/guardianship team.

🧠 What is Cognitive Impairment?

Cognitive impairment refers to difficulties with memory, thinking, reasoning, language, or executive function that affect a person's ability to carry out everyday activities or make decisions. In the clinical setting, you will most commonly encounter three main causes:

🧠 Dementia
  • Progressive and usually irreversible
  • Affects memory, language, behaviour, judgment
  • Types: Alzheimer's (most common), Vascular, Lewy body, Frontotemporal
  • Gradual onset over months to years
  • Capacity may fluctuate early; typically declines over time
  • Consider communication adaptations — short sentences, visual cues, familiar faces
⚡ Delirium
  • Acute onset — hours to days
  • Fluctuating consciousness, disorientation, agitation or hypoactivity
  • Usually reversible with treatment of the underlying cause
  • Common causes: infection, medications, pain, urinary retention, constipation, dehydration, post-op
  • Use 4AT or CAM screening tools
  • Non-pharmacological management first: reorient, familiar environment, mobility
🧸 Acquired Brain Injury
  • Occurs after birth — stroke, TBI, hypoxia, infection
  • Variable deficits depending on injury location and severity
  • May affect memory, attention, impulse control, language
  • Can be stable or improving with rehabilitation
  • Capacity assessment is essential — deficits are often domain-specific
  • Collaborate with OT, speech pathology, neuro rehab

⚖️ Assessing Decision-Making Capacity

💡 Key principle: Capacity is decision-specific and time-specific. A person may have capacity to consent to some decisions but not others, and capacity may change throughout the day (especially in delirium). Always presume capacity unless there is evidence otherwise.

When assessing whether a person can make a specific decision, four functional abilities must be present:

1
Understand the information — Can the person explain the relevant information in their own words? Do they understand what is being proposed?
2
Retain the information — Can they hold the information long enough to make a decision? They do not need to remember it indefinitely.
3
Weigh up the information — Can they consider risks and benefits, and understand the consequences of their choice (including declining)?
4
Communicate their decision — Can they express their choice in any form (verbal, written, gesture, AAC device)?
⚠️ Impaired capacity ≠ refusing treatment. A person without decision-making capacity cannot legally consent — but this does not mean treatment proceeds automatically. A substitute decision-maker (SDM) must be identified in the correct order of priority, and decisions must reflect the person's known wishes, values, and best interests.
👥 Substitute Decision-Maker (SDM) — SA Priority Order

When a person lacks capacity, the SDM is determined in this order (first available and willing person):

  1. Person appointed under a valid Advance Care Directive (ACD) as substitute decision-maker
  2. Person appointed under a valid Enduring Power of Attorney (EPA) or Enduring Power of Guardianship (EPG) — if the powers apply to healthcare/personal decisions
  3. Spouse or domestic partner (if in close and continuing relationship)
  4. Adult carer (unpaid, caring for the person at the time)
  5. Adult relative — in order of closeness: parent, child, sibling, grandparent, grandchild, aunt/uncle, nephew/niece
  6. If no SDM is available or willing → refer to SACAT / Public Advocate

📄 Legal Documents — ACD, POA & POG

📄 Advance Care Directive (ACD) SA
  • A legal document made under the Advance Care Directives Act 2013 (SA)
  • Allows a person to record their wishes, values, and goals for future healthcare
  • Can appoint a substitute decision-maker (SDM)
  • Can include binding refusals of treatment (must be followed even if the person would die as a result)
  • Must be made while the person has decision-making capacity
  • Must be witnessed by an authorised witness (e.g. health practitioner, lawyer)
  • Supersedes family preferences when in conflict — the ACD takes priority
  • Check My Health Record and hospital documentation for existing ACDs
💰 Enduring Power of Attorney (EPA)
  • A legal document appointing a trusted person (the attorney) to make financial and/or property decisions
  • In SA, a financial EPA does not extend to personal/healthcare decisions unless specifically drafted to include them
  • Must be registered with the SA Lands Titles Office to be used for real estate transactions
  • Ceases on death
  • Nursing note: A financial EPA does not automatically give authority over medical decisions — check what the document actually authorises
  • The Advance Care Directive is the correct document for healthcare SDM authority in SA
🤴 Enduring Power of Guardianship (EPG)
  • Appoints a guardian to make personal/lifestyle decisions when the person lacks capacity
  • In SA, governed by the Guardianship and Administration Act 1993 (SA)
  • Powers include: where the person lives, what health care they receive, who they associate with
  • Must be witnessed and signed while the person has capacity
  • Activated only when the person lacks decision-making capacity
  • The guardian must act in the person's best interests and consistent with their known wishes/values
🔍 Checking Documents in Practice
  • Check My Health Record and the patient's medical record for uploaded ACD/EPA/EPG
  • Ask the patient (while they have capacity) if any documents exist
  • Ask family/next of kin — but note family cannot override a valid ACD
  • Contact the ACD Registry (SA Health) if needed
  • If documents cannot be found, document your attempts and escalate
  • Notify the treating team and social worker if there are concerns about decision-making capacity

⚖️ SACAT — Section 32 Special Powers

🧴 SACAT (South Australian Civil and Administrative Tribunal — Guardianship Board) has authority under the Guardianship and Administration Act 1993 (SA) to make legal orders when a person with impaired decision-making capacity needs protection. Section 32 grants Special Powers — these are significant legal interventions used when the person refuses or cannot consent.
⚠️
Important: Section 32 orders are legal instruments. As a nursing student or RN, you do not make these applications — that is the responsibility of the treating team, social worker, or hospital legal team. Your role is to understand what these orders mean clinically, document the patient's behaviour accurately, and provide safe care within the order's scope.
32(a)
Treatment Order — Consent to Medical Treatment
Medical Treatment

What it does: Authorises the use of physical force (or direction) to carry out medical or dental treatment for a person who lacks decision-making capacity and is refusing or unable to consent.

  • Applied when a person refuses necessary treatment and there is no SDM able to consent
  • Examples: wound care, administration of essential medications, IV access, investigations
  • The treatment must be in the person's best interests
  • SACAT appoints a guardian with authority to consent, or the Tribunal itself authorises the treatment
  • Nursing role: Document refusal behaviours accurately; provide care compassionately within the authorised scope; use minimum necessary force; prioritise dignity
32(b)
Accommodation Order — Where the Person Resides
Accommodation

What it does: Authorises the use of force or restriction to place a person in, or prevent them from leaving, a particular place — such as a residential aged care facility (RACF), hospital ward, or memory support unit.

  • Used when a person is at risk of harm if they leave their current environment
  • Examples: person with advanced dementia who wanders into danger, refusing hospital discharge to safe place
  • The accommodation must be the least restrictive option appropriate for their needs
  • SACAT appoints a guardian with authority over accommodation decisions
  • Nursing role: Understand the order's scope — what restrictions are permitted; ensure care environment is as normalised as possible; document incidents of attempted elopement
32(c)
Restraint Order — Use of Force or Restraint
Restraint / Force

What it does: Authorises the use of physical force or mechanical restraint when necessary to carry out treatment or maintain the person's safety or the safety of others, in conjunction with a 32(a) or 32(b) order.

  • This is the most significant intervention — it directly restricises bodily autonomy
  • Restraint must be the least restrictive option; all alternatives must have been trialled
  • Examples: soft limb restraints to prevent IV removal, enabler beds, restrictive clothing
  • Must be regularly reviewed and documented — restraint is never indefinite
  • Chemical restraint (sedation) requires medical authorisation and is separate from physical restraint
  • Nursing role: Check regularly (every 30 min minimum); assess circulation, skin integrity, distress; document rationale and observations; de-escalate and remove restraint as soon as safe to do so; ensure family are informed
🚨 Restraint is a last resort. Before any physical restraint: try verbal de-escalation, environmental modification, distraction, comfort measures, and engagement of familiar persons. Document that alternatives were trialled.

🚫 Reducing Restraint

📚 What is Restraint?

"Restraint is the restriction of an individual's freedom of movement."
— Australian Commission on Safety and Quality in Health Care (ACSQHC)

It includes mechanical restraint (physical devices), physical restraint (hands-on force), and chemical/pharmacological restraint (medication whose primary purpose is to sedate or control behaviour).

Things that count as restraint — these may not always look like restraint, but legally they are:

💊 PRN psychotropics (chemical)
🎡 Bed rails
🔒 Inpatient Treatment Orders
🚨 Code Black / Security Assist
🦻 Physical restraint devices
⚠️
Improper restraint can cause falls, skin tears, pressure injuries, aspiration, increased agitation, and psychological harm. Restraint should always be the last resort — not a convenience measure.

✓ What Can We Do to Reduce Restraint?

💊 Medication & Pain
  • Understand the benefits, indications and risks of common psychotropic medications — what to use and when
  • Identify and manage withdrawals — nicotine, alcohol, opioids, benzodiazepines
  • Use accurate pain assessment tools — PAIN-AD scale for non-verbal patients
  • Use analgesia as first line if the patient has a known painful condition (e.g. fracture, wound) — unmanaged pain is a common driver of agitation
  • Chemical restraint should only be used when a patient is a risk to themselves or others and other measures have failed
💬 De-escalation & Communication
  • Attend Safety Intervention / de-escalation training at your facility
  • Understand non-verbal communication — behaviour is often communication
  • Identify early signs of agitation — intervene before escalation
  • Use a calm voice, non-threatening posture, and give the person space
  • Offer choices and validate feelings — "I can see you're frustrated"
  • Involve family or familiar people — their presence can significantly reduce distress
👥 Planning & Team
  • Prompt and comprehensive discharge planning — prolonged hospital stays increase restraint risk
  • Multi-disciplinary discussions — involve nursing, medical, allied health, social work
  • Have open conversations with family — discuss expectations, concerns, and options
  • Know your support options: Code Black, Security Assist, AIN/carer specials, PAO
  • Consider ITOs or SACAT orders through the appropriate team when clinically indicated
🌞 Workplace Culture & Self-care
  • Foster a culture where patient care is the priority — not staff convenience
  • Speak up if you see restraint being used inappropriately — it is your professional obligation
  • Access staff psychological support — managing agitated patients is emotionally demanding
  • Debrief after difficult incidents with your manager, peers, or EAP
  • Familiarise yourself with Australian national standards and SA Health guidelines on minimising restrictive practices
📺 SA Health e-learning: Complete 'Minimising Restrictive Practices' on Learning Central — this is relevant for all nursing students and graduates working in SA Health facilities.

🔒 Detention Orders

⚖️ Mental Health Act 2009 (SA) — Involuntary Detention

Detention orders are distinct from SACAT guardianship orders and arise under mental health legislation when a person poses a risk to themselves or others due to a mental illness.

Emergency Examination Order (EEO)
  • Allows police or health practitioners to take a person to an approved hospital for assessment
  • Does not authorise ongoing detention — triggers assessment only
  • Used when person is at immediate risk and unwilling to present voluntarily
Inpatient Treatment Order (ITO)
  • Authorises involuntary admission and treatment in an approved mental health facility
  • Made by authorised medical practitioners / psychiatrists
  • Reviewed by the Mental Health Tribunal within 21 days
  • Patient retains rights — access to advocacy, legal representation, regular review
💡 Nursing role: Understand the type of order in place. Document behaviour, mental state, and interventions accurately. Treat the person with dignity — an involuntary order does not reduce their rights to respectful care and communication. Engage the mental health liaison team / consultation liaison psychiatry (CLP) as needed.

🚨 Wandering Patient — Alarm & Safety Checklist

Patients with cognitive impairment may be at risk of wandering or absconding — leaving the ward or facility without the knowledge or consent of staff. When this risk is identified, the following safety checklist must be completed and documented. Work through each step below.

⚠️ If a patient is actively missing, follow your facility's Missing Patient Protocol immediately. This checklist is for prevention — complete it as soon as wandering risk is identified, before an incident occurs.
🚨 Wandering / Absconding Risk Checklist
0 of 11 complete
✓
1
Is the patient at risk of absconding/wandering? Confirm clinical indication — consider history, diagnosis (dementia, delirium, ABI), current behaviour, and any prior absconding incidents.
✓
2
Spoken to family / carer — consent obtained Inform the family or carer of the wandering risk and the safety measures being put in place. Document the conversation and consent in the patient's notes.
✓
3
Patient moved to a room away from exit doors Allocate a bed furthest from main ward exits, stairwells, and lift access. Discuss with the Nurse in Charge / Shift Coordinator to arrange room reallocation if required.
✓
4
Wandering alarm & wristband obtained from Clinical Manager's office Collect the door alarm and patient identification wristband. Apply wristband to patient. Set up alarm on exit door(s). Test the alarm is functioning correctly before relying on it.
✓
5
Alarm explained to patient (as able) Explain the wristband and alarm to the patient in simple, reassuring language — even if comprehension is uncertain. Reassure them it is to keep them safe. Document explanation attempted.
✓
6
All staff aware of what patient looks like Conduct a verbal handover to all ward staff (nursing, AHA, ward clerk, allied health). Ensure night staff are also informed at changeover. Consider showing a photo if available and if family consent is obtained.
✓
7
Patient's clothing documented in nursing notes Document exactly what the patient is wearing — including colour, type of clothing, and footwear. Update this documentation each shift or if clothing changes. This assists in rapid identification if the patient leaves the ward.
✓
8
'Absconder' alert added to iPM (patient management system) Add the relevant alert flag in the patient management system (iPM or equivalent) so that all clinical staff accessing the patient's record are alerted. Ensure the alert is documented with date and your name.
✓
9
'Keep Door Closed' signs on fire doors and main ward doors Place clearly visible signage on fire exit doors and the main ward entrance/exit doors reminding staff and visitors to keep doors closed and secured. Check doors are actually closing properly.
✓
10
Sign placed on patient's room door (with their name) Place a discreet identifier on the patient's room door to help staff quickly locate the patient and remind them of the wandering risk. Follow your facility's policy on confidentiality regarding door signage.
✓
11
Sign placed on patient's toilet door Ensure the toilet nearest the patient's room also has signage. Patients may enter the toilet and then attempt to leave via a nearby exit. Escort the patient to the toilet where possible, or ensure supervision.
Complete all 11 steps and document in nursing notes.
📝 Document everything. Each step completed must be documented in the patient's nursing notes with date, time, and your name. Escalate to the Nurse in Charge if the wandering risk is high or immediate. This checklist is a guide — always follow your facility's specific Missing Patient / Wandering Patient protocol.

📈 Key Dementia Statistics — Australia

Source: Australian Institute of Health and Welfare (AIHW)

425,000
Australians living with dementia — equivalent to 16 per 1,000 people
65%
Of those living with dementia are women
1.1 million
Estimated to have dementia by 2065 — expected to double in 40 years
68%
Of all people with dementia live in the community (not in care facilities)
16%
Of those in the community live alone
25%
Of all people with dementia were born in a non-English speaking country
101,900
Unpaid carers looked after people with dementia in 2024
42%
Of family carers provided over 60 hours per week of care
69%
Of people with dementia in the community have a 'profound disability'
💔 Mortality & Disease Burden
  • In 2023, dementia was the leading cause of death in Australia — 1 in every 10 deaths
  • It is the second leading cause of 'disease burden' after cardiovascular disease
  • 6 modifiable risk factors contribute to 43% of all dementia cases
  • Australia spent $3.6 billion of the direct health and aged care budget on dementia in 2020–21
⚠️ Stigma & Equity
  • 65% of people living with dementia feel discrimination is common or very common
  • 90% of friends and family say their person with dementia has received less respect than others
  • Only 54% of Australians feel comfortable around people with dementia
  • People with dementia receive less pain relief than others with the same conditions (e.g. fractured bone)
  • People born overseas are less likely to be placed in nursing homes — often cared for at home by family
🧠 Clinical implication: Understanding the scale of dementia — and the stigma that surrounds it — is essential for providing respectful, dignified, person-centred care. Every patient statistic represents a person with a life history, relationships, and individual preferences.

👴 Nursing Considerations

💬 Communication
  • Use short, simple sentences — one idea at a time
  • Allow extra time for processing — do not rush or finish sentences
  • Maintain eye contact; approach calmly from the front
  • Use the person's preferred name
  • Avoid arguing about orientation — use gentle redirection
  • Non-verbal communication is powerful — tone, touch, posture
  • Consider speech pathology referral if communication is significantly impaired
🏠 Environmental & Behavioural Strategies
  • Minimise environmental noise and stimulation, especially at night
  • Maintain consistent routines and familiar staff where possible
  • Ensure adequate lighting — sundowning is worsened by poor light at dusk
  • Encourage meaningful activity and gentle mobility
  • Address pain, hunger, thirst, and continence needs proactively
  • Involve family in care — familiar faces reduce distress
  • Identify and treat delirium causes early
📝 Documentation
  • Document capacity assessments — when, by whom, the decision, and rationale
  • Note SDM details and their relationship to the patient
  • Record all restraint episodes with start/end time, type, and monitoring
  • Document behaviour objectively — what you saw, heard, and did
  • Record legal orders (SACAT orders, ITO) and their scope in the care plan
  • Always document discussions with the treating team and any escalation
👥 Escalation
  • Escalate concerns about capacity to the treating team immediately
  • Involve Social Work early — they navigate SACAT and legal document issues
  • Refer to Aged Care / Geriatric team for complex dementia presentations
  • Refer to CLP (Consultation Liaison Psychiatry) for delirium or mental health concerns
  • Contact the Nurse in Charge before applying any form of restraint
  • Use your facility's Rapid Response / PACE system if patient deteriorates
💬 Respectful Language — Person First & Identity First

Language matters. There has been a significant shift towards Person First Language — placing the person before their diagnosis to recognise they are more than their condition. Some individuals prefer Identity First Language (e.g. "autistic person") — always ask and follow the person's preference.

✗ Avoid ✓ Try instead
Suffers with / suffers from dementia Lives with dementia
Wheelchair bound Full-time wheelchair user / uses a wheelchair
Victim of / afflicted by / crippled by Person who has / person living with
Demented / simple / cuckoo Person with dementia / person with cognitive impairment
Special needs / handicapable / differently-abled Person with a disability / person with support needs
Retarded / handicapped / invalid / spastic Person with an intellectual disability
"Inspirational" (for simply living with a disability) Treat the person as an individual — not a symbol

Why this matters clinically:

  • Stigma makes people less likely to disclose their diagnosis, which means they are less likely to request accommodations — directly impacting their care outcomes
  • Offhand comments may be heard by patients, families, or colleagues who have that condition — making them feel unwelcome and unsafe
  • Older patients and staff may use outdated terms due to different generational exposure — correct gently and without shaming
  • The Social Model of Disability reminds us it is often the environment — not the person — that creates the barrier. Modify the environment wherever possible

🔗 Resources & Further Learning