Voluntary assisted dying
The issue of legalised voluntary assisted dying for terminally ill people is important for anaesthetists and specialist pain medicine physicians who may be involved in end-of-life discussions and decisions.
Recognising this, prior to responding to the Victorian government’s voluntary assisted dying discussion paper in 2017, the college sought the views of a wide range of ANZCA committee members, fellows, trainees and specialist international medical graduates.
The feedback received helped shape the college’s response to this and subsequent voluntary assisted dying consultations in other jurisdictions. The college has made submissions to voluntary assisted dying consultations in New Zealand, New South Wales, Queensland, Victoria and Western Australia.
ANZCA has a neutral position on voluntary assisted dying laws as it considers that this is an issue for the people and governments of Australia and New Zealand to determine. The college does however consider that it has a responsibility to ensure that any such legislation, if enacted, protects both patients and health practitioners as far as possible. Our approach to voluntary assisted dying is firmly based in patient and health advocacy:
- To protect patients' rights and to ensure that patients can exercise these rights.
- To ensure that research into palliative care is not an unintended casualty of the availability of voluntary assisted dying.
The college is also concerned with ensuring that medical practitioners, in particular anaesthetists and specialist pain medicine physicians, are protected appropriately under any voluntary assisted dying legislation and not required to undertake activities which they deem inappropriate or contrary to their personal beliefs or their professional responsibilities towards their patients.
Broad themes in relation to ANZCA’s position on voluntary assisted dying are summarised below.
Involvement of specialist medical colleges
- Prescribed information that medical practitioners provide those considering voluntary assisted dying should be a guideline only in any legislation.
- Specialist expertise required for medical practitioners to participate in voluntary assisted dying must be guided by input from specialist medical colleges.
Specialist expertise required
- Medical practitioners should receive appropriate education and be trained as part of their continuing medical education to develop the skills needed to participate in voluntary assisted dying and to provide appropriate advice to those seeking it.
- The voluntary assisted dying process should be patient-centred.
- Alleviation of patient suffering should take priority; no period of intolerable suffering is “acceptably short”.
- A patient suffering debilitating pain may be unable or unwilling to travel long distances to seek appropriate advice and care and should have the same rights and choices as an individual living in a metropolitan area.
Legal protections for medical practitioners
- A medical practitioner should be allowed to be present at the time the patient self-administers the lethal dose of medication if this is requested by that patient.
- A medical practitioner treating a patient who has chosen to self-administer a lethal dose of medication should be obliged to follow and respect the patient’s wishes, and to act with the high a degree of professionalism that is expected when providing usual care.
- The recorded cause of death should be the underlying disease process or primary diagnosis that made the patient eligible for voluntary assisted dying.
- Death as a result of voluntary assisted dying should not be reportable if undertaken in accordance with the legislative requirements, as the death would not meet the criteria of being unexpected or illegal.
- Unusual or suspicious circumstances surrounding a death should be dealt with in the usual manner, including a report being made to the coroner.
- A report to the Assisted Dying Review Board should facilitate practitioner support, rather than investigation.
- An oversight body should refer a matter to another agency (such as the Coroner’s Court) when there are concerns about irregularities including: acting outside the scope of practice; acting outside the law; family coercion; or, misuse of a lethal drug.
- This oversight body should not have investigatory powers and any investigation should be conducted by existing independent agencies.
- It will be essential to ensure voluntary assisted dying is not a substitute for good palliative care and does not diminish research into palliative care.
- Support should be shown for the concept of death with dignity and comfort and the right of terminally ill patients to receive expert palliative care.
- There should be resourcing for alternative therapeutic and palliative care services and for rural/remote areas, including access to suitably qualified healthcare professionals.
- All safeguards in the framework should be applied meaningfully and not just as an administrative process to complete.
- Safeguards to protect vulnerable patients are crucial.
- “Subtle coercion” and the difficulty in identifying it are of concern. Family members or parties known to have an interest, including pecuniary interests, in whether the patient lives or dies should not be able to be witnesses to the request process.
- There must be additional safeguards that protect both the patient and the medical practitioner involved in all cases of self-administered medication.
- The form of storage and the location of the lethal dose of medication must be documented to ensure accurate accounting of whether or not the patient has ingested it.
- Participation by medical practitioners and health services in voluntary assisted dying should be voluntary with no need for any objection to be qualified.
- There may be difficulties in compelling medical practitioners to make a personal referral to another medical practitioner when a patient requests voluntary assisted dying information or assistance. Some medical practitioners will consider such a referral to be a violation of their personal values.
Regional, rural and remote considerations
- People in rural and remote areas are disadvantaged by inter-related issues of distance, travel and access to services.
- Medical practitioners who live in rural and remote areas and who agree to be part of the voluntary assisted dying process may face ostracism by the community where they live and practise.
- A patient suffering debilitating pain may be unable or unwilling to travel long distances to seek appropriate advice and care but should have the same rights and choices as an individual living in a metropolitan location.
- Rural patients may be disadvantaged by difficulties of access to services (for example, a palliative care physician or palliative care services, obtaining two independent medical reviews and, in particular, the advice of a medical practitioner who has knowledge of the disease process and its prognosis; and psychiatric or other specialist referral), and difficulties in accessing their wishes due to lack of access to advanced care plans, living wills, statements on electronic health records and websites in urgent care situations.
- Mechanisms should be developed to ensure access to information on voluntary assisted dying at any medical facility a patient might present to (in their own community or in a centre away from home in cases of a rapid deterioration or trauma while travelling).
Other aspects of voluntary assisted dying
- Mandatory psychiatric assessment for all patients considering voluntary assisted dying is not necessary. Psychiatric assessment should be required only where there is reasonable doubt or concern relevant to the patient’s capacity so that support can be provided in borderline or complex cases.
- Predictions for end of life are often inaccurate and any minimum timeframe should be applied with caution to avoid prolonging suffering.
- “Homicide” is a very severe term and should not be applicable to voluntary assisted dying legislative requirements. It should be reserved for deliberate abuses of the legislation.
- Two appropriately qualified practitioners from different specialties who are appropriately trained in the legislative requirements of voluntary assisted dying should undertake the voluntary assisted dying patient assessments and provide information.
- As the dispenser of the lethal dose of medication from a community or hospital pharmacy, the pharmacist will play a key role in the understanding of, and adherence to, the voluntary assisted dying legislation.
- Appropriate compensation for medical practitioners involved in the voluntary assisted dying process will need to be considered. voluntary assisted dying will be time-consuming and emotionally draining. Separate Medicare Benefits Schedule item numbers or alternative state-based compensation may be required.
- Ongoing discussions with the community should be encouraged and facilitated alongside the discussions regarding voluntary assisted dying, such as the issue of “futile surgery” as part of the spectrum of discussions around respecting the rights of the patient to accept death.
- It may occasionally be necessary to provide pain relieving procedures and/or anaesthesia (and surgical) services to an individual who has chosen and been approved for voluntary assisted dying. Consideration must be given to either suspension of such wishes during the acute period of medical care (as in advanced care directives) or a specific acknowledgement of the limitations of resuscitation to be undertaken. This is in recognition that an individual may not ‘have reached the time’ for ending their life.
- Consideration must be given to the obligations of, and legal protections for, health practitioners (including paramedics) in cases where the lethal dose of medication is not effective for any reason, particularly in the absence of the patient having an advanced care directive.
Resources for clinicians
The Queensland Law Reform Commission (QLRC) report: A legal framework for voluntary assisted dying contains a useful comparative guide to the main provisions of current voluntary assisted dying legislation in Australia and selected overseas jurisdictions (Appendix C).
Queensland University of Technology has a range of online resources for clinicians on voluntary assisted dying available. They also run a free training program for doctors called End of Life Law for Clinicians, covering the law on end of life decision-making more broadly (module 11 is specifically on voluntary assisted dying).