Our duty to relieve suffering

MEDICAL practitioners form their opinions based on their clinical teaching, their clinical experience and their knowledge (hopefully) of peer-reviewed literature.

Medical students get no teaching on voluntary assisted dying, and precious little on palliative care; that is to say, about the care of dying and intolerably suffering patients. I doubt they are introduced to the concept of medical suffering.

In practice they confront dying patients with little, if any training, with no idea how to engage in the difficult conversations about end of life, and an inherent fear of the vague and opaque law that controls their actions. They are able to learn more about palliative care if they are interested, but many are probably only too happy to handball such patients to organised palliative care.

I doubt many have the time or the interest to become informed about the voluminous palliative care literature, or the numerous, careful empirical studies of voluntary assisted dying from the Netherlands, Belgium or Oregon.

It is my view that doctors in Australia are poorly informed about voluntary assisted dying, and to a lesser extent, palliative care, and about how to deal with requests for a hastened death.

Professor Stephen Leeder, in an MJA InSight opinion piece titled Dying well, opined that Australia was the second best country in the world in which to die. It was not made clear that this conclusion was based on an assessment by palliative care specialists of their own efforts. It did not describe the results of Australian palliative care as shown in the Palliative Care Outcomes Collaboration – this study revealed that of people in the terminal phase of their dying, 4% had severe pain, 7.5% had other severe physical symptoms (breathlessness, fatigue, nausea) and 3% had severe psychological distress.

Although you will never hear it publicly stated by the palliative care sector, it does provide, when it deems the patient’s symptoms sufficiently refractory, terminal sedation, or “deep continuous sedation” (the European phrase); it prefers the more benign term “palliative sedation”. This involves the gradual, titrated increase, by continuous infusion, of sedatives and analgesics, usually without the provision of food and fluids, until the patient enters a coma and remains so until death occurs.

That such treatment may be necessary at the end of life highlights the fact that some suffering is intolerable and unrelievable, and that some such suffering will only end with death. It is also an indication that doctors have a duty to relieve suffering, and that a necessity to hasten death does occur.

• Related: MJA InSight -- Rodney Syme: Dying autonomy
• Related: MJA InSight -- Stephen Leeder: Dying well

The incidence of terminal sedation in Australia is unknown, but in Belgium and the Netherlands, where the manner of dying is carefully analysed, it is 12.0% (2013) and 12.3% (2010) respectively among medically certified deaths.

The fundamental differences between palliative sedation and voluntary assisted dying are clear and stark. The decision for terminal sedation and its rate of implementation are controlled by the doctor, and the journey to death is slow and with incremental relief of suffering. Voluntary assisted dying places complete control in the hands of the suffering person (they may decide not to use it). When it occurs using a quick-acting oral barbiturate, gentle sleep occurs in about 3 minutes and a peaceful and dignified death occurs in 10 to 20 minutes; the family can say goodbye and share in a profound moment. Terminal sedation provides a highly doctor-centred death, which is completely medicalised, in contrast to the person- and family-centred voluntary assisted death.

In February 2015, the Supreme Court of Canada determined unanimously that the prohibition of assistance in suicide to persons suffering intolerably was contrary to Canada’s Bill of Rights, and directed the government to legislate to provide that human right. It did so after an exhaustive analysis of practice in other countries, which convinced them that safe practice could occur with appropriate legislation. Numerous parliamentary, provincial, ethical and medical bodies reported on the matter; these have all found that the principles embodied in Dutch and Belgian legislation and practice were safe and appropriate. 

The Canadian Medical Association determined that end of life decisions were a matter of conscience between a doctor and his or her patient, and have also developed medical guidelines for safe and ethical practice which are almost identical with Belgian and Dutch practice.

The Australian Medical Association’s ethics committee is reviewing its policy on end of life. 

The Royal Australia College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists have adopted neutral positions in the matter. It is to be hoped, at least out of respect for the autonomy of our patients, that the Australian Medical Association, one of the principal stumbling blocks to change, will see the light and move into the 21st century.

Dr Rodney Syme is a Melbourne urologist who is vice-president of Dying With Dignity Victoria.