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WHEN Victoria’s Voluntary Assisted Dying Act 2017 (Vic) comes into force on 19 June 2019, Dr Claire Hepper, a GP in rural Victoria with a special interest in palliative care, will be a conscientious objector.
“My objection will be in the form of not being the coordinating or consulting practitioner,” Dr Hepper told InSight+. “I will always provide information to all patients who raise the issue of voluntary assisted dying (VAD) with me and, the part that is probably more important, commit to symptom control and support of the patient and family pre-death and the family post death and in their bereavement.”
Dr Hepper said the introduction of the VAD legislation will have a “huge impact” on GPs, particularly those in regional and rural areas.
“The GP might be either in solo practice or small group practice and still considered a central pillar in the community,” Dr Hepper told InSight+. “I already wake up at 3 am ruminating and worrying about decisions I have made in treating patients. I cannot imagine how I would cope if I had assisted in a decision that would end someone’s life – without addressing any symptoms of the patient or care of the community.”
Supporting and managing conscientious objection will be just one of several clinical implementation challenges as the VAD legislation becomes operational, say experts in an Ethics and law article published in the MJA.
Professor Ben White, Professor Lindy Willmott and Dr Eliana Close, of the Australian Centre for Health Law Research at the Queensland University of Technology, wrote that the implementation of VAD must balance two important policy goals.
“It must facilitate access to VAD, but restrict that access to only those who are eligible under the legislation.”
An Implementation Taskforce was appointed in February 2018 and is overseeing the development of clinical guidance, models of care, medication protocols and training for doctors participating in VAD.
Under the legislation, which includes 68 safeguards, Victorian residents are only eligible for VAD if they have an incurable disease, illness or medical condition that is advanced, progressive and expected to cause death within 6 months (or 12 months for neurodegenerative conditions). Also, the condition must be causing suffering that cannot be relieved in a manner that the person can tolerate.
The authors wrote that the legal right for doctors to conscientiously object to providing VAD is clearly stated in the legislation, but the VAD law does not establish a framework for respecting conscience.
Speaking in an InSight+ podcast, Professor White said: “The question that the legislation doesn’t tackle is the practical steps when a request for VAD is received by someone who says ‘look, no, I don’t want to be involved’,” he said, noting that the legislation does not address the provision of information or referral.
“Our hope would be that the balance that is normally adopted in medicine is achieved, and that is that it’s very important to respect conscience. People shouldn’t be required to do things in this setting which they may not wish to do, but it is very important that access to lawful care … is not impeded.”
A further implementation challenge is the translation of prescriptive legislative processes into appropriate clinical practices, the authors wrote. For example, Section 8 of the Act prohibits doctors and other health professionals initiating VAD discussions with patients.
Professor White said the goal of this prohibition was to ensure that there could be no suggestion of coercion from health professionals, but this could potentially hinder open and honest discussions about end-of-life care.
“The training and the guidelines will deal with this and help clinicians to step through some of these challenges, but for those at the coalface with a patient in front of them, this will be a challenge.”
Professor White said clinical guidelines were being developed by an external team being supervised by the Implementation Taskforce, and are expected to be available before the law comes into force in June.
Professor Peter Martin, Professor of Clinical Communication and End of Life Care at Deakin University, said that, as with any significant legislative change, the introduction of VAD would also present unexpected challenges.
Professor Martin said a new focus for workforce development will be on helping clinicians to tackle the “really tough conversations” around VAD.
“End-of-life conversations, delivering bad news and discussions about prognosis are all complicated, and this is a new element to these conversations,” said Professor Martin, who is supportive of the new laws.
“If a patient raised [VAD] previously, you could be empathetic and respectful and say, ‘yes, I can see how you would be thinking about that’, but you didn’t have to take it any further. Now, there are a whole bunch of complexities and sensitivities because it is available. This will be a big change for the whole health workforce, whether you’re a nurse, an allied health professional or a doctor.”
Dr Hepper said other practical concerns included the impact on GPs of having case reviews by the Coroner and remuneration for VAD services, given the lack of a Medicare Benefits Schedule item number.
“If you do bill a patient or family, do you need to tick the box on the death certificate saying you have financially benefitted from their death?” Dr Hepper said.
She said, in her view, there was not yet enough information to make informed comments to people who ask GPs about VAD.
“There is a great deal of work occurring to try to ensure guidelines and supportive material are available to those doctors who wish to participate, but all doctors will need to remain informed about this important legal change to the landscape,” Dr Hepper said.
“GPs have to be up to date with a broad range of issues to care for their patients – it’s just what we do. However, the gap between when the supporting information will be available to be digested and reflected upon and when the law is enforced is getting quite small.”
The MJA authors highlighted the importance of continuous monitoring and improvement once the VAD regime is operational. In addition to the 18-month implementation phase, the VAD Review Board will oversee the system, as well as individual cases.
“Translating this complex law into appropriate clinical practice will be challenging,” the authors wrote. “Victoria has strategically designated both time and resources to a period of planned implementation.”
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I watched my 25 year old son with Duchenne Muscular Dystrophy die over three days after choosing to stop food & water because he did not have access to VAD at that time. He deserved to be able to choose a dignified death.
His condition was terminal and there is no cure. He was going to die there was no doubt about that and no amount of medical intervention or palliative care could stop that.
He wanted to control his death, he wanted to die at home.
I will not and cannot understand a doctor not wanting to honor the wishes of a patient who has placed their trust in them, who is mature, of sound mind and has weighed up all the arguments both for and against VAD.
My son was in constant pain that was unable to be managed without him being literally comatose. How any individual, doctor or not could feel that this was ok is beyond me.
But in saying that, if a doctor does not want to be involved in VAD then referral to either a doctor or technician who does should be made available to the patient. Isn’t that the patient’s ultimate right???
Agree with Anonymous in point 2. That’s right, an executioner can do it.
If only as much effort and resources had been placed in achieving better rural outreach, chronic care programs, aged care and disabilities programs. The Victorian government has ignored so many majority agendas pretending to “care” and bullying healthcare and those with true coalface expert and evidence based experience to be voiceless. Real care and compassion and effort in healthcare have been squandered by this legislation, and the true preservation of dignity through appropriate care of those needing these programs have been undermined. This legislation deserves our conscientious objection on medical and social policy grounds.
How can the authors state that this legislation could ever be “appropriate clinical practice”? Making things legal does not make them appropriate clinical practice nor make unethical practices otherwise. Trying to make doctors and other healthcare workers complicit by placing this legislation in healthcare with attempts at enforced referral, does not make these acts medical treatments. Legal issues of this nature should not be cooperated with.
What would I want? A simple question we should all think about when confronted by a terminal illness. Rather than take a moralist view put yourself in the patients position. If you cannot be involved in VAD then referral to either a doctor or technician should be made available to the patient. Similar to termination of pregnancy, I do not make the decision but are purely offering and performing a service for the patient. Patients will usually find a solution. Prior to legalisation of termination, I used to see the effects of self induced termination often with dire consequences for the woman. Patients may consider self induced suicide if physically capable without seeking medical assistance. This undoubtedly already occurs. If the legislation looks unworkable, negotiate a workable solution in the patient’s interest
As a hand surgeon I have often been asked by patients to amputate a finger or even a limb for conditions such as neuropathic pain. Others will ask for internal fixation of a boxer’s fracture of the fifth metacarpal, which is one of the few fractures where the results are much worse with surgery than without. I explain to them that that will actually make the situation worse, and if they keep begging for it, that I am not willing to do it because I believe it is harmful to them.
Conscience is always a feature of clinical medicine, and while we must acquiesce to patients’ refusals of treatment, we are not obliged to actively do bad things to them.
Where an advanced Care Directive has been completed, there is no excuse for the wishes of that person to be ignored and life maintained for the sake of egotistic “ethics”.
My concern is that once euthanasia is legal, the restrictions will be progressively relaxed,until it becomes routine following certain diagnoses, and from being performed at the patient’s request, becomes part of daily practice. Just think how much money would be saved by euthanasing everyone with dementia!
The effects on individual doctors and the medical profession have rarely been considered . Proponents have effectively drowned out any perceived opposition or any serious consideration of ethical issues — including the effect on the profession of medicine . A review of the impact on practice was presented at an ethics conference in Townsville last year and the peer reviewed article covering what was presented has subsequently been published:
KennedyJ, Kennedy M The other side of euthanasia:A practice perspective from Australia. Research in Ethical Issues in Organisations 2019; 20:55-66.
When in consultant O&G practice in the days before legal termination and ready access to contraception, I saw many women who previously had gone to practices where for religious, moral or conscientious reasons that doctor would not prescribe nor refer. These poor lasses were shown the door without being recommended another doctor who did prescribe, refer etc. I guess those doctors felt that to give such compassionate advice would be tantamount to their pulling the trigger themselves.
Like so here perhaps? If Doctor Red is consulted but who is a conscientious objector, will he/she refer to Doctor Blue, or just throw the patient out? What do your readers think??
Typical moral coercion by progressive supporters of VAD: “Sure, you can conscientiously object to participating in intentional killing but don’t impede ‘access to lawful care’.”
Memo to Prof White et al: if we as doctors think it is a violation of the foundation of law, a profound corruption of the doctor-patient relationship and a gravely unethical act to participate in the intentional killing of a fellow human being, then VAD is an abuse, not “lawful care”, and will not collaborate in any way. We will remain as an alternative point of contact for patients who want supportive care until natural death; if they want a doctor to given them the required lethal cocktail, they can seek such a doctor on their own volition, but the law should not compel any doctor to collaborate with an act they consider wrong on every level.
I thoroughly agree. Killing people can be done by a technician. A medical degree is not needed! A patient needs to have the confidence that his/her Doctor will always have their best interest at heart to make an accurate diagnosis, prescribe the most appropriate treatment, and care for them until the end.
Victorian politicians have created a nonsense in healthcare. Since when is taking a life part of healthcare or a medical treatment and suicide an accepted course of management? Why do doctors who realise this nonsense, and who practice best practice end of life care with true accompaniment of those at this period of their life, have to conscientiously object to be able to do so, when it is societal agendas only that create request to do otherwise?
VAD legislation should remain outside of healthcare and be facilitated by legislators not health care professionals.