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I GRADUATED in medicine in 1981 and completed my physician training in 1991. I have been a general physician, with hospital and academic appointments in Ballarat and Western Victoria, for more than 25 years. While I was trained broadly in internal medicine, my training in end-of-life care was acquired “on the job”.
I was a late convert to the voluntary assisted dying (VAD) concept. I thought my training as a physician was complete, until I faced the end-of-life experiences of four close family members over the past 5 years. For two of these, one in a hospital and one in a hospice, the experience was distressing for all. For two others, a desire to die in their own bed at home in their 90s, pain-free and with their family close by was met, unassisted.
This experience sharpened my views on VAD as a justifiable end-of-life option in a way that no medical training or work experience could ever do. Two years ago, with VAD becoming Victorian law, I undertook the VAD training in order to facilitate access to VAD for people in towns across western Victoria.
Over 2 years, I have assisted more than 50 patients through VAD, although only some have proceeded to assisted dying. Several patient experiences were memorable in a way that eclipsed my typical general physician experiences caring for complex general medical cases.
All the patients have been supported by their families. Even though access to VAD is now a legal right across most of Australia, the application processes that patients are required to negotiate are not simple and require expert assistance and family support to navigate. Several have had to overcome conscientious objection from other health practitioners and religious order-owned aged care facilities, which otherwise would have effectively blocked their application by not allowing VAD to happen or to even be discussed in their facility.
For applications made against the views of the treating doctor or aged care facility, in some cases, this has required the patient to be physically lifted by the family members from their nursing home bed, into a private car and transported long distances for each of the four or so visits required for the VAD application process. Some choose not to proceed, several do not meet the eligibility criteria, and many apply too late and die before their application can be completed – which in my experience typically takes 3 weeks. Fewer than ten patients did not meet the eligibility criteria in my assessment. These patients I referred to either active therapies or other supportive or palliative options.
VAD is not for every doctor. First, training in VAD is required. This is usually done online with occasional face-to-face opportunities. The training is not hard but it is an essential requirement.
Second, the VAD application process for each patient is time consuming. Each application requires face-to-face consultation time with the patient. Additional to this is the screen time to register the patient’s criteria for eligibility to a level that the VAD Board will approve. In my experience, this requires one hour for each of the initial and written declaration steps and the ultimate prescription.
Third, some doctors conscientiously object to VAD. In my experience, other doctors genuinely wish to avoid a perception of wearing “two hats” in their role, even – or perhaps especially – palliative care physicians. I have learnt to respect those views. However, I do ask that doctors who conscientiously object consider the views of the patient and acknowledge that respect is a two-way street.
For the treating doctor to tell their VAD patient that, as a conscientious objector, they will no longer care for them and will not be doing their death certificate is, in my experience, confronting. It is distressing, and several patients seek medical care from another doctor, who, if they live in a one-doctor town, may be in the next town.
However, more often, I find that the views of most doctors are similar to community views. Indeed, I find that most doctors and health facilties do not object, they simply find VAD to be too awkward.
Fourth, to be present at the moment of death and stand back goes “against the grain”, even though masterful inactivity may clearly be the right thing to do. This is difficult for any doctor, even sometimes for experienced doctors. Let’s not forget, for the family members, it will typically be their first time and it will always be difficult for them. To be the doctor present in the patient’s own home when this occurs increases the level of the doctor’s discomfort.
Finally, how can assisting a death ever be justified? The justification, in my opinion, comes from the patient. It comes from when a patient looks you in the eye and says “I want you to assist me to die to relieve my suffering”. Likewise, it comes when the family says, “we want you to assist our family member to achieve the death our family member chooses”.
When this happens, it is not difficult to assist. Indeed, in my experience, it would be more difficult not to.
The VAD training makes explicit that it is never the role of a VAD practitioner to advocate how people might choose to end their lives. For me, the VAD experience has been an unanticipated contribution that I can offer at my late stage of career. Not only can I provide consultant physician opinions for VAD applications as required, I can provide support to patients and families with the initial and written applications and whatever else is required along the way. For the first time in my 30-year career of hospital medicine I have started to do home visits.
Working as a VAD physician has enabled me to give back to the community using my medical qualifications in a way that I did not anticipate. At the end of the day, is not the relief of suffering for an incurable illness, on the terms that the patient requests, and to likewise provide comfort to their families, part of being a physician?
Dr James Hurley is a general diseases physician at Ballarat Health Services.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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One thing that worries me is the “online training” aspect. I was thinking of applying for VAD myself as I have incurable cancer with 3-6 months to live, but I really noticed straightaway the lack of any trauma informed care.
I’ve chosen now not to pursue that route, but I think this program still has a long way to go towards getting it right.
There can be no more important occasion than one’s own death. It needs to be respected and honoured for those facing it – and I did not experience that kind of care!
In response to the anonymous contributor’s hypothetical about a colleague with ‘endogenous depression’, it is clear that under any Australian state VAD legislation, that colleague would not be eligible. Indeed I would view him/her as suicidal and refer urgently and appropriately.
The issue VAD for people with ‘intractable’ psychiatric disorders or dementia is the source of much ongoing discussion and debate in other jurisdictions particularly Canada and Belgium. Whilst it is interesting to have intellectual discussions about these hypothetical scenarios, Australian jurisdictions are a long way from ever considering such expansion of these laws, despite what the ‘slippery slopers’ might say.
Any broadening of such laws would only occur in response to much public discussion and societal changes that would widely support changes.
And please believe me that so many of our VAD patients are not old, by any definition!
A beautifully written article Dr Hurley . The opportunity to assist patients to access VAD and
relieve suffering is so humane. In 30 years of nursing it is the most rewarding and compassionate work I have done. Thank you for your dedication
As a GP with a small palliative care load, I tend to bulk bill patients. I am curious with VAD coming to Qld next year, what is the financial cost for the patient?
Perhaps a case of subeditorial comment, or an ironic juxtaposition. This article appears in the email between an article on “100 years of physician suicide” and “Medication-related harm in older adults: underdiagnosed.”
It did cause me to wonder why we regard an incurable mental illness as different from an incurable physical illness, or whether we regard doctors as more important and worth treating than old people or cancer patients.
If it is an endogenously depressed colleague who “says “I want you to assist me to die to relieve my suffering””, should they be eligible for VAD?
Anonymous says that “Those seeking VAD could in almost all cases die very peacefully with excellent palliative care support.” That’s great, for the “almost all”. but VAD is there for those who are unable to achieve that sort of death. We know that there will always be people who suffer to a tragic extent IN SPITE of the best palliative care. Like all therapies, Pall Care is not 100% effective, even with plenty of resources and skilled staff. That’s why those exceptions from the “almost all” deserve VAD.
I am really proud of you James for vocalising about VAD. I think it is so important. It is wonderful that you have finally realised the importance of home visits to really understand the impact of disease on a patient.
Thankyou for what you are doing and not being pushty that other doctors have to do the same thing.
I have always thought you specialised in infectious diseases I did not realise you were a broader physician. I am really gad to finally know that and to knoew that you have a good deal of compassion.
Thankyou
Once again the profession is absent from the important debate and legalisation becomes a sudden ‘therapeutic’ reality. The result is a single value judgement of a vocal minority enters medical practice without the prequisite basis in scientific evidence and consensus opinion of varied experts, let alone open forum. This is the social pseudomedicine of the modern age. “No one has the right to tell me I shoudl live on” sounds a lot like “noone has the right to tell me where I can and can’t go without a vaccine” and “noone has the right to tell me what I can and can’t do to my body”. I’m not saying you don’t have rights – I’m saying don’t insist upon your position as directive for the WHOLE medical profession to endorse.
A society uptriaging the individual rights and depth of client experience (whether that be “dignified death”, or “aesthetic medicine”) above interweaving mutual obligations, interconnected shared realities, pathphysiology and epidemiology will not solve the most pressing problems of Australian public health. When the patients single minded agenda is prioritised over the principles of the profession we uncover yet more varied and extreme agendas that we are resigned to appease (because we stopped operating on principles). And every intervention has the possibility of complications. That’s why we base our interventions on evidence via the scientific process, peer review consensus opinion and regular review. Why is VAD not subject to the same scrutiny BEFORE it is legislated for our States?
What does the parent with terminal inoperable cancer tell the infant/14year old with terminal inoperable cancer – If we accept VAD for the adult, what about for a infant/14 year old? Can we defend VAD in these circumstances?
What does the willfully unvaccinated partner tell the pregnant partner bleeding out unable to access the ICU, filled with covid patients? If we defend unvaccination, do we defend ICU bed-block?
What does the breast altered mother tell her daughter that inherits her physique? If we defend aesthetic modification, do we resign our genetic inheritors the same modification?
What does the preterminal death-choosy have to say to the suicidal youth born to negligent parents? Whose suffering do we accept as valid and on what basis?
Excellent article James
Like it or not “Anonymous”, we live in a modern era of increasingly secular thinking and behaviour.
It is really time to retire Hippocrates – well past his used by date! If you think I’m being frivolous I really suggest you read the following article. It is written by a medical ethicist who was an advisor on the World Medical Association’s workgroup for revision of the Declaration of Geneva, 2017. He cogently deals with the “romanticised myth” that the Hippocratic Oath has become.
And don’t try to tell me, an experienced palliative care physician, that I can deal with all suffering.
Weising, Urban. 2020. The Hippocratic Oath and the Declaration of Geneva: legitimisation attempts of professional conduct. Medicine, Health Care and Philosophy 23: 81-86.
Lovely piece, James.
I wonder if Anonymous is aware of the wording of the earliest Hippocratic Oath: “I will not use the knife, not even, verily, on sufferers from stone (kidney stones), but I will give place to such as are craftsmen therein”.
If Anonymous has ever lanced a boil, or assisted in surgery, I’m afraid they have also violated “the” Hippocratic Oath. Indeed the inclusion of the practice of chirurgery into Medicine was itself a violation of the Hippocratic Oath. Should we send them back to the barbers?
Can we stop parading the Hippocratic Oath around as though it was carried down from the mountains by Asclepius himself as a Moses-esque style commandment?
This feels very much like the people who cherry-pick passages of the Bible to tout about others and make themselves feel ethically-superior. Just stop for a second and listen to your patients. Poll after poll after poll tell us that this is something that the public wants. When did doctors stop being learned servants of their patients and start being such gatekeepers?
Excellent Article, Dr. Hurley. I am also going to facilitate VOLUNTARY AD in Queensland from January next year. I wish more caring doctors will share the demand which I am sure will be great.
To anonymous ” In my view they are just misguided agents of the state and bring the profession into disrepute .” I suggest you reveal yourself if you are proud of your opinion. I hope I am never under your care.
To. Anonymous 2:
The Hippocratic oath is mostly irrelevant. Have you read it?
My Medical school (Addenbrooke’s) did not require us to swear an oath.
I consider my Ethics to be exemplary.
My guiding tenets are that my duty is ‘to relieve suffering’ & ‘premum non nocere’.
Your assertions in your posting are far from the truth & indicate only that you have no knowledge of how VAD works on a practical level. I would be very happy to elaborate in a discussion, should you have any real interest.
As a Palliative Medicine physician, I see any referral to discuss VAD as an opportunity to provide the best care & advice I can (the Law around VAD requires the Practitioner to ensure that the patient understands the ‘other options’).
The process certainly takes, generally, at least 3 weeks so there is plenty of opportunity to discuss options.
The Law also requires that the Practitioner ensures that there is no coercion.
Much more commonly than wishing for the patient to access VAD, relatives are distressed by the patient’s request; although, I would say that the majority are supportive of their relative’s decision despite this distress.
It is really quite a confronting thing to contemplate taking a substance that means that ‘one moment you are here & the next you are dead’. I think these patients are often very brave.
Given the choice between dying of ex-sanguination or ‘going quietly’ I think I understand why people choose the substance & there are many others.
As you are well aware, I hope, many people do not actually take the substance but find its present a ‘comfort’ in that it is there ‘if required’; an element of control in what might otherwise be a very challenging demise.
And, by the way, we are not ‘killing people’.
People take the substance themselves (except in the vast minority).
In my opinion people with your views are being deliberately obtuse, are likely misguided agents of restrictive religions & risk bringing the profession into disrepute.
Please try to understand & not condemn what you do not understand.
Excellent article. Good on you James for being prepared to provide this rather different kind care, from what we traditionally think of as medical care.
Just because VAD is legal doesn’t make it ethical or consistent with the Hippocratic oath. .Those seeking VAD could in almost all cases die very peacefully with excellent palliative care support. Yes it may not be where or exactly when they want. Suffering is of course subjective and so can never be said to be absent but includes a lot of fear that would be better overcome by information and support services not VAD . Yes VAD can be very convenient for some relatives who might prefer a quick end to what can otherwise sometimes be a drawn out and distressing experience.
We all like it when we get what we want so VAD is good fir a few. But it’s a sad day for medicine when some colleagues really think they are doing medical good by intentionally killing people . In my view they are just misguided agents of the state and bring the profession into disrepute .
Dr Hurley, you are my kind of colleague. But I would like to take the legislation one step further, if for no-one else except myself. I have a 90 year old mother as a sole living relative. If I end up in a nursing home with dementia I would like to be put down. I do not want to be fed at one end and wiped at the other, kept alive by staff who ‘do a great job’, but do a job that should not have to be done. I would like the power to dictate terms that, should I satisfy strict criteria a), b) and c), someone slips some pentobarbital into my morning tea. By then I will have forgotten that I ever made that decree, so would not live in fear of it happening.
I forsee too many reactionaries and religious zealots with loud voices to bring this concept to reality any time soon, but unless someone starts the conversation it will never happen. Just as no-one has the right to tell me when I should die, no-one has the right to tell me that I should be forced to live on. That right is mine alone, but is a decision that should be allowed to be made in advance, before one loses the ability to make the decision at all.