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“It is not death that a man should fear, rather he should fear never beginning to live” – Marcus Aurelius
George* was a stoic and pragmatic man. At 90 years old, he knew he didn’t want aggressive treatment for the metastatic cancer which, at diagnosis, was already encasing a major artery.
Still sharp as a tack, his determination to access voluntary assisted dying (VAD) was unwavering, and I admired both his candour and his courage.
On the day of his planned VAD administration, he arrived wearing his prized possession: a Coober Pedy Akubra hat. By complete chance (or as I like to believe, fate) I had worn my favourite opal earrings, which perfectly matched the stone set in the hat’s band.
We were both awe-struck.
Just before he died, George gently touched my cheek, lifted the Akubra off his head and placed it on mine.
We stared at each other for such a long time that to this day I truly believe I caught a glimpse of his soul. I wear the Akubra often, the tops of my ears resting in the little dimples made by his.
Moments of human existence
These moments of beautiful, intimate, unparalleled connection are part of the reason I work in the area of voluntary assisted dying.
I came to the practice of VAD more by accident than design. From a young age, I was fascinated by the great transcendental moments of human existence: birth and death. As my medical career progressed, I had my sights set on dual training and being both an obstetric anaesthetist and a palliative care physician.
My palliative care fellowship coincided with when VAD was being debated in WA and I was stunned by the opposition from the specialty in general, and the perceived incongruence between VAD and other forms of supportive end-of-life care.
When my organisation put out an expression of interest for a VAD clinical lead to guide and shape the service implementation ahead of law enactment, I applied, and it’s fair to say that my experiences in offering VAD have changed the entire trajectory of my life and career.
I was one of the first VAD practitioners in WA, have remained the clinical lead for the health service I work for, and am now privileged to sit on the board of the peak body VADANZ.
Rewarding and meaningful work
It’s understandable that doctors may initially feel reluctant to become involved in VAD.
Doctors traditionally see themselves as healers in pursuit of cure and cite the Hippocratic oath as forbidding assistance to die. Many have other ethical and moral objections to assisted dying.
VAD laws in Australia enshrine the right to individual conscientious objection, and I fully support those holding this view.
But for doctors who may simply be unsure of what is involved in VAD — I can highly recommend signing up for online VAD training to learn more.
I have never questioned my ongoing involvement and like to think of myself as a resolute and determined conscientious provider not only of VAD, but of uniquely holistic, patient-centred end-of-life care.
Offering VAD is without a doubt the most rewarding and deeply meaningful work in my entire medical career.
End-of-life choice
Our laws in WA (similar to other Australian states) are among the most conservative in the world; a person can only access VAD if they are already terminally ill.
Assisted dying then does not offer a choice between living and dying, only between dying and dying. Giving a person the ability to regain a sense of agency over a disease that has all but consumed them, is the most extraordinary gift. I consider it an immense privilege to be able to bring peace and comfort to the terminally ill.
VAD is still fairly new in Australia. It became available in Victoria in 2019, with other states following. It will be implemented in the ACT in November 2025. Only the NT has not passed VAD laws.
There is much work to do in ensuring VAD doctors are properly acknowledged and remunerated for their time. Importantly, the peak body VADANZ is providing a forum for practitioners to share expertise and provide mutual support, which is important for reducing a sense of working in stigma and isolation.
VADANZ also advocates for changes to VAD laws that honour patients’ autonomous right to self-determination in end-of-life decision making.
A better death
Assisted dying is vitally important because through deep and meaningful conversations between doctors, patients and their loved ones, we can bring death and dying out of the shadows. We allow patients and their families a better quality of life, and quality of death. Everyone dies; not everyone has to suffer.
I would strongly encourage any doctor who values compassion and connection with their patients to embark on the extraordinary journey that is offering VAD care. On a personal level, I am indebted to all the dauntless warriors I’ve cared for over the last three years, for all they’ve taught me about living, loving and being.
*name has been changed
Dr Clare Fellingham is the VAD Clinical Lead of a large metropolitan health service. She is on the board of VADANZ, the peak body for voluntary assisted dying health professionals and features in the recently-released book Power of Choice (New South) by Julian Kingma documenting personal stories of VAD in Australia.
For information about online VAD training in your state or territory, see here.
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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From what I have seen and heard, VAD is a truly patient-centred service. Thank you, Clare, for your pioneering efforts. I, for one, would like to become involved in this line of work, which I see as easing suffering which cannot be managed even with the best available palliative care.
Thank you Dr Clare.
My best friend, love of my life, my wife, chose VAD. I got to witness 3 days of what her end of life might look like. Not very pleasant. The palliative care was fantastic, but she had had enough. Her passing was peaceful, in great care and surrounded with love. We were able to farewell each other as we wished. Her last moments will stay with me forever.
Dr Clare, you and other VAD doctors, perform a much needed role, with great care, compassion and professionalism.
Thank You and others in your very tough profession.
My impression is that many who oppose Voluntary Assisted Dying (VAD) because of some kind of moral objection proffer the same tired reasons. Here we have the “slippery slope argument” of “where will it end?”
There is evidence from other countries that this does not happen, or where assisted dying has been extended, it is in very limited and very specific circumstances. The information is there for those who genuinely seek to understand more about VAD. The absolute numbers of people seeking VAD is small.The peace of mind that VAD patients acquire when they know they can access a peaceful death at the time of their choosing is immense and is absolutely wonderful to see.
I am a VAD practitioner and can only agree with Dr Clare Fellingham and Dr Angela Cooney. VAD can provide a significant period of peace and comfort to those faced with a form of suffering that is not just about pain. As Angela has described, it’s about dignity and autonomy, not just simply about fear of pain or other physical symptoms.
But above all, it is a personal choice, and as such, it should not be limited by the narrow views of those who staunchly oppose VAD and often appear to want to remain deliberately uninformed.
It is disappointing that some of us feel it is preferable to actively hasten death with the associated bureaucratic requirements rather than providing adequate symptomatic relief and emotional and personal support. Hippocrates recognised that there was an ethical component to medical practice which is even more important today than in his time. Many if not most of us will continue to respect the value of human life in spite of any opposition to this
Love your work Clare!
My sentiments exactly [COI disclaimer – I am a VAD Victorian practitioner with >100 satisfied patients and families who are able to say that when they came to consider THEIR options, their voice was heard].
If the author was “stunned” by the initial medical opposition to VAD, then she has failed to fully understand the codes of ethics and practice that doctors have adhered to for many generations, basically that we should not kill but neither should ” strive officiously to keep alive “. The intent is the key factor in treating dying patients, personally i prefer to give sufficient medications to relieve any suffering, without the primary aim of killing. i believe there are very few cases where palliative care cannot relieve terminal suffering, but I accept there may be a few instances, and VAD might be justified in those cases. The problem is that it soon becomes accepted as the norm and we have already seen many demands to relax the fairly tight controls that were initially insisted on. If the indications continue to widen, we risk losing the trust of the community. T
Our first ‘anonymous’ commenter is hamstrung by the all-too-common failing of the conservatives among us, especially those from a religious background, which is that they are unable to hear the patient, When the dying person says ‘I am afraid of my family seeing me so fallen away’, ‘I hate how this disease has taken control of my life’, the conservatives offer more pain relief (the issue is not somatic pain but existential distress) or talk about the ineffable intentions of God. Why not listen to what the person is trying to tell you? ‘This is not a life’. ‘I want to take back control’. ‘I am afraid that I will lose myself to this disease’. The profound relief and gratitude that people express when they are heard is what we should all aim for. And many patients die without needing to use VAD, because the knowledge that they are in control and have a choice for end of life is all that they need.
Thank you Clare, you are a credit to the profession.
With all due respect, how the VAD process makes the doctor feel is utterly irrelevant: it’s about the patient (only).
And we remain with the conundrum that we apparently wish to support the autonomy of the patent in exercising their choice, yet won’t allow them that autonomy in other settings, such as suicide.
Canada has recognised that, and as a consequence is heading into territory that is profoundly uncomfortable to many.
VAD is expedient; but remains philosophically and morally challenged.
Thankyou for being so open & sharing.
At present I am very interested to know if there is any help available for those who have had to assist a close family member with their wish to choose VAD ?
It seems to me that there are a number of perfectly legal ways to hasten death under the eye of the medical profession and with its active assistance. Rejection or discontinuation of life-saving treatment either in person or via an advance directive, offer and acceptance of terminal sedation, voluntarily discontinuing eating or drinking – all have the same outcome: death hastening.
So why is VAD any different? Because it’s quicker and more peaceful? Because the patient has more agency and drives the process?
All of the above are intended to relieve suffering. None of the above is intended to “kill” a patient. They are all just methods of death-hastening which is, sadly, sometimes necessary to end suffering.
Thank you, Dr Clare Fellingham, for your realism and for your unwillingness to abandon your patient in their hour of greatest need.
Thankyou for the thoughtful and moving reflection on your involvement with VAD. Respecting our patients’ views and wishes can be challenging at times, but having personally cared for someone who chose VAD, I can see how regaining control and agency at a time when it feels like these have been lost, can really empower and provide comfort.
Thankyou for choosing the difficult path as a doctor, providing healthcare that our patients can struggle to access.
There are many ways for medical staff to provide compassion to and connection with suffering patients that don’t involve ending their lives .
This shouldn’t be about how it makes doctors “ feel “ . It’s about the patients. This reads like a promotional advertisement .
If a need to be terminally ill is conservative I don’t want to think about where VAD laws in Australia will be in a few years time .
At the top of the article where it states author he title has not been included. I feel this is an oversight which female doctors often receive. I’d suggest rectifying it.
Beautiful article and an incredible role she plays for society.
It’s interesting the relative ease with which someone can end their life when they are feuds with the status quo, when compared with the extreme difficulty that can be encountered in getting an increase in aged care funding to provide assistance to similar elderly persons who want to continue their lives.
As a student, I was once asked to think about my own doctors who inspired me to study medicine. I was stuck at the time- girls were offered little in the way of informed consent or respect for autonomy in the 1990s. Thank you for sharing your insights, your values and your experience. You stand out as an exciting and inspiring role model today.