Voluntary assisted dying: What GPs need to know

Matt Woodley

14/06/2019 11:06:35 AM

With Victoria’s legislation set to come into effect – and other states considering similar laws – newsGP examines regulations, eligibility, functionality and other structures of what is a major change in Australian healthcare.

Voluntary assisted dying
Voluntary assisted dying has travelled a long path in Australia. (Images: Tracey Nearmy, David Crosling, Mick Tsikas)

Wednesday 19 June will be a historic day for Australia.
That is when Victoria’s voluntary assisted dying legislation comes into effect. For the first time in more than 20 years, eligible patients will be able to request access to voluntary assisted dying.
Patients facing an inevitable, imminent death as a result of incurable disease, illness or medical condition, will be able to ask a doctor – such as a GP or other specialist – for information on how to begin the process of ending their life on their own terms.
Similar legislation is being considered in Western Australia and Queensland, with both states already having requested public submissions on the issue, while last year the ACT and Northern Territory unsuccessfully lobbied to overturn federal law that prevents both territories from legalising voluntary assisted dying.
Accessing the scheme will require patients pass 68 different safeguards, making Victoria’s Voluntary Assisted Dying Act 2017 one of the most protective of its kind in the world.
This situation will no doubt affect GPs; newsGP examines the major aspects and structures of the scheme.
Who is eligible?
In order to be eligible in Victoria, patients must be independently assessed by two doctors to be suffering from a condition expected to cause death within six months, or 12 months for a neurodegenerative condition.
Patients must also be an Australian citizen or permanent resident over the age of 18, possess decision-making capacity throughout the entire process, and have lived in Victoria for at least 12 months prior to making the request.
People with a degenerative brain condition such as Alzheimer’s disease are eligible to access voluntary assisted dying, provided they meet all other criteria; however, having a condition such as dementia alone is not deemed sufficient cause to access the voluntary assisted dying substance, and the patient will lose access to the scheme should it affect their decision-making abilities.
The same criteria apply to patients with a mental illness or disability.
How does it work?
Following the assessment by two doctors, the patient must sign a written request confirming they are making an informed, voluntary and enduring decision, as well as make a final verbal request before they can receive access to voluntary assisted dying.
The written declaration has to be witnessed by two independent individuals, who:

  • will not benefit financially or in any other material way from the death of the person making the declaration
  • are not an owner or responsible for the day-to-day operation of a health facility at which the person making the declaration is being treated or resides
  • are not directly involved in providing health or professional services to the person.
Additionally, only one witness may be a family member of the person making the written declaration.
To ensure the patient’s decision to access the voluntary assisted dying substance is not rushed, the process cannot be completed in fewer than 10 days, unless the person is expected to die within that time.
On receiving a final request, the patient’s doctor will apply for a permit to prescribe a voluntary assisted dying substance that the person may use to end their life at a time of their choosing.
According to the Victorian Government, it is expected most people will take the voluntary assisted dying substance themselves orally. However, if a person cannot swallow or otherwise physically take the substance themselves, they are able to request assistance from a doctor.
Access to the voluntary assisted dying substance will be limited during the initial rollout, with only three pharmacists at Melbourne’s Alfred Hospital tasked with mixing the substance for patients. The pharmacists will deliver the substance in person to the approved patient in a locked box, and the patient will appoint a contact person so any unused substance is returned safely.
Regulation and facilitation
The Voluntary Assisted Dying Review Board (VADRB) will monitor all activity under the law and receive reports from all health practitioners who participate.
No health practitioner or healthcare provider is obliged to participate in voluntary assisted dying and conscientious objectors are protected by law.
GPs interested in participating are required to apply for a voluntary assisted dying permit from the Victorian Government, and will need to submit a number of forms to the VADRB. To help find willing participants, the Government has appointed two voluntary assisted dying care navigators, and will appoint two more at a later date.
Their role includes connecting a person seeking voluntary assisted dying to a doctor who may be willing to assess eligibility. They have also already been assessing interest from doctors across Victoria and are expected to play a critical role in addressing access issues, particularly during the initial stages of the scheme.
Training can be completed online and should take approximately six hours.
The VADRB will review every case of voluntary assisted dying and make suggestions for changes or improvements in the law. Other organisations, such as Victoria Police, the Coroner and the Australian Health Practitioner Regulation Agency (AHPRA) will also ensure that laws and professional standards are observed.
Other considerations
A person seeking voluntary assisted dying may be cared for in an institution like a hospital or residential aged care facility – where some practitioners may be opposed to voluntary assisted dying.
Patient access to the scheme in these cases will be affected by how institutions respond to any requests, and the Victorian Government has developed three pathways to help health services consider their approach.
Should a patient speak a language other than English, including Auslan, they can use a suitably qualified interpreter to help them make their requests. They are also able to use the interpreter during the doctors’ assessments.
Where there is doubt about a person’s capacity to understand the doctor, it is necessary to use a suitably qualified interpreter.
People with disability who have difficulty communicating can use their preferred means of communication, such as a communication aid, writing, or gestures to request voluntary assisted dying.
Family members cannot be interpreters, and should one be required, they must be independent and approved by a professional body.
People who have difficulty writing can ask someone else to sign the written declaration requesting voluntary assisted dying for them, however; the person seeking voluntary assisted dying must be present when the written declaration is signed.
More information specifically tailored for health practitioners, including a step-by-step guide on how to respond to a patient request for access to voluntary assisted dying, can be found on the Victorian Government website.

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Nadim Taoum   15/06/2019 8:21:20 AM

As a GP I feel uncomfortable to manage these kinds of requests form patients or families at this stage.
What if I differ theses requests and refer them to other doctors or I do not accept them, is there any legal consequences that may affect my professional practice.
For those GPs who wish to assist patient to die, is there any special training to make them eligible to provide the service.

Peter Coleman   15/06/2019 1:25:47 PM

I call all medical practitioners do have nothing to do with this evil law. I believe we doctors provide life not death to patients with good symptom control. I repeat stand up for good medicine and life and protest loudly against murdering our fellow human beings. Cecily Saunders wrote you live until you die. We will do everything we can to care for you until you die. I ask stop and think . Peter Coleman

Dr Rachel Nicole O'Neil   16/06/2019 12:08:19 PM

I did have a friend raise a good question. Once the patient is given the medication is it actually then monitored to check that only the patient themselves takes what is dispensed? How is it ensured they don't give it to someone else?

joanne fitzsimons   18/06/2019 2:31:35 PM

We don't allow animals suffer at the end of their life, why should we insist on the suffering of our fellow human being. I believe in the fundamental right of a person to chose their own path in life and in death. This law is highly detailed and ensures that the patient has full capacity in order to fully inform their decision. I support a woman's right to chose to end the life of her unborn child, I support a man or woman's right to choose to end their own life if their suffering is indeed too great despite all the best that excellent palliative care can offer.

Dr Michael John Pearcy   18/06/2019 5:57:31 PM

No matter how many safeguards are put in place it won't prevent the exploitation of sick & elderly people. Experience overseas has shown that in countries where this has been legalized it is a very slippery slope down to the point that healthy non-cancer patients are being euthanized

Dr Maha Farid Hanna   22/06/2019 12:42:46 PM

Where are you going Australia? Very sad. The death day and hour for anyone on this planet is only decided by the creator. That is gone too far in my opinion for a doctor to assist his patients to end their lives.

Johnny Khoury   22/06/2019 12:58:37 PM

My friends, do not stand idly by and allow evil to be perpetrated. Stand together, shout out and let your patients and society know how horrendous this is.