Feature

Will palliative care and voluntary assisted dying clash – or collaborate?


Doug Hendrie


14/01/2019 11:54:22 AM

As voluntary assisted dying becomes legal for a quarter of all Australians later this year, experts say that well-funded palliative care will only become more important – not less.

An Australian report found the palliative care sector had actually benefitted in overseas jurisdictions where assisted dying legislation had been passed. (Images: Georgios Kefalas, Mick Tsikas)
An Australian report found the palliative care sector had actually benefitted in overseas jurisdictions where assisted dying legislation had been passed. (Images: Georgios Kefalas, Mick Tsikas)

From mid-June, suffering Victorians at the end of life who meet strict eligibility criteria will be able to seek voluntary assisted dying via a substance causing death.
 
The move is not insignificant, as Victoria accounts for 25% of Australia’s population. And such a shift in policy begs the question, will palliative care and voluntary assisted dying clash or collaborate?
 
A new report commissioned by Palliative Care Australia found that the palliative care sector had actually benefitted in overseas jurisdictions where assisted dying legislation had been passed.
 
‘[There is] no evidence to suggest that the palliative care sectors were adversely impacted by the introduction of the legislation,’ the report states.
 
‘If anything, in jurisdictions where assisted dying is available, the palliative care sector has further advanced.’
 
The report is designed to help Palliative Care Australia review its position on euthanasia and assisted dying before the first Victorians can seek assistance dying. 
 
Palliative care specialist Dr Nicola Morgan told newsGP assisted dying will not replace the need for palliative care.
 
‘Palliative care is not against the debate around euthanasia, because where debates have happened palliative care starts to improve,’ she said. ‘That’s because when people realise the alternative [to voluntary assisted dying] is not crash hot, governments look at funding palliative care better.
 
‘We have to have a viable alternative, and good palliative care in the community requires improved funding. 
 
‘People think if you’ve got euthanasia available, they can get it. But many people are probably not going to ask for it at the right time. People who come to my ward at the end of the cancer journey are not going to be covered by euthanasia. It’s a rigorous process.’
 
Victoria has a number of safeguards for its voluntary assisted dying model:

  • Only adults with decision making capacity, who are suffering and have an incurable, advanced and progressive disease, illness or medical condition that is likely to cause death within six months (or 12 months for people with neurodegenerative conditions) can access the scheme.
  • A person may only access voluntary assisted dying if they meet all of the strict eligibility criteria, make three clear requests and have two independent medical assessments that determine they are eligible.
  • The request must always be initiated by the person themselves, with health practitioners treating the person who raise the issue subject to unprofessional conduct investigations.
‘When you come to the hospital in the last week of life, you won’t be eligible. Your mother suffering from dementia in a nursing home, she won’t be able to get it,’ Dr Morgan said.
 
The Palliative Care Australia report states that ‘implementation of legislation may drive a stronger focus on upholding patient choice and autonomy, and there may be opportunities to introduce system improvements in palliative care, either as a direct or indirect consequence of the planned implementation of assisted dying’.
 
Dr Morgan’s husband, Associate Professor Mark Morgan – who is Chair of the RACGP’s Expert Committee – Quality Care (REC–QC) – told newsGP he would strongly advocate for high-quality palliative care in tandem with moves to introduce voluntary assisted dying.

Mark2-Morgan-hero.jpg
Associate Professor Mark Morgan said he would advocate for high-quality palliative care in conjunction with moves to introduce voluntary assisted dying.

In a 2017 Medical Journal of Australia article, Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, Professor Ezekiel Emanuel, stated assisted dying and euthanasia would only help a tiny minority of patients.
 
‘Euthanasia and PAS [physician-assisted suicide] do not solve the problem of inadequate symptom management or improving palliative care. These interventions are for the 1% not the 99% of dying patients,’ he wrote.
 
‘We should end the focus on the media frenzy about euthanasia and PAS as if it were the panacea to improving end-of-life care. Instead, we need to focus on improving the care of most of the patients who are dying and need optimal symptom management at home.’
 
GP Dr Horst Herb, who gave qualified support of euthanasia last year, told newsGP palliative care and euthanasia are complementary.
 
Dr Herb worked for decades as the only GP in Dorrigo, inland from Coffs Harbour in NSW, and provided palliative care to many long-term patients. But he would have been prepared to help them die if it were legal and if he knew the patient well. 
 
‘I’d need to be very sure this is something the patient has thought long and hard about, that this fits with what the patient usually would decide or act upon,’ he said. ‘That’s impossible to do if you don’t know the patient well, to know if it’s out of character or not.
 
‘With [long-term] patients where I’m confident I understand where they are coming from, I would be very happy to be involved. I wouldn’t be happy to treat a patient I’m not familiar with, as it would be hard to understand if it was just the spur of the moment.’
 
‘Palliative care has always been neglected. I hope [assisted dying debates] will bring funding to palliative care.
 
‘Most people will still die with palliative care. Euthanasia will be the minority, for many reasons. One key reason is inertia. Choosing the right time and making that decision [for assisted dying] is very difficult, so many will instead die a natural death.’
 
Other states may soon follow Victoria, with Western Australia to introduce a bill next year and Queensland to establish an inquiry considering assisted dying. New South Wales and Tasmania have voted down voluntary assisted dying legislation. Efforts last year to allow the Northern Territory and the Australian Capital Territory to be able to pass their own legislation were voted down.

The Northern Territory was the first jurisdiction in Australia to pass euthanasia legislation in 1995, but the laws were overturned by the Federal Government less than a year later. Four people ended their lives with medical assistance during that period. 



euthanasia palliative care voluntary assisted dying



Peter Coleman   15/01/2019 6:35:02 AM

I would suggest that RACGP be protesting to Victorian government against this terrible and unnecessary law. Palliative care is good medicine. Killing a patient is never an option and unnecessary. The safeguards are not safe. In medicine at the end of life we stand for life until we die. Peter Coleman


TR   15/01/2019 1:55:02 PM

The report was commissioned from an independent consulting organisation but does not reveal the author (and hence the author's private views which may implicitly affect the conclusions cannot be known), is internally consistent in part and presents a fairly selective review of the evidence which is concerning. Not a good move from Palliative Care Australia.


Dr Peter j Strickland   15/01/2019 4:38:05 PM

The simple answer is that palliative care and voluntary assisted dying should collaborate. There is a time for palliative care treatment, and a time for voluntary assisted dying, but it is NOT 105 year=old depressed humans deciding to to have themselves "knocked off". In Godly terms, the 'body' only knows the present, the 'mind' only knows the past and analyses it, but the spirit (or soul) knows the future, and is the master. When the soul decides to go for voluntary dying (and NOT the body or mind), and certain about its future, and no longer wants palliative care, then it is ethical to proceed. Voluntary dying should NOT be administered by medical practitioners, as they cannot break their Hypocratic Oath, and this should only be done via those outside the medical profession, and probably approved in Western Society only by a committee (advised as one of its members possibly being a doctor to advise on drugs and/or methods). Palliative care is the doctor's role along with all the other medical, nursing and paramedical support professions, but NO voluntary dying positive action --it is a problem for society, and NOT the medical profession.


GEORGE QUITTNER   16/01/2019 3:04:35 PM

HOW ARROGANT that some people and even doctors presume to know what is best for me!! I have seen enough people die "NATURALLY" and with palliative care, to know there are many occasions when I would find my situation intolerable. You die your way Peter Coleman, and let me die mine. Dr Strickland. The privilege of a life-long role as a patient's doctor, carries with it the responsibility to do everything possible to secure a dignified and pain-free death. Again there is no compulsion for you to do anything you do not feel comfortable about.... but then refer the patient to a doctor who is more compassionate.


Jill Gordon   16/01/2019 3:59:52 PM

There’s little doubt that patients benefit from having genuine choices about their end of life care and that palliative care services improve as a result. While it’s true that VAD will only assist a small number of patients, each and every one of them (and their families) deserves our respect and support.


David Leaf   16/01/2019 4:22:10 PM

The law is finally catching up with both science and public opinion internationally. We have known for many years that palliative care frequently is not the answer and is not able to slve all patients problems every time. Palliative Care Australia’s own figures suggest that they cannot help at least 5% of patients. It is probably more

There is another group of patients that everybody tends to forget. These are the ones who will reject palliative care even after adequate explanation Palliative care is like all other specialties - it has its limits. Mostly they do a good job .

Whilst one can hope that palliative care will change it attitude towards voluntary assisted dying )VAD), we must not forget that this organisation and its disciples have steadfastly opposed any change to the law for many years. Many of its specialists have ignored the international evidence supporting VAD.

For the collaboration to work, it must be through the general practitioners Who have known the patients for many years.

Hospital doctors I really have the intimacy of patients over long period of time that is required for this discussion.

For ths short-term the process should be regulated independently and not through palliative care. In the future if the two organisations are able to coexist happily then they can be integrated . Once the politicians and our specialist palliative care colleagues have caught up with international evidence there maybe more of an even field .

We live in hope.

Dr David Leaf
New South Wales convener
Doctors for assisted dying choice


JAMES LEONARD PARK   16/01/2019 11:34:52 PM

Yes, end-of-life medical care
can and should include the option of gentle poison
if and when all of the other methods of managing dying
do not work satisfactorily.

Here is a chapter exploring all five medical methods of managing dying:

https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/MMMD2.html


Jan Markby   20/01/2019 1:01:12 PM

Surely, this should come down to personal choice.. What right has anyone else, including anyone with a Medical degree, to decide what is right for someone else. The medical profession needs to understand that they are not the be all and end all in this debate, we the individual are. We know our bodies, we know our limits. In my opinion it's not for another person to decide how I wish to end my life.


Dr Peter Robert Bradley   1/03/2019 10:21:57 PM

["What right has anyone else, including anyone with a Medical degree, to decide what is right for someone else."]
That's the whole point Jan - they shouldn't, and under the proposed legislation, they will not, contrary to what those against often wrongly claim.

But yes, I can see palliative care getting quite a boost when VAD is provided for. Because up to now, I know some patients fear palliative care, and often tend to not utilise it enough, "because they/it is just going to keep me alive to suffer longer doc".

However, if they have the comfort of knowing that, in advance, they can set in place a fallback option of VAD should all else fail, then they will be less inhibited in accepting all that palliative care can provide.


Dr Peter Robert Bradley   2/03/2019 6:54:54 PM

["What right has anyone else, including anyone with a Medical degree, to decide what is right for someone else."]
That's the whole point Jan - they shouldn't, and under the proposed legislation, they will not, contrary to what those against often wrongly claim.

But yes, I can see palliative care getting quite a boost when VAD is provided for. Because up to now, I know some patients fear palliative care, and often tend to not utilise it enough, "because they/it is just going to keep me alive to suffer longer doc".

However, if they have the comfort of knowing that, in advance, they can set in place a fallback option of VAD should all else fail, then they will be less inhibited in accepting all that palliative care can provide.


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