Voluntary assisted dying and the role of the GP

Doug Hendrie

25/10/2019 3:44:26 PM

With assisted dying debates taking place in parliaments around the country, the question now is: What does it mean for GPs?

RACGP panel on voluntary assisted dying.
The RACGP's panel on voluntary assisted dying was held on the second to last day of GP19.

Victoria’s voluntary assisted dying legislation came into effect in June.
With other states like Western Australia and Queensland now moving to introduce similar laws, the question now is – what does assisted dying mean in practice for GPs?
To tackle the practicalities of the process, SBS Insight host Jenny Brockie facilitated an expert panel at the RACGP’s GP19 conference in Adelaide.    
Panellists included:

  • Justice Betty King QC – chairs the Voluntary Assisted Dying Review Board in Victoria
  • Michael Gorton AM – former AHPRA Chair and health lawyer
  • Professor Liz Reymond ­– palliative care physician
  • Dr Horst Herb – NSW GP and locum
  • Courtney Hempton – Monash University bioethicist
  • Belinda Teh – consumer advocate
Introducing the panel, RACGP Victoria Chair Dr Cameron Loy pointed out that the laws are expected to be used by around 150 Victorians a year.
Justice Betty King outlined the voluntary assisted dying process in brief.
Patients must first make a clear unambiguous request to their doctor to access assisted dying, she said. Next comes an assessment by their treating GP or another specialist, who must have undertaken the six-hour online training course, who then becomes the coordinating doctor.
The patient must be referred to a consulting doctor. One of these two doctors must be a specialist in the field relating to the specific illness, and one must be five years’ postgraduate.
‘Each of these doctors has to speak to the patient and make an assessment,’ Justice King said.
‘It has to be face-to-face, which means telehealth can’t be used. That’s a problem in the country.
‘The patient must be informed of all options: “Here are the palliative care options which may be enough for you and your illness”.
‘The patient’s request has to be enduring – a consistent enduring request – and they have to be assessed as having less than six months to live.’
Justice King said doctors should assess whether the patient is mentally competent to make the decision, and assess whether depression or another issue might be pushing them in the direction of assisted dying.
If both doctors agree on the competence, documents must be submitted to a government portal to be checked.
If the Department of Health and Human Services finds the request is compliant with the law, the coordinating doctor can contact Melbourne’s Alfred Hospital – which is the dispensing hospital pharmacy – who will then bring the patient the lethal substance. The substance arrives in a locked box, with the patient provided a key.
The patient can choose to use the substance whenever they like. It must be mixed and taken by the patient, unless they are unable to do so, in which case a doctor can – after receiving a permit – administer the substance.  
Ms Brockie asked Justice King what a clear request might sound like.
‘What’s made clear in the literature is that it must be clear and unambiguous,’ Justice King said.
‘You can’t say, “You wouldn’t keep a dog like this”. It has to be, “I would like to die”. It can be written down, or sign language. But it must be unambiguous.’
Ms Brockie asked GP Dr Horst Herb about his experience with assisted dying in Germany, where he has previously worked.
‘The most important issue here is, it takes time,’ he said.
‘There are lots of misconceptions and fears – sometimes irrational, sometimes rational. You can’t do it in a 15-minute consult. You have to be prepared to spend hours and hours taking on family concerns, talking to patients, exploring all options.
‘We are not allowed to prompt the patient in any way, shape or form about voluntary assisted dying.
‘But on all the other issues you can still prompt: “What would you like us to do about the pain? Distress? Loss of dignity? What are your wishes?”.’  
Professor Liz Reymond said that palliative care must be addressed alongside assisted dying.
‘We need to address deficiencies in palliative care provisions across Australia. There’s not enough money in the system,’ she said.
Professor Reymond called for careful assessment for terminally ill patients, cautioning that assessing capacity and checking for depression can be complicated by the process of dying.
‘You can’t rely on somatic indicators,’ she said.
‘Have they lost weight – yes, most people who are dying do. Do they have trouble sleeping – yes, they’re up all night thinking terrible thoughts.
‘So capacity is a real issue.’

VAD-2-hero-3.jpgThe voluntary assisted dying panel at GP19 featured a range of experts and was chaired by SBS Insight host, Jenny Brockie.
Ms Brockie asked consumer advocate Belinda Teh – whose mother died in 2016, after unsuccessfully seeking assisted dying in WA – about what she would have wanted from a GP.
Ms Teh praised her mother’s palliative care consultant for their educative, objective approach.
‘That meant I didn’t fear palliative care and neither did Mum, because we knew what would happen,’ he said.
‘It would have been extremely beneficial for Mum as a patient if she’s had education from a GP [on assisted dying]. Mum would have wanted to air out her concerns and reasons why she’s requesting this.
‘We didn’t have the chance to do that in 2016.’
Ms Teh said her mother’s excellent oncologist had to decline her request for an assisted death, and instead offered her morphine.
‘He’s a wonderful man, but there was an assumption Mum’s question was through the fear of pain,’ Ms Teh said.
‘What I wish could have been done was ask, “Why do you want assisted dying? The pain or other concerns? Is it about dignity? Autonomy? Not enough control?”
‘It’s an amazing opportunity for GPs, who are in a really good position to sensitively deal with that.’
Health lawyer Michael Gorton said there is good legal protection for participating doctors under the Victorian legislation.
‘If you have a conscientious objection, that’s fine. If you wish to be involved, there are clear and strong protections,’ he said.
‘If you follow the law, even if you make mistakes while acting in good faith, there are protections from being sued or from other offences under the act, and from a professional complaint.
‘You have to deliberately flout the law not to have access to these protections.’
For bioethicist Courtney Hempton, conscientious objection is not a black-and-white issue.
‘The legislation is very broad in terms of what GPs can object to – it can be information, referring, any part of the assessment or being present at the death. It’s a very broad provision,’ she said.
‘But some people will object to voluntary assisted dying entirely, while others may be willing to provide information and referrals.’
Ms Brockie asked about research conducted by Ms Hempton and her colleagues into clinical attitudes towards assisted dying, based on a survey of more than 5000 doctors.
Ms Hempton said early results indicated that while there is broad support for the legislation among doctors, that does not necessarily translate into a willingness to participate.
Justice King concurred, saying the biggest problem faced at present is finding enough doctors to do the training.
‘Most doctors don’t really think about it until a patient comes and asks. Then they make a decision,’ she said.
Until recently, Dr Herb said he would have liked to have a longstanding relationship with a patient before agreeing to be involved in assisted dying, to know if it was in character or out of character.
After working as a locum for three years in remote areas, however, Dr Herb said his views are changing, due to the difficulties of people in remote areas having access to a regular long-term GP.
‘You can’t deny it to people who don’t have access,’ he said.
‘It’s difficult to engage other doctors in the process. Often these are one-doctor towns and legislation prohibits teleconferencing. I can’t see any other way [to help] other than increasing resources or allowing telemedicine.’
Professor Reymond said that with an increasingly mobile population of patients and doctors, the traditional close relationship between GPs and patients is breaking down to a degree.
‘Increasingly, people can let their wishes be known and that can be documented,’ she said.
‘While you can’t do that for voluntary assisted dying, you can record your values – how you want to die and what you see as a good death. If people say what’s important to them in their documents, that can help whoever picks it up later.’
Mr Gorton agreed, saying the inability to use telecommunications ‘makes it very tricky’ for voluntary assisted dying patients, as two doctors are mandatory.
Justice King said that, in practice, it is not the specialists who are travelling to patients, but rather patients travelling to the specialist.
‘We can have patients travel seven hours to see the specialist [for the voluntary assisted dying assessment]. And you have to do that twice,’ she said.
‘But the law is the law.’
Ms Teh said that patients and their families in these situations are ‘desperate for help’.
‘My mum couldn’t move, with the tumour in her spine. To go somewhere [for an assessment for voluntary assisted dying] wouldn’t have happened,’ she said.
Justice King pointed to the role played by Victoria’s care navigators, who can help patients locate a doctor trained in voluntary assisted dying.
‘Four or five new navigators are going into rural areas in the next couple of weeks. That will be a real help for people whose doctors have said they are not interested and will not refer,’ she said.
‘So that’s a solution being tried in Victoria.’
Mr Gorton said, that around the world, up to 30% of people seeking assisted dying would not go ahead with it after initiating the process.
‘The numbers are not expected to be large – between 150 and 250 a year [in Victoria],’ he said.

VAD-3-Hero.jpgThe expert panellists discussed issues around voluntary assisted dying from a range of perspectives, including patient, legal and medical.
GP questions
Ms Brockie then moved to questions from the floor.
One GP asked if there are now more palliative care dollars in the system, in order to avoid patients choosing assisted dying due to a lack of resources in palliative care.
Professor Reymond said that the whole palliative care community needs to use the voluntary assisted dying laws to boost palliative care services.
Another GP asked what would happen for patients with dementia or others who did not fit the criteria.
Justice King was clear in her response that dementia patients would not qualify, due to the need to make competent decisions.
In response to a question on what the death certificate would state as, Justice King said the underlying disease would be listed as the cause of death, while the voluntary assisted dying status would be recorded elsewhere.
Another GP asked how to deal with the fact many terminally ill people would be depressed due to their condition.
Justice King said that if doctors are not satisfied the patient had capacity or if they have concerns over whether there is a psychological issue, they are required to call in a consulting psychiatrist.
Another GP asked whether the online training course would relieve GP anxieties around the process. In response, an audience member who works at Alfred Health in Melbourne described the course as ‘extremely detailed and excellent’.
‘It’s really well put together,’ the doctor said. ‘But it’s frustrating because it takes longer than two days to get access.
‘What I’ve learned is to be proactive – if you’re likely to want to participate, do it when you can. Don’t wait until a patient request.’
A WA GP asked whether lessons had been learned from the Victorian experience, given the fact WA’s proposed voluntary assisted dying laws will be debated in the upper house.
Mr Gorton said Victoria’s legislation is very strict.
‘To get it through [Victorian] Parliament, it had to be seen to have a strong protective effect,’ he explained. ‘It has 68 protections.
‘This [WA’s laws] is the second iteration, and some of the stricter protections they’re choosing not to use.’
Justice King described Victoria’s laws as ‘ultra-cautious’ compared to the rest of the world.
‘That was what was required,’ she said.
A Wollongong GP asked if GPs could discuss voluntary assisted dying during advance care planning.
Justice King said she could see no reason why not, while Mr Gorton said there are ‘shades of grey’, such as if the patient had a disease that could become terminal. 
Other GPs had questions around the safety of the lethal substance. Justice King said the drug had to be self-administered.
‘We don’t send an armed guard. You have to go on the basis that people will do what they’re expected to do,’ she said.
GP and RACGP Chair Dr Charlotte Hespe asked about how to best have a conversation with patients regarding what to expect from the actual dying process.
Justice King said that the government had decided not to publically name the lethal substance, as part of an effort to deter people from seeking the drug on their own.
‘Everyone who does the training will know exactly what the drug is and can tell the patient how it will go,’ she said.
‘There must be some trust in the community. [This patient] sought this medication.
‘There is a great fear that people are out there trying to kill others, but there’s a huge instinct to stay alive. In Canada, they’ve found that people who are seeking assisted dying – it’s their children who are the ones opposing them, because they want their parents to be there.’

euthanasia GP19 VAD Voluntary assisted dying

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Dr Julie Anne Copeman   26/10/2019 10:19:45 AM

Have to ask the question that if all the resources involved in this process were directed into palliative care training and provision of services everywhere and the education of relatives re the dying process would this be the better step to take at this time? And yes I have worked in palliative care and yes I have sat with dying family and friends to the end.

Dr Paul Vernon Jenkinson   26/10/2019 1:40:39 PM

If depression is a treatable illness which has to be addressed before a request for VAD can be considered,it would be helpful to know if the doctors involved had the necessary skills to diagnose it in the terminally ill.
Because it cannot be diagnosed on somatic complaints,the diagnosis is particularly difficult.
How many doctors,GPS and specialists,would have those skills?
Personally,it wasn’t until I did Palliative medicine,that l became aware of it as an entity ,previously believing that everybody with a terminal illness “should “ be depressed.

Dr Peter James Strickland   27/10/2019 11:46:49 AM

The problem here is that VAD is a legal and moral problem, and NOT a medical problem. It is totally against our whole medical ethics to be putting people to death by fatal medications. Administration of VAD medicines should be done by the patient, their relatives, or their EPA, and NOT by a doctor. If relatives believe in VAD then they could be the administering agent of the fatal medications. No one can --that is no one can--- predict death time in weeks, months or years, so any so-called legal or medical authority is guessing longevity; one can predict death in days or hours, and VAD is not relevant here. Doctors preserve life, and relieve suffering to their best, but do NOT put patients to death. That has always been murder. Is shooting a fatally injured soldier mate in war, and who is asking to be shot to relieve extreme suffering actually murder or VAD (as an example)?

Dr Raymond Yeow BA MBBS   28/10/2019 11:03:00 PM

I am still trying to distinguish between society's attempts to prevent suicide (eg Scheduling a suicidal patient to prevent death) versus assisting a suicide to occur (also called euthanasia)