Victoria's system places additional burdens on doctors and can increase the suffering of sick patients, some argue.
A survey of Victorian doctors working on the ground with patients undergoing voluntary assisted dying (VAD) have revealed their frustrations with a system that may place added stress on patients and their families.
Professor Lindy Willmott, a legal academic and socio-legal researcher with the Australian Centre for Health Law Research at the Queensland University of Technology, led a team interviewing doctors who participated in VAD.
The 32 doctors – including 12 in general practice and 10 in medical oncology – were involved in VAD as coordinating or consulting doctors within the first 12 months of the legislation in Victoria.
Doctors were confident that regulations prevented ineligible patients from accessing VAD, Professor Willmott told the 2021 Annual Scientific Meeting of the Clinical Oncology Society of Australia.
However, many doctors thought the requirements of the process may restrict access for eligible patients, place additional burdens on doctors and families, and increase the suffering of very sick patients, Professor Willmott said.
“We do wonder whether the goal of the legislation, to seek a balance between access and system safety, has been reached,” she said.
“Doctors told us they had no concerns about safety. The system is safe, and ineligible patients won’t receive VAD, but all the safeguards may have implications for allowing patients access. Eligible patients may abandon the process or die while trying to navigate the process.”
The doctors reported challenges in three key areas:
1. The ban on raising VAD as an option with patients
In Victoria, health professionals are prohibited from initiating conversations about VAD or suggesting it to a patient as an option because health professionals might influence their patients to pursue that option, Professor Willmott said.
However, many doctors thought this prohibition could prevent patients from making an informed choice if their cancer treatment had failed. “When talking about this prohibition, doctors used terms such as ‘morally compromised’, ‘deceitful’ and ‘intellectually dishonest’,” Professor Willmott said.
However, some doctors said the prohibition was an appropriate safeguard, and it may be safer that some people miss out rather than accidentally influencing patients.
Non-English-speaking patients with no exposure to information about VAD may also have less awareness of it as an option.
2. The need for face-to-face consultations
Under Commonwealth legislation, all VAD interactions involving patients, doctors and pharmacists must be face to face.
“Doctors were often critical of the burden it placed on very sick patients required to travel long distances, on already busy doctors and pharmacists. This burden is particularly pronounced when patients live in rural and remote Victoria.” Professor Willmott said.
Some doctors, however, said there was merit in having at least one face-to-face consultation. “You definitely have to see them. I can’t imagine doing this by telehealth,” one doctor said.
3. The challenges of implementation
Doctors reported challenges around the complexity of the process, including a portal that’s difficult to navigate and the need to gather documentation.
One doctor told a patient she needed to find a rates or a rental bill from 12 months ago to prove she’d been a resident of Victoria. The doctor said: “She looked at me as if I’m some blithering idiot and said, ‘I’m going to be dead in two months’ time. I’ve thrown out all my paperwork’.”
Doctors also reported long delays from the time permits were issued to the delivery of VAD to patients. One specialist said: “We’ve had quite a number of patients die waiting. They’ve had their permit and they’re either waiting for the collection of the script or for the delivery.”
Dr Willmott said redesigning the system may help, as may legislative changes around the prohibition against raising the topic of VAD with patients. At a Commonwealth level, legislation could be changed to allow telehealth, if it was appropriate, she said.
In another conference presentation, Dr Cameron McLaren, a medical oncologist at Monash Health and PhD candidate at Monash University, said that 1.6% of general practitioners had registered to participate in VAD, compared with 14.4% of oncologists and 4.7% of palliative care physicians.
Dr McLaren’s research found that the average age of people seeking VAD was 72, and 54% were male, 98% spoke English at home and 71% had at least secondary education.
Dr Camille La Brooy, a political sociologist at Monash University, told the conference that a 2018 survey of healthcare professionals by the Medical Oncology Group of Australia found that 47% disagreed with VAD legislation, 36% agreed, and 17% were neutral.
“Only 14% agree that physicians involved in VAD should be required personally to administer the lethal medication,” said Dr La Brooy.
Since the legislation was enacted, 83% of patients who had VAD permits were cancer patients, but only 41 out of 253 doctors participating in VAD were oncologists, Dr La Brooy said.