VAD laws are working ‘safely and as intended’, but some safeguards are having unintended consequences. Meanwhile the number of doctors participating remains low.
The arbitrary timeframes imposed by VAD legislation were acting as a barrier to some in need seeking access to voluntary assisted dying, while the culture of “prolonging life at all costs” was doing patients a disservice.
Speaking at the VAD Conference 2024 in Brisbane today, panelists discussed the impact of one of the intended safeguards VAD legislation around the country has in common: the six to 12-month prognosis.
VADANZ director Dr Clare Fellingham spoke out against the arbitrary timeframes.
“We know that timeframes can, and in some instances do, act as a barrier to those who would eventually be eligible but may suffer terribly while they wait for these arbitrarily imposed timeframes,” she said.
“We know that barriers can discriminate against others by ensuring that they’ll never be eligible. For instance, in those dementing neurodegenerative conditions, where you lose capacity before you get the chance to access VAD, we know that the timeframes truncate the window of opportunity for a suffering person to begin a VAD journey.”
The undue emphasis of medicine remains to “prolong life at all costs”, said Dr Fellingham.
“But I see at the other end of life that that does people a disservice.
“It doesn’t necessarily honor them, because we’re all going to die one day … it is the one great truth that all of us share in this room, irrespective of how different we are, we’ll die one day.
“If we don’t honor that, then we miss a great opportunity.”
In the ACT – which will offer VAD from November 2025 – there will be no specified timeframe to death, unlike all other jurisdictions.
Instead, practitioners must deem that a patient’s condition is “advanced” – the definition of which is still under discussion.
When asked about the AMA’s position on the change, GP and ACT AMA president Dr Kerrie Aust said that safeguards were important, as was access.
“When you review the discussions around the world, often timeframe feels very, very safe, but it has the opportunity to hinder appropriate access to VAD,” she said.
“Taking it away also represents its own challenges of how we enable the clinicians who are in those assessment roles to consistently assess eligibility against the criteria.
“While we don’t want someone to be blocked from appropriately accessing VAD, we also want to make sure that they access it at the right time for their own personal and clinical journey.
“Within all of these discussions, there is a patient who is a human being, and then those clinicians who are looking after them are also human beings who come with their own moral compasses.”
GP and VAD clinical lead for Tasmania Dr Keith McArthur was fervent in his opposition to prognostic timeframes for VAD eligibility.
“Having practiced VAD for 23 months, I believe it’s an obstruction,” he told delegates.
“It doesn’t help me at all. It makes the process more difficult.”
Dr McArthur said it was every doctor’s responsibility to be good at end-of-life care.
“Many years ago … I was learning palliative care and the palliative care specialist said to me, ‘Keith, every doctor needs to be good at end-of-life care, because life is a sexually transmitted condition that has 100% fatality’.”
Today, VAD advocacy charity Go Gentle Australia released its inaugural annual state of VAD report at the VAD Conference 2024 in Brisbane.
According to the report, since VAD was legalised in Victoria – the first jurisdiction to legalise the practice – in June 2019, over 7200 terminally ill people across the country and NZ have sought VAD access and 3242 have died by VAD.
In all states, doctors are required to undertake the eligibility assessments, meaning access is contingent on doctors being willing to participate.
In Victoria, over the almost five and a half years since implementation, only 1.2% of the licensed physicians in the state – 347 practitioners – have registered to provide VAD. In WA, only 0.75% after two years.
In 15 months, Queensland has recruited 187 clinicians, while NSW has 228 doctors registered to deliver VAD after only three months in operation.
The proportion of VAD practitioners who are GPs varies across jurisdictions: 81% in Tasmania, 59% in Victoria, 50% in SA and 45% in WA.
“The high representation of GPs involved in VAD reflects the important role that GPs play in end-of-life care for people living with a life-limiting illness,” read the report.
From the available data, around 60% of VAD-registered doctors go on to care for a VAD applicant.
According to the National VAD Survey 2023, 80% of non-engaged practitioners would consider participating in VAD if appropriate workplace support was in place.
“These supports included caseload management, pastoral care, mentoring for newly qualified practitioners and professional development,” reads the report.
Related
Poor compensation for VAD services remains a barrier to service provision.
“The Medical Benefits Schedule has not been updated to reflect contemporary practice and still retains a general explanatory note that ‘euthanasia and any service directly related to the procedure’ will not attract Medicare benefits,” reads the report.
“This fails to acknowledge the significant and time-consuming role that health professionals play in VAD, and in particular the key role of GPs in VAD provision.
“As a result, many doctors do not charge their patients for care they deliver, often leaving them unreimbursed for [services provided]”
The report stated that expecting tens of hours of pro bono work was “not reasonable nor sustainable”.
“VAD must not become a care option only for those with the economic means.”
While WA and NSW have implemented new practitioner funding packages, inconsistencies across jurisdictions were “undesirable”, said the report.
“MBS provision to allow GPs to claim against existing item numbers would go some way to address concerns, alongside state funding provision.
“Australia should look to New Zealand, where comprehensive funding has been available to VAD practitioners since their law’s inception.”
According to the report, overall, VAD laws are working “safely and as intended”.
But inappropriate pay, gag clauses and some of the intended safeguards, such as burdensome specialist and residency requirements, inadequate guidelines for non-participating practitioners and telehealth bans, are impeding access.
