Throughout history, many have suffered a slow, painful and undignified death. Some have taken their own lives in lonely, often violent circumstances. Sadly, this is still all too common. It is only in the past 50 years that medical attention has been focused on this last stage of life.

Despite much progress, some patients still suffer a ‘bad death’. Figures from the University of Wollongong’s Palliative Care Outcomes Survey suggest that over 5% of palliative care patients fall into this category.1

Strategies for such patients have included avoiding futile intervention and the withdrawal of life-supporting treatment. In addition, the ‘doctrine of double effect’ allows for medication that, while relieving suffering, may hasten death.

Dr Peter G. Beahan

Terminal sedation (TS) stems from this. While it may be defensible in the courts, TS is a form of assisted dying not exempt from a charge of murder under the Criminal Code.

Another type of assisted dying is Voluntary Assisted Dying (VAD), where the physician provides the necessary means, as specifically requested by the patient. This previously taboo subject has undergone reappraisal, driven by:

  1. Diagnostic and prognostic certainty of a high degree.
  2. Management options able to prolong life without necessarily including its enjoyment.
  3. Medications that can provide a painless dying process.
  4. Community demand that has reached a critical point.
  5. Attitudes that have moved in a more kindly, less judgmental and less patronising direction.

The case for VAD is based on the right of individuals to autonomy and dignity with respect to their personal lives. The World Medical Association’s Declaration of Geneva was recently updated to include: I WILL RESPECT the autonomy and dignity of my patient.

The difference between TS and VAD is contrived rather than real.

The fine line between intention to relieve suffering and intention to end life is so fine as to be apparent only in the mind of the physician. It is not measurable, transparent or accountable.

In application, there are differences:

  1. With TS, timing is prolonged and uncertain. The patient may linger in a semi-comatose state, dehydrated and deteriorating.

With VAD, the process is quick and certain. The patient makes a personal decision while dignity and purpose are intact. This is both a rational and a mentally healthy choice.

  1. With TS, documentation is cryptic and statistical information difficult to collect. There is no regulatory framework.

With VAD, documentation is clear, frank and open to scrutiny.

  1. With TS, death can be a trial for all concerned, and remembered with guilt and horror.

With VAD, death is remembered with reverence and thankfulness – a fitting end that rounds off a special life.

  1. With TS, the decision is made by the physician.

With VAD, the decision is made by the patient.

Most opposition to VAD stems from faith-based beliefs. Such beliefs are often subliminal, undisclosed and unacknowledged. Even the double effect doctrine (itself a religious concept) rests uncomfortably with some, and is not always applied.

The bulk of the population prefers government to follow a path based not on dogma, but on reason, evidence, science and fairness. Over 70% of those who identify as Catholics and of those who identify as Anglicans, support VAD.2

The word “suffering” suffices to cover the whole gamut of what motivates a patient to seek VAD, including existential considerations. Pain is not at the top of the list of motivating factors.3 More common concerns are those of losing independence and autonomy, of losing dignity, of being unable to carry out usual activity and of being a burden on others.

There are other benefits of VAD:

  1. Giving a patient the option of VAD can greatly relieve anxiety. Over a third of patients granted access to Nembutal never actually use it.4
  2. Giving patients control over the timing of death can make parting with loved ones easier to organise and to cope with.
  3. Retaining consciousness up to the point of death allows for communication that can have an easing effect on the process of ‘letting go’.

Among points of opposition to VAD are:

  1. That better funding for palliative care is the answer.

But funding cannot be expected to reduce the residual proportion of ‘bad deaths’ that occur even in the best-run centres. Funding can help access problems, and should be suppported.3 We see VAD not as an alternative to palliative care; rather, it is a natural, fitting and complementary part of the spectrum of service that should be available to the dying patient.

  1. That pressure may be applied to the patient by family members, or other interests.

In his study of overseas jurisdictions, Andrew Denton came to the conclusion that this was a near impossibility. Nevertheless, we recommend monitoring, and case review, as occurs overseas.

  1. That of a ‘slippery slope’ and of ‘normalisation’.

These are largely unsubstantiated fears. Increasing uptake may just reflect the unmet need.

  1. That VAD will ruin the doctor-patient relationship.

On the contrary, the empathy and consideration given is much appreciated by the patient and loved ones.

Support for VAD in the WA community runs at 88%.5 Support among other doctors is also strong, running at about 60%.

Once VAD is legalised, it is likely that a greater number of doctors would be willing to support it publicly. There is every reason to believe that VAD would be seamlessly embraced. Those who do not wish to participate would be fully respected.

Dr Peter G. Beahan, in collaboration with Doctors for Assisted Dying Choice (WA) – Dr Alida Lancée, Prof Max Kamien, Dr Richard Lugg, Dr Roger Paterson and Dr Ian Catto

References:

  1. Connolly A. et al. (2017) Patients Outcomes in Palliative Care: Results for Western Australia, July-December 2016 Palliative Care Outcomes Collaboration, University of Wollongong
  2. 2007 Newspoll Survey
  3. ABC News 3 Dec, 2017 Euthanasia: it’s not just about unbearable pain, it’s about self-determination, expert says
  4. Callinan The Hill 25 Dec 2017 Allow Modern Medicine to Relieve Agonizing End-of-Life Experiences
  5. Roy Morgan Survey 10 Nov 2017, Finding No 7373
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