Update on voluntary assisted dying in Australia

More research is needed to ensure safe and unimpeded access for eligible applicants and to inform practice

We now have two years’ experience in providing voluntary assisted dying to terminally ill patients in Victoria. Western Australian legislation will come into force on 1 July 2021; Tasmanian legislation has received Royal assent, and the early stages of implementation are underway. The South Australian Voluntary Assisted Dying Bill has been passed by both Houses and may have been sent for Royal assent by the time this article is published. The Queensland Law Reform Commission report and draft bill1 were tabled in parliament on 18 May 2021; a bill is expected to be tabled in the New South Wales parliament in late 2021. There have been calls for the Commonwealth to repeal the Euthanasia Laws Act 1997 to reinstate Australian territories’ rights to debate voluntary assisted dying legislation.

Given the differences in legislation between states, and therefore variations in practice, comparative research is needed to facilitate evidence‐based legislative review and modifications of practice. It is time for voluntary assisted dying to be viewed similarly to other areas of medicine, and for debate to be based on evidence, rather than emotion or personal viewpoint. Aspects such as changes in community perspectives, impact on health care providers at the individual and organisational levels, as well as assessment of patient‐reported outcome measures and the effect on grief and bereavement experiences for close contacts are crucial to refining how this service is provided. Funding for such research is unfortunately scarce: grants for studies of end of life care often explicitly exclude research focused on voluntary assisted dying.2

Willmott and her colleagues are to be applauded for their contribution to understanding voluntary assisted dying in practice, published in this issue of the MJA.3 The themes described in their article are subject to rapid change. For example, concerns regarding the Statewide Pharmacy Service have been met by streamlining prescription delivery and increased staffing. Dispensing remains problematic for cases outside business hours or metropolitan areas. The Voluntary Assisted Dying Review Board (VADRB) has responded to concerns about the online portal with steps towards its redesign, the results of which are eagerly awaited by practitioners.

The most recent VADRB report states that 4.1% of applicants for assisted dying spoke languages other than English at home.4 This may reflect cultural differences in end‐of‐life care, but health care education, particularly for marginalised groups, often takes place during one‐on‐one consultations. Removal of this core mode of patient education may reinforce socio‐demographic differences in health care awareness and access. Inadequate education in the broader health care community means many health care professionals are unclear about their responsibilities and limitations, leading to unease with the topic and perpetuation of the stigma attached to voluntary assisted dying.

The risk of contravening Commonwealth law5 by discussing assisted dying via telemedicine has been a major impediment to equitable and timely access, particularly during the COVID‐19 pandemic. Although the VADRB reports indicates that demand for the service is being met, the toll on the doctors who were involved in the system early is palpable, amplified by the added threat to both patients and doctors of attending patients’ homes and nursing homes during COVID‐19 lockdowns. Research from the World Federation of Right to Die Societies suggests that using telemedicine in voluntary assisted dying assessments would be in keeping with the international response to the pandemic.6 Lack of clarity regarding the appropriateness of telemedicine for assessments will be more problematic for states with large, geographically dispersed populations and centralised health care workforces.

Victorian legislative problems include documentary deficiencies; as they are stipulated by the legislation, they require legislative amendment to modify. Two cases have been referred to the Victorian Civil and Administrative Tribunal for determining residential eligibility because the governing Act is unclear.7,8 Medication for self‐administration must be returned before an application for practitioner administration can be submitted,9 causing delays for eligible patients who have lost the ability to administer the medication. If the coordinating and consulting medical practitioners are unable to undertake intravenous administration, several steps must be repeated to introduce a third practitioner. A review of the legislative problems encountered in the application of the Act is currently scheduled for the fifth year of its operation (2023).

Process problems include the model of care pathways for health services;10 most organisations have identified as “pathway C” organisations (information and support service only) and adopted a case‐by‐case approach to patient care. The average time for voluntary assisted dying training is four hours, and fewer than half the doctors who register for online training progress to registration on the portal.11 Training is generally unfunded, unprotected time, and continuing professional development (CPD) points are not approved. Training assessment is not focused on the practical knowledge required for voluntary assisted dying assessments. Interactions with palliative care continue to be problematic. Many institutions prohibit assessment, medication dispensing, or administration by or to inpatients;12 some have been accused of withholding standard‐of‐care services from patients who choose to pursue voluntary assisted dying.13

Voluntary assisted dying will eventually be available in all Australian states and territories. The Victorian experience has not been perfect, nor should it have been expected to be. Research needs to be funded, conducted, and promoted, to ensure safe and unimpeded access to voluntary assisted dying for eligible applicants, to inform practice, and to allow other jurisdictions to learn from accumulated experience.