Pain Management's Influence on Voluntary Assisted Dying Decision-Making

Abstract

Background: Voluntary assisted dying has only recently been legalised in the Australian state of New South Wales. Clinical judgement must be exercised by the doctors of patients requesting voluntary assisted dying, regarding the likelihood that the patient’s condition is terminal and that no adequate relief or management can be provided to them. Actual case: An elderly man, with multiple comorbidities, experienced functional decline and worsening of osteoarthritic right hip pain following the cancellation of a total hip arthroplasty. Due to this and medical complications deeming him unfit for surgery, the patient expressed a wish to initiate the voluntary assisted dying process. Pharmacological analgesia was ineffective in controlling his pain. Possible courses of action: Applications for voluntary assisted dying may come from any patient. The application needs first to be supported by two physicians, before independent review; adequate pain management should occur simultaneously to preserve the patient’s quality of life as much as possible. Formulation of a plan: The patient was supported in his decision to begin the voluntary assisted dying process, but education was also carried out regarding pharmacological and non-pharmacological methods of pain management. After some thought and familial input, the patient was agreeable to an interventional pain referral, and later consented to radiofrequency ablation of the right genicular and femoral nerves. Outcome: Following radiofrequency ablation, the patient reported a significant decrease in his hip pain, and an improvement in his quality of life; he elected to cease the voluntary assisted dying process. Discussion: The presence of pain is a key factor in both quality of life and a patient’s perceptions of such; this has major implications where voluntary assisted dying is concerned. Interventions such as radiofrequency ablation are minimally invasive and can often have significant impacts on improving mood and quality of life. Conclusions: Interventional pain management is an important management tool in improving the quality of life of patients, especially in a palliative disease stage. It may lead patients to reconsider programmes such as voluntary assisted dying, which are still poorly understood by many inside and outside of the health profession. Education of doctors and medical students on the presence and role of interventional pain specialists should be undertaken.