Voluntary assisted dying in the Australian state of Victoria: an overview of challenges for clinical implementation

Abstract

On 19 June 2019 the Voluntary Assisted Dying Act 2017 (Vic) came into effect, making Victoria the first state in Australia to permit the practice of 'voluntary assisted dying'. As defined in the legislation, voluntary assisted dying refers to "the administration of a voluntary assisted dying substance and includes steps reasonably related to such administration", "for the purpose of causing a person's death". In essence, the model of voluntary assisted dying established in Victoria is designed for patients within the final weeks or months of life, who may receive medical-assistance to 'choose the manner and timing of their death'. The purpose of this paper is to overview the clinical implementation of voluntary assisted dying in Victoria, attending to three broad challenges: balancing tensions in policy goals and ensuring the legislated 'safeguards' function as intended, translating the complex legislation into clinical practice, and managing conscientious objection to voluntary assisted dying. While there is somewhat limited information available regarding the practice of voluntary assisted dying in Victoria, available data and anecdotal reports indicate the implementation of the state's complex model of voluntary assisted dying has not been without challenges, particularly in terms of balancing the legislated 'safeguards' and patient access to voluntary assisted dying, and translating aspects of the complex legislation into clinical practice. The release of more systematic voluntary assisted dying data by the state, alongside independent research into the operation of voluntary assisted dying, is necessary to better evaluate the implementation and impact of voluntary assisted dying as a new component of clinical practice.

The End of Life Choice Act: A Proposed Implementation and Research Agenda

“…9,16,17 Recommendations from this literature include: establishing working groups led by experts overseen by a dedicated implementation taskforce to ensure alignment across groups; creating models of care that illustrate varying levels of organisational participation in providing AD; step-by-step clinical guidance; mentoring and training for providers; accurate consumer information; a centralised medication service; transparent data and government-funded independent evaluation research; and regular communication and meetings between Ministry and relevant organisations/stakeholders. 1,5,9,14,16,18,19 Designated local contacts from the health services could be established as a productive conduit for information between the Ministry and health services. 9 This could help ensure effective implementation at the coalface and also provide feedback about feasibility of different aspects of the process in practice.…”

“…The Australian state of Victoria funded a "navigator" service 9 (as did Western Australia) as a proactive approach to enable providers and consumers to understand and engage with the statutory process. New Zealand should draw on the experience with the challenges in Victoria 3,5,6,15,24,34 and Canada 18,19,35 to ensure access to legally available AD is not unduly hampered by process which does not materially enhance the safety of the system. There are procedures, forms and documents required at each step of the process.…”

“…Compliance with the procedural steps and safeguards is important, but if they are disproportionate or bureaucratic, this can present barriers to access for eligible patients and deterrents for providers, without actually improving safety. 1,5,6,15,24,34 Research from overseas suggests safeguards and processes, each of which have merit on their own, when put together can become burdensome for those involved and may undermine the stated aim of the law, to establish a lawful process for assisting eligible persons to request medical assistance to end their lives. 3,5,6,15,18,19,24,34,35 The Act does not prescribe the availability of clinical ethics advice when there is a moral or ethical dilemma.…”

“…1,5,6,15,24,34 Research from overseas suggests safeguards and processes, each of which have merit on their own, when put together can become burdensome for those involved and may undermine the stated aim of the law, to establish a lawful process for assisting eligible persons to request medical assistance to end their lives. 3,5,6,15,18,19,24,34,35 The Act does not prescribe the availability of clinical ethics advice when there is a moral or ethical dilemma. Healthcare practitioners and other stakeholders will require access to a multi-disciplinary clinical ethics advisory group to assist in analysing the decision-making dilemmas that will inevitably arise.…”

“…1 Health practitioners will need written guidelines for responding to requests for AD, procedures for providing AD and support for the clinical dilemmas that will inevitably arise, some of which are discussed below. [2][3][4][5][6] Patients and families will also need significant support; 7,8 their concerns are not the focus of this article. This article outlines the Act, highlights key implementation issues and identifies priorities for research.…”