Voluntary assisted dying training for medical practitioners

Martha: So, what are my options?

Doctor: What do you mean by that, Martha?

Martha: Well, I've been dealing with this for so long and I'm so tired of doctors, hospitals, treatments. I just want to go home and die.

Doctor: Have things changed?

Martha: Well, it's basically all over for me, so isn't there some way that we can speed this up? I couldn't handle a slow decline and maybe choking to death. I don't see the point in a couple of extra months just slowly dying.

Doctor: What are your main concerns?

Martha: I guess it's just all getting too much. I mean, I can't do the things I enjoy anymore. And I have to depend on other people to do things that I used to be able to do so easily, all by myself.

Doctor: Hmm.

Martha: I can't eat properly, I can't remember the last time I had steak. I don't know, it's just... I feel like I'm just sitting around, waiting to die. And I can't remember the last time I had a good night's sleep.

Doctor: There are certainly things we can do to help with your sleeping, Martha. There's medication we can give and relaxation exercises, a whole range of things. And there's also things we can do to help with your diet. So, if you're happy, I'll refer you off to the dietitian, who can give you some suggestions about that.

Martha: Well, that sounds good, but right now I just would like to know my options in terms of you helping me to die. I read that there are laws regarding this.

Doctor: Yes, Martha, the law has changed. If you want to access voluntary assisted dying, you need to meet certain criteria. So, you have to have a terminal illness, like you do have, but you have to make a formal verbal request to your treating doctor. So, I know you're seeing Gary after you've seen me, so if you want to ask him that question, you can. There's quite a process that you need to go through to decide if you're eligible. But I can give you some information on that if you'd like. And once you've been through that process, I will continue to support you, whether you go ahead or you don't. On top of that, I'll talk to the rest of the team about getting some extra supports in for you and about maybe getting you some counselling support as well. How would that be?

Martha: OK, that'd be good.

Dr Peter Hunter: Assessing decision-making capacity is a critical part of a medical practitioner's work, and something we do every day, often without thinking about it. Every time we have a discussion with a patient about their treatment options and they consent to treatment, you make sure the patient understands the decision they are making. Like any other medical treatment or other treatment decisions around end-of-life care, a person must have decision-making capacity to make a choice to access voluntary assisted dying. This requires you to consider four things. Does the person understand the information being provided about voluntary assisted dying? Can the person retain this information? Can the person use or weigh this information as part of their decision-making process? And can the person communicate this decision?

To assess these four points, you should have a conversation with the person about voluntary assisted dying. The simplest way to do this may be to ask the person what they understand about voluntary assisted dying. Listen to their response and assess their understanding of the information. Red flags may include a failure to understand their condition or not being able to identify their other treatment options. Then ask the person why they want to access voluntary assisted dying. Remember that it is not your job to assess whether the person is making a good decision. It is your job to assess whether the person is using the information about voluntary assisted dying to make a reasoned decision. If a patient keeps reversing their decision or cannot express their decision in a consistent way, this may indicate a lack of decision-making capacity. The person must be able to communicate their decision, but this does not have to be orally. People communicate in a range of different ways and should be supported to do so. Other health practitioners, such as speech pathologists, might be able to help in these circumstances, but it is important that a person is communicating their own reasons and someone else is not filling in the gaps.

Dr Peter Hunter: The end of a person's life may be a very stressful time. People approaching the end of their life may require a considerable amount of care, and this may place a strain on families and carers. The decision to access voluntary assisted dying must be a voluntary and informed decision made by the person themselves. This does not mean the person cannot discuss their decision with their family or carers, but care must be taken to ensure the person is not being pressured by others.

We, as doctors, should already be alert to coercion in a range of healthcare decision scenarios, for example which treatment, if any, should a patient undergo and whether surgery is the best option for a particular condition. Families and carers can apply pressure to patients in any of a number of situations. You should always ensure there is sufficient time to discuss and understand the reasons a person is requesting voluntary assisted dying. These discussions will provide insight into the person's concerns and why they think accessing voluntary assisted dying will address the suffering.

If a person requests access to voluntary assisted dying because they are concerned they are a burden on their family, you should explore their situation. This may include looking at other options for supported care or respite care. You should also explore why the person has raised this concern and what they mean by it. Some people may say they feel like they are a burden to family because their family are struggling. Others may use this as a way to start a conversation about their struggles with their current situation.

Other indicators of possible coercion, often detected during a consultation with carer present, could include excessive deferment by patient to carer for answers, reassurance and explanation, carer talking over the top of patient and answering on their behalf, inconsistencies in patient's answers to questions from the doctor about suffering, disease experience and voluntary assisted dying in general. For this reason, it might be helpful to talk with the patient away from their family or usual carers to see if there is potential coercion.