Conversations with Voluntary Assisted Dying Medical Practitioners (Voluntary Assisted Dying Board Annual Report 2022-23)

Deciding to participate in voluntary assisted dying as a medical practitioner is a personal and professional decision. Since the commencement of voluntary assisted dying in South Australia over 100 medical practitioners have registered to participate and more than 60 have completed the mandatory training to support access to voluntary assisted dying.

Dr Cuong Do, Medical Oncologist, Regional South Australia

Dr Cuong Do came to South Australia from Victoria where he had previously acted as a Coordinating Medical Practitioner in the Victorian voluntary assisted dying scheme. Cuong works across Whyalla and Pt Lincoln, and he says that his reason for choosing Oncology as his specialty was his desire to treat and cure people. Cuong is realistic however and recognises the limitations of medicine, and the importance of patient choice.

“I see it as an important service to people in the community.”

Voluntary assisted dying provides another end of life choice, which in his experience is used as an option when suffering is intolerable to the person. Cuong says he feels empathy for patients who seek this service from him.

“We cannot judge someone’s suffering, there are different levels of suffering and tolerance to suffering.”

While Cuong is happy to support patients who are seeking to self-administer the voluntary assisted dying medication, to date he has not engaged in practitioner administration. Not every medical practitioner will become a voluntary assisted dying practitioner and the Act makes this provision by respecting an individual health practitioners right to conscientiously object to participating in any or all of voluntary assisted dying. So how does Cuong manage this?

“I respect my colleagues views” I do, however, feel that voluntary assisted dying should be openly discussed. I do not want to make patients feel that it is a secret that they have to hide.”

Honesty between health professionals and patients contributes to best outcomes for both parties. Cuong is happy to accept referrals from his colleagues to support regional patients seeking voluntary assisted dying.

When considering the positives and negatives of being a voluntary assisted dying practitioner, Cuong says that this legislation is all about providing choice at end of life. It is more than the prescribing and taking of a medication, it is the process that he believes patients find most rewarding. People feel listened to and that goes a long way to alleviating anxiety.

Cuong recognises that people may find the actual process of voluntary assisted dying challenging. The time required to support a person on the voluntary assisted dying pathway is significant. Managing the expectation of the person, whilst navigating the rules of the legislation and meeting the administrative requirements are challenges that the Coordinating Practitioner must juggle.

“People feel empowered and in control of their own destiny.”

When considering the support services to assist the Coordinating Practitioner, Cuong is very complimentary of the Care Navigators, VAD Liaisons, Pharmacy Service and VAD Operations Team. These services provide a critical function in assisting medical practitioners to chase up documents, arrange telehealth appointments, support the practitioner with medication related questions and guiding both patients and medical practitioners through the voluntary assisted dying pathway.

Cuong’s final reflection is on the goodwill that exists for him to be able to support patients to access voluntary assisted dying. He sees the support from his employer as a key enabler to his involvement in being able to assist people seeking voluntary assisted dying as an end of life choice.

Dr Carolyn Lawlor-Smith General Practitioner, Adelaide

Dr Carolyn Lawlor-Smith, General Practitioner, is a valued voluntary assisted dying medical practitioner who is supporting patients to access choice at end of life. Carolyn encourages fellow GPs to consider adding voluntary assisted dying to their scope of practice.

‘Supporting patients who are exploring voluntary assisted dying is both a privilege and professionally stimulating. It is quite unlike routine general practice. There is a depth to the doctor patient relationship that emerges quickly as you explore the impact of a terminal illness on the patient’s life. Your obligation to explore and assess suffering means you really meet the person before you.”

Carolyn appreciates being part of a team. She works very closely with the SAVAD Care Navigator Service and Pharmacy Service and cannot rate their support highly enough.

Carolyn is clear that more medical practitioners are needed to support this valuable work. While the training is rigorous it is enjoyable. There is emphasis on the legislation, and the training uses case studies to illustrate the learning needs, and this makes the education real.

Dr Chloe Furst and Dr Peter Allcroft, Voluntary Assisted Dying Clinical Advisors

Dr Chloe Furst is a Geriatric Medicine Physician who also specialises in Palliative Medicine. Chloe works as the Head of Geriatrics at the Royal Adelaide Hospital.

Dr Peter Allcroft is Senior Staff Specialist at Southern Adelaide Palliative Service and is trained in respiratory/ sleep medicine and palliative medicine. Peter has worked with the Southern Adelaide Palliative Care Service for over 20 years and was instrumental in setting up the Statewide Motor Neurone Disease Clinic.

Both Peter and Chloe have been actively involved in the implementation of voluntary assisted dying. They were jointly appointed in their role as Voluntary Assisted Dying Clinical Advisors in July 2023.

What is it like to support patients through the Voluntary Assisted Dying pathway?

Both Peter and Chloe refer to the privilege of providing support to patients and their families as they explore an autonomous end of life journey. Chloe reflects on the transition from patient to person and describes how she at times encounters a vulnerable patient who is worried that their application for voluntary assisted dying will not be supported. When she confirms a patient’s eligibility, she sees them visibly relax and transform to a person who regains their strength and control.

Peter supports this by saying that providing voluntary assisted dying is the ultimate in providing person centred care. He expands this to capture the essence of non-abandonment in being able to support people along the full continuum of their end of life journey.

What have you found surprising about supporting patients to access voluntary assisted dying?

Chloe has been surprised by the diversity of people accessing voluntary assisted dying and inspired by how rewarding the work is and the strength that individuals show. Of significance for Chloe is seeing families who didn’t think they would be able to support voluntary assisted dying, change their mind in response to their loved one’s experience.

Peter has said he is pleasantly surprised at how well hospital staff have adapted to incorporating voluntary assisted dying into end of life care. Despite some nervousness at the beginning, clinicians are adapting to the availability of voluntary assisted dying as an end of life choice.

What have you found helpful?

Both Peter and Chloe mention the positive relationships between all voluntary assisted dying support services. The Care Navigator Service, VAD Liaisons, Pharmacy Service and VAD Operations Team all work together to ensure the person on the pathway progresses as smoothly as possible and their care aligns with the person’s wishes.

If you were able to change something what would it be?

Chloe and Peter both refer to the limitation on medical practitioners raising voluntary assisted dying as an end of life option with patients. Peter says that if a person is coming to him after they have been seen by a Care Navigator or VAD Liaison it is easier as he can speak directly about voluntary assisted dying, but for those that might approach him directly the conversation can be cumbersome and difficult.

Chloe says that this restriction means that the person may not be adequately informed. Chloe emphasises the importance of informed consent within the health system, and the requirement on medical practitioners to explore all options with a patient, noting this is not permissible under the legislation.

What advice would you give to medical practitioners considering adding voluntary assisted dying to their scope of practice?

Chloe says, ‘Do it, it might seem scary and strange to start with, but it is very rewarding.’ The assessment process gets shorter as you become familiar with the Voluntary Assisted Dying Clinical Portal and there are now Clinical Advisors here ready and willing to support new practitioners. Peter echoes this view and says that the support from the Care Navigators, Liaisons, Pharmacists, and the VAD Operations Team means that help and assistance is never far away.

Can you share your thoughts about the Community of Practice?

Chloe and Peter Co-Chair the Voluntary Assisted Dying Community of Practice in their role as Clinical Advisors. The Community of Practice is a safe place to share concerns and any learnings with a group of peers. It is an important forum to gain support and discuss difficult cases. It also offers the opportunity to take time to reflect on the important work and the relationships forming between the medical practitioners is supportive and proving to be very important.

Do you have any final thoughts you would like to share?

Chloe believes South Australia was set up well for voluntary assisted dying through the implementation process. There was extensive stakeholder engagement which meant a balanced view was always represented. Having committed clinicians available to support people to access voluntary assisted dying as an end of life choice is the foundation of a successful program.

The Review Board is grateful to Cuong, Carolyn, Chloe and Peter for sharing their thoughts, and recognises all clinicians involved in supporting people and commends them for the work they are doing to provide South Australians with this end of life choice.