In 2022, the New South Wales Parliament passed the Voluntary Assisted Dying Act (henceforth “the Act”). The passage of the Act allows for “persons with a terminal illness” – i.e., one which will cause death at most within half a year (one year for non-dementia neurodegenerative conditions) – for which they experience inadequate relief and intolerable detriment to their quality of life, to make what is termed an “enduring request” to enter the voluntary assisted dying process, and ultimately for their life to be ended either by themselves or an approved medical practitioner.1 The New South Wales Parliament passed the Voluntary Assisted Dying Act, following in the footsteps of other Australian states like Victoria, which legalized voluntary assisted dying in 2019, and allows individuals with terminal illnesses to request assistance in ending their lives under strict regulations.2
The passing of such legislation has raised various challenges and implications for healthcare professionals, including nurses who anticipate impacts on their practice.3 Additionally, the Act has prompted discussions among geriatricians regarding their attitudes towards voluntary assisted dying.4 The introduction of the Voluntary Assisted Dying Act in New South Wales aligns with the broader trend of assisted dying legislation globally. Countries like Germany and New Zealand have also been considering or implementing similar laws.5 As the Act is implemented, it is crucial to consider the perspectives of healthcare providers, including doctors, who play a central role in the regulation and administration of voluntary assisted dying.6
The Act's impact on patients and their families, particularly in cases where institutions may object to assisted dying, is also a significant area of study. Understanding the barriers and facilitators to accessing voluntary assisted dying under the Act is essential to ensure that individuals who qualify for such assistance can navigate the process effectively.7
A recent survey of health practitioners in New South Wales found that while approximately three-quarters of the survey population were in favour of the legislation, this proportion was higher among allied health practitioners and nurses, and that less than half of medical practitioners surveyed were willing to play any part in the process.8 It is worth noting that a provision is made in the Act for practitioners to be able to conscientiously object and remove themselves from a patient’s application at any point, e.g., by refusing a patient’s first request.1 The reasons for why a medical consultant might wish to do this are largely unexplored, and while acting as co-ordinating, consulting or administrating doctors in the process is optional, the Act is at pains to state that normal medical care should continue as it otherwise would.1,8
Palliative care is a crucial component in addressing the physical, emotional, and psychological needs of patients with advanced, incurable diseases. The Lancet Commission on Palliative Care and Pain Relief has emphasized the significant gap in pain relief services globally, highlighting the essential nature of pain management in palliative care.9 Pain relief is a fundamental aspect of palliative care, aiming to provide comfort and minimize suffering for patients nearing the end of life.10 Research has indicated that adequate management of pain and other symptoms is a fundamental aspect of palliative care and is recognized as a key element of a 'good death'.11 For many patients – and their families – one of the major reasons for supporting voluntary assisted dying in principle is the prospect of long-term unmanageable pain.12 An important corollary for some patients involved in the process, however, is that a reduction in or lower level of pain can be a factor in the withdrawal of an application for voluntary assisted dying. Arguably even more importantly, the availability of alternative (palliative) treatment options – and by definition, treating doctors’ knowledge of them – is also correlated with withdrawal from the voluntary assisted dying process.13
Chronic pain is a common issue in palliative care, necessitating attention from healthcare providers and family caregivers to ensure effective management.14 The World Health Organization (WHO) defines palliative care as an approach that focuses on early identification and comprehensive assessment and treatment of pain and other physical, psychosocial, and spiritual symptoms.15 Studies have shown that pain is associated with the endorsement of euthanasia and the desire to die.16
Addressing pain relief and palliative care within the framework of voluntary assisted dying necessitates a comprehensive understanding of the ethical, legal, and practical considerations involved. Ensuring that patients receive appropriate pain management and palliative care remains a cornerstone of end-of-life care, irrespective of the specific circumstances surrounding end-of-life decisions. The multidisciplinary approach in palliative care integrates pain management as a core component in treating cancer patients.17 Specialized palliative care interventions have been shown to lead to improved pain relief and overall quality of life for patients with advanced diseases.18
The willingness of healthcare professionals, including palliative care providers, to engage in euthanasia or physician-assisted suicide varies. While some professionals may be open to performing euthanasia under certain circumstances, the majority express reluctance towards these practices.19 Specialty and training also influence healthcare practitioners' attitudes towards end-of-life decisions, including euthanasia.20
Actual Case
In adherence to ethical standards, informed consent has been obtained from the patient, as is required for studies involving humans. A man in his eighties was admitted to a private hospital in New South Wales for elective arthroplasty of his right hip secondary to progressive osteoarthritis. He soon developed abdominal pain and was diagnosed with a-calculous cholecystitis, for which a cholecystectomy was performed. While he was recovering from this, the patient’s hospital stay was then further complicated by a (likely vasovagal) syncopal episode, requiring a permanent pacemaker insertion. He became severely deconditioned during his subsequent admission to the intensive care unit, and was deemed to be unfit for further surgery. He requested that his treating doctor cease all medications, and after referral to the palliative care team, it was clarified that he was making a formal request for voluntary assisted dying.
Possible Courses of Action
The Act is at pains to explicate that even once a patient has made a request to engage in the voluntary assisted dying process, it is their right and they are entitled to medical treatment as any other patient would be – especially with regards to the palliation of otherwise intolerable symptoms, such as pain1. For many years, medication has been the mainstay of pain control – including opioids, upon which there has been a growing reliance around the world to the point of well-documented large-scale dependence at a societal level (e.g., in the United States of America).21
Given that there were early signs that the patient was suffering from opioid toxicity, this would not have been a beneficial form of pain relief, and while his voluntary assisted dying request was being assessed, other paths needed to be pursued.
Formulation of Plan
Initial management for the patient included involvement of his immediate family in the voluntary assisted dying process, as well as medication changes to optimise pain control and referrals to the hospital’s pastoral care programme. The patient was counselled not only regarding the necessity of rationalising his pain medications (even while his voluntary assisted dying application was being processed), but also that a pain intervention would constitute reasonable care in his case. The hospital’s interventional pain team was consulted and the patient was subsequently offered radiofrequency ablation of the right hip.
Outcome
After some thought and discussion with his wife, the patient was agreeable to radiofrequency ablation of the right genicular and femoral nerves, which was performed as a day procedure. There were no complications, and the patient reported a significant improvement in pain control and mobility subsequently, to the point that he asked for his application for voluntary assisted dying to be withdrawn. His medical issues resolved to the point that he was able to undergo his hip arthroplasty and be discharged home soon after.