We, the undersigned Past Presidents of AMA Queensland, wish to highlight significant matters of concern in the current proposed legislation regarding Voluntary Assisted Dying (VAD) to come before the Queensland Parliament. Whether individuals are opposed to or supportive of VAD these are unacceptable risks in the current proposed legislation.
- The insufficient skills required of the co-ordinating and consulting doctors is inconsistent with good medical practice and the principles of informed consent.
- Making eligibility conditional on an estimate of twelve months until likely death from a disease provides significant risk of inaccurate assessment.
- The impositions regarding institutional conscientious objection are not consistent with accepted principles of provision of care and of choice and thereby pose a risk to those seeking VAD, as well as other patients, residents and staff of institutions with a conscientious objection.
- The underlying assumption that every Queenslander approaching end of life can access palliative care cannot be achieved
1. The required skillset of the co-ordinating and consulting practitioners
Under the proposed legislation the co-ordinating and consulting doctors are not required to have any expertise in the particular disease, illness or medical condition that will cause death, nor in end-of-life care of patients (palliative care).
Doctors who have no or very little expertise in that area of medical practice will decide on life expectancy, the counselling and care of the vulnerable patient and the assessment of competence. This is contrary to best medical practice and it presumes that the medical practitioner will always act appropriately with knowledge commensurate with their decision-making power. This does not provide appropriate protection for the vulnerable with a terminal illness because it does not ensure that a patient has been adequately informed about possible treatments and palliative care options.
2. The estimate of a twelve-month timeframe until death is likely to occur as a result of the disease process.
Part 2 10 (1)(a)(ii) states that a person is eligible for access to voluntary assisted dying if the person has been diagnosed with a disease, illness or medical condition that is expected to cause death within 12 months.
The closer a patient comes to dying the easier it is to give an accurate assessment of life expectancy. Giving an accurate assessment 12 months prior to death is a difficult task even for the most experienced doctor – let alone one that has little or no knowledge of the disease’s progress or end of life care.
Furthermore, access to appropriate palliative care which includes physical and mental health, may not be available at 12 months prior to death even if it is available in the few months before death. As is the case of point 1 above, this inadequately protects a patient’s right to make medical choices based on appropriate and adequate information. A 12 month prognosis is too inaccurate to meet this standard.
3. The legislative conditions regarding institutional conscientious objection are not consistent with accepted principles of provision of care and of choice.
There are two groups that come under this section. It includes hospitals where patients are generally short stay and residential aged care facilities where residents are long term.
The proposed legislation states that institutions that have a conscientious objection to VAD must allow VAD doctors to attend patients in that institution’s facility. It also requires that decisions concerning patient transfer from that institution are left solely to the VAD doctor’s discretion. If the VAD doctor rather than the patient’s usual treating doctor decides the patient cannot be moved then the VAD doctor can ensure VAD occurs there in that institution despite it being known that VAD is contrary to that institution’s published ethos.
Patients and staff choose individual institutions to be treated in and work in often because of the published ethos of the institution. The choices made by these patients and staff are as worthy of respect as a patient who may chose VAD.
Seriously ill patients are transferred between hospitals in Queensland very frequently on a daily basis. Similarly, if in some unusual circumstance a patient who had fulfilled the requirements for VAD was taken by ambulance to a hospital where VAD was not undertaken then the transfer of that patient to another institution would be available. There may be a very rare situation in which this provided significant difficulties and this would need to be addressed on an individual basis at that time. In this circumstance the best decision-maker is the treating medical team not the VAD doctor.
It would be wrong for legislation to protect the choice of the one patient on a very rare occasion but disregard the choice of the many thousands of patients and staff who on a daily basis choose to be treated or to work in institutions that do not support VAD. Especially as transfer is a routine process that occurs regularly for many patients.
In aged care facilities, although the facility is considered to be the patient’s home, there is also an expectation that each resident will be respectful of the others around them. If an aged care facility that has a conscientious objection to VAD is forced to require each stage of the VAD process on their premises that could have a detrimental impact on other residents and staff who have chosen to live and work in that facility
Furthermore, the bill does not require that the aged care facility is informed that a resident may intend to undertake VAD; this will force institutions to abandon their duty of care. If a resident in such a facility completes VAD then the staff and other residents may of necessity be involved in the aftermath whether in the care of the deceased or their relatives or in the safekeeping, or otherwise, of the drugs used in VAD.
4. The ability of the underlying Principle 5(d) to be adhered to i.e. access to palliative care for every person approaching the end of life.
Currently and even with future funding promised to date this principle could not be adhered to in Queensland. It is of concern that one of the underlying principles of the legislation cannot be guaranteed into the foreseeable future. Palliative care services and resource funding is a critical issue.
Inadequate provision of, or access to, palliative care goes against the principle of respecting choice as the patient is not being given a choice of palliative care.