Legislation for Voluntary Assisted Dying has now been passed in all Australian states. With the passage of the “Restoring Territory Rights” Bill this year, it is likely that VAD will soon be a legal end-of-life option for people in all of Australia.

 

Enactment of VAD legislation has not been without complexity. All states have subtly different eligibility requirements for patients seeking access and healthcare practitioners seeking to provide care. There are inconsistencies between clinicians in terms of assessment of prognostication. Widespread consultation has occurred in all regions during implementation, but this change has caused many to grapple with what is perceived to be a fundamental alteration to the ethical landscape.

 

The author will reflect on their journey from Emergency Physician, to agnostic VAD-trained practitioner, to advocate for VAD and Advance Care Planning as models that enable patients to access the care that is appropriate for them. 

Background:

The management and response to VAD in the community context and manner and timing of death of individual’s accessing palliative care and VAD requires further exploration.  The complexities surrounding palliative care services and voluntary assisted dying (VAD) have been well established since the Voluntary Assisted Dying Act 2017 (Vic) was introduced.

Aim:

To evaluate the experience of community palliative care clients participating in VAD and support other healthcare organisations in understanding and exploring this end-of-life choice.

Method:

Data was collected over a period of 45 months on community palliative care clients who had sought access to VAD. A retrospective analysis was then performed to assess the manner and timing of death of individuals. 

Results:

A total of 108 clients wanted more information about VAD during this period. These deaths were reviewed. Of those, 28 clients (26%) died from administration of the VAD substance. The median age was 70 years, 54% male, 46% female. All had a malignant primary diagnosis. Preferred site of death (PSOD) met was 100%. Median length of engagement with palliative care was 115 days. This equates to 1% of total deaths that occurred within our organisation. 

A total of 80 clients (74%) died without administration of the VAD substance. The median age was 69 years, 60% male, 40% female. Almost all (90%) had a malignant primary diagnosis.  PSOD met was 72%. Median length of engagement with palliative care was 90 days.  

Conclusions:

Palliative care is an important aspect of end-of-life care and can provide specialist support for individuals accessing VAD. Whilst all palliative care clients evaluated had access to VAD, only a quarter of clients died from administration of the VAD substance. Further evaluation and research to ascertain why the VAD substance was not administered for the remaining clients would provide greater understanding in this area.  

The speed of approvals for VAD within Queensland had an unexpected and immediate impact on the culture and commitment of staff within the Palliative Care Unit (PCU) and their “Continuum of Care”. 

 

Despite continuing discussions and education there was a lack of awareness of VAD principles by staff and the understanding of their rights, roles and responsibilities resulted in tensions arising across the unit and Multidisciplinary team.  This led to differing views and levels of acceptance by individual staff members. 

 

The services Palliative Consultants were one of the most challenged groups and emotionally distressed by the resulting dilemma.

 

Another presenting issue and underlying expectation within the Health Service is that any person who elects VAD could be managed within the PCU as the perception exists that PCU is skilled in managing the dying. 

Representing dignity for the deceased and family is of significance within the PCU. VAD has brought a different challenge around dying, the acceptance of that death and best way to care for families and carers as the result of the passing of a loved one.

 

·      Ongoing provision of information and training on the role of Palliative Care in the VAD process

·      Clear delineation of roles and responsibilities of PCU staff and VAD team.

·      Utilisation of Coverlet and hand held heart framed by community and cultural symbolism

·      Open team forums to address unresolved issues around VAD and what is culturally important 

·      Helping and supporting families in managing mixed feelings as recognising there was a definite end to a person’s life

·      Managing perceptions of VAD team

 

Although there is now much written about VAD, what is not published or readily available is how to deal with the emotional and ethical dilemmas that present to all members of the Palliative Care and how it was dealt with.

Introduction: 
Interstate data shows that 85% of patients accessing Voluntary Assisted Dying (VAD) are receiving palliative care. Palliative care providers may be involved in their patient’s VAD journey, including facilitating access to VAD substances by engaging pharmacy for efficient service delivery. Due to the vast geographical spread of palliative care patients across Queensland, the VAD pharmacy service model was developed to optimise service efficiency across urban and rural/remote areas. This study outlines the VAD pharmacy service model developed to suit Queensland geographical challenges.  

Aim: 
To outline the VAD Pharmacy service model implemented in Queensland.  

Methods:
The Queensland VAD service implementation team explored assisted dying pharmacy models of care published internationally. A literature review yielded studies exploring pharmacists’ and other health professionals’ perspectives on the challenges and benefits of centralised and decentralised pharmacy models. 

Additionally, the team evaluated skills required for pharmacists to deliver good quality palliative and end-of-life care to patients accessing VAD. 

Results:
Based on the findings, a centralised VAD pharmacy service model was adopted to create time and cost efficiency, and a central point of contact for all referrers including palliative care providers. 

To enable VAD pharmacists to be highly skilled in supporting patients at end of life, the pharmacy stream lead was recruited from the palliative care sector and all employed pharmacists are provided with extensive palliative care training. This includes: 

1.       Over 76 hours of palliative-care related orientation training

2.       Continuous palliative care-related pharmacy education such as
-          Journal clubs

-          Professional developments

-          Structured debriefing sessions

-          Supervision 

-          Multidisciplinary case conferences 

 

Discussion:
A centralised pharmacy service supports a cost-effective and time efficient service model that has the advantage of trained specialist palliative care pharmacists employed to provide streamlined and responsive support to referring services including palliative care providers and their patients. 

Background: Voluntary Assisted Dying (VAD) commenced in South Australia on the 31st  January 2023 after an 18 month implementation process. The Legislation is promoted as conservative and provides multiple safeguards for patients. Consequences for breaching these safeguards (even accidentally) can range from a report to the Medical Board to fines or imprisonment.

In order to ensure safety and confidence for staff and patients at our Local Health Network an extensive education program has been undertaken.

Although not administering VAD, new medical graduates commencing as Interns may well find themselves at the forefront of patients requesting VAD and need to have a process for addressing this.

Aim and Method: To gain an understanding of the knowledge and concerns of new medical graduates about VAD, a de-identified survey was undertaken during their Orientation week, which included a presentation on VAD.

Results:  78 new Interns commenced at Flinders Medical Centre in 2023. The majority of these are South Australian Medical Graduates with no prior exposure to VAD, and 80 % are aged between 20-30 years of age. Most (80%) had very little or no teaching around End-of-Life care in the curriculum, and only 7% had received prior education around VAD. The majority (90%) had considered their personal stance on VAD, but in contrast a minority had thought about the potential roles around VAD that they may be asked to undertake. Of concern a small number believed it was legal to raise the topic of VAD with a patient, which puts them at risk of an automatic report to the Medical Board (AHPRA).

Conclusion: The results of this survey demonstrate the critical need for education and support around end-of-life care, and the myriad complexities associated with VAD to ensure safety for patients and staff.

Background
Voluntary assisted dying data from services across Australia shows that majority of people seeking VAD are concurrently receiving palliative care, suggesting that effective, quality end-of-life care would be advantaged by seamless collaboration between palliative care and VAD services. 

Aim
To present an exemplar case study incorporating collaboration between VAD services and palliative care resulting in optimal patient and family outcomes. 

Method
This case study describes the cross-service management of a 47-year-old male patient diagnosed with metastatic colorectal cancer. The patient was known to a specialist community palliative care team for over one year, where he received ongoing symptom management and psychosocial support for himself, his wife and his three children. 

Results
Prior to the introduction of VAD in Queensland on 1/1/2023, the patient discussed the possibility of VAD with palliative care staff.  When VAD was legalised the palliative care staff referred the patient to the VAD service. The patient provided consent to allow both services to discuss his condition and provide on-going care. After he was assessed as eligible for VAD, palliative care staff addressed both his and his family’s VAD questions. Both services remained in close communication, delivering an effective working relationship and integrated care. The patient was able to self-administer the VAD substance in his home in the presence of his family. The palliative care service then provided bereavement care for the family.

Discussion
This case demonstrates how a collaborative approach between specialist palliative care and VAD services can result in quality end-of-life care for palliative patients seeking VAD. 

The patient’s request to access VAD triggered a cascade of collaborative service interactions aimed at accommodating his preferred place, time and manner of death. 

Such case studies could be used to inform guidelines that highlight barriers and enablers in the context of patient care and effective interservice collaboration.