Voluntary Assisted Dying clinician series

The Voluntary Assisted Dying (VAD) Clinician Series explores VAD from a clinician's point of view and provides advice about being involved with VAD. The series includes insights from Victorian and Western Australian clinicians.

VAD Clinician Series: 1. My involvement in VAD

Transcript for VAD Clinician Series - 1. My involvement in VAD

Dr Clare Fellingham

Really it's two-fold–it's people, the motivation to do this work, and it's suffering and it's the interplay of how suffering affects individuals.

Dr Gareth Wahl

Working in the emergency department, I've had lots of experiences of people dying badly. Dying badly, dying in ways that they didn't want, in situations where their family may or may not be able to be there, where really the whole thing just doesn't go as that person would have wanted, if they had had the opportunity to sit down and talk about what they wanted.

Dr Cameron McLaren

I finished my medical oncology training the year that the VAD legislation went live in Victoria and when it became active I just thought it was something that we were all going to do because this is part of patient-centred care. And managing cancer patients, we really deal with them from diagnosis until death and this was going to be something that our patients were going to ask for.

And so, I thought it was expected of us to really get involved and support our patients through it.

Meg Plaster

Working for over 30 years in cancer as a cancer nurse and having been involved with and witness to often death and dying in people with cancer and seeing many deaths and not all of them beautiful. And I think also being involved in supporting families in sometimes quite traumatic bereavement after that and once this legislation became available in Western Australia I was pretty committed to… once the roles became available, to being involved in supporting people to access a different way of dying.

Dr Cameron McLaren

I got involved in voluntary assisted dying quite early and I had one of my own patients go through the process in the first, say, ten patients in the state. After that, I became aware that there were many patients who weren't able to be contacted with doctors who were trained, and they didn't really know where to turn. So, after speaking with the Victorian care navigators, they put me in contact with many other patients who required a specialist to assess them, and I fulfilled… fulfilled that role for them.

My involvement in voluntary assisted dying so far has been in providing both coordinating and consulting assessments to patients in Victoria. I've been involved in over 200 cases of application for voluntary assisted dying. I've been present at between 50 and 60 voluntary assisted dying deaths, in support of the patient and their family.

Dr Gareth Wahl

So I've been involved in a variety of roles. I've been the... the coordinating practitioner for lots of different people and the consulting practitioner for a variety of others. So, I've seen a bit over 100 people now and they've crossed all of the territories.

I am based in metropolitan Perth, but I've seen patients from my hospital catchment area, so up the northern corridor of Perth I've seen people down south, I've seen people in regional areas, so as far north as Kununurra and as far south as Albany.

So, you know, a couple of hour flight away and I've done all of the things from being... you know, writing prescription for somebody who has self-administered and didn't want me present and being involved with them and their family in the before and the after, through to practitioner assisted administration in all of those different locations.

VAD Clinician Series - 2. Personal experiences and professional learnings

Transcript for VAD Clinician Series - 2. Personal experiences and professional learnings

Dr Clare Fellingham

Working with people on a voluntary assisted dying journey is an incredible experience. It is humbling. It's inspiring. It's challenging. It's emotional, but it's so deeply moving and so meaningful to be able to support someone through very, very difficult decision making as they acknowledge that the end of their natural life is coming and they grapple with the reality of that and make choices that are appropriate for them.

Meg Plaster

So my personal experience in voluntary assisted dying is one of profound privilege, actually, it’s some of the most privileged work I think I've experienced in my career. Humbling is a word that I think is overused, but it's very humbling for people to trust us, to trust me, at one of the most intimate moments in their lives and for their families to trust me as well.

Dr Cameron McLaren

I think personally it's been very rewarding. It's been great to be involved and to try and offer these patients what they want. And it's not been as emotionally stressful, as I thought it might have been. I don't require a lot of debriefing because I believe in what I'm doing.

Prof. Michael Dooley

Professionally, the impact has been, I suppose, firstly rewarding, in being able to have a role in developing a voluntary assisted dying service in Victoria. We're acutely aware that with Victoria being the first state that we needed to put in safeguards that made sure patients had access, but at the same time doing that in a way that mitigated any risks there were.

We knew that if things didn't go very well in Victoria, associated with voluntary assisted dying, that would be a barrier to the further adoption elsewhere.

Dr Gareth Wahl

I found the first few experiences of particularly practitioner assisted administration confronting, but not in a way that I hadn't experienced in healthcare generally. It's just that as you get further through your career, you've experienced a lot more things. So, things that you found confronting when you're a junior doctor, you don't find confronting when you're a consultant and you've spent years in training.

Dr Cameron McLaren

Being involved in voluntary assisted dying professionally was a concern at the start. I wasn't sure how, particularly my referrers in private practice or my employees in public practice would perceive my involvement in support of this.

Ultimately, it's been quite positive, actually. There have been a lot of doctors have been in favour and supportive of my involvement. It's not been something that everyone wants to be able to do, but they are very glad that the service is provided for them. So it hasn't affected me negatively in any way professionally.

Dr Clare Fellingham

So, from a professional perspective, this work, I won't lie, at the beginning was quite challenging, because I was well aware of the negative perceptions about voluntary assisted dying that exist, not just in Western Australia but across the world and particularly in amongst medical professionals. You know, the words ‘voluntary assisted dying’ is interchangeably used with ‘physician assisted suicide’, ‘euthanasia’, you know, they’re big words that conjure up very strong feelings and it's a very polarising subject.

It's quite divisive and it's morally controversial. It’s... It wasn't... I would be lying if I said it wasn't with a sense of trepidation that I began this work. But really what that catalysed me to do was, first of all, learn and explore and gather an immense amount of knowledge from around the world, where jurisdictions have legalised some form of voluntary assisted dying.

And then, to approach this with openness and honesty and support for all points of view, acknowledging how deeply challenging voluntary assisted dying, as well as just confronting our own mortality, can be and I think that has helped me move forward with more of a sense of professional conviction.

Dr Gareth Wahl

I think we all found that early time challenging, but rewarding. And I think, there were a few things that we put in place. So, we had regular community of practice meetings which provided a really great opportunity for us to all meet together, discuss our common experiences and to debrief and really get that feeling that I'm not alone in this.  I'm not the only one having this experience.

We also tended to do a lot of assessments together, and that's probably very different to what I'd experienced within the hospital system, where I would generally be a sole practitioner. You know, I was then going out to people's houses with perhaps a pharmacist or, you know, one of the navigators or my hospital co-ordinator and so we would always have, particularly in the early days, I would always have somebody with me for things like any practitioner administrations, particularly.

So, there was definitely support for me and I think it's a really great thing that that exists in Queensland.

Meg Plaster

Often in a situation, a professional setting, that they don't always understand or feel heard in a healthcare decision making sense and that's been a very different experience. So as a nurse, it's really… I think, has been very refreshing to see how we can all work together as peers in this space.

Dr Clare Fellingham

I've become less and less afraid and more and more willing to be an advocate, a champion and a part of this process, because I see unfolding before me, through the lives of the patients that I care for, the need for these laws and the immense amount of anxiety they reduce, suffering they diminish, and peace and dignity that they bring to people accessing them.

VAD Clinician Series - 3. Advice for working in voluntary assisted dying

Transcript for VAD Clinician Series - 3, Advice for working in voluntary assisted dying

Dr Gareth Wahl

So, my message to anybody who is considering or is eligible to be an authorised practitioner in Queensland would be, absolutely do it. You will be asked, is the other one.

So, I think when we started in Western Australia we often talked in sort of hypothetical situations of–you might get asked one day, you might, you know, a patient might come to you–a patient will come to you.

This is not the most common mode of death for people, but it is really common, you know, somewhere around, you know, a half a per cent of people will probably want to have voluntary assisted dying as their mode of death. And so, people will ask you and I think the... knowing how the process works, then it allows you to be the best advocate for your patient in accessing the care that they want.

Dr Cameron McLaren

So what I'd say to doctors and nurses who are considering voluntary assisted dying in Queensland is really to get in and do it. Early on, there's going to be a demand. There are going to be patients who have been hanging out for this legislation and when it goes live they're going to want to access it quickly.

Dr Clare Fellingham

I would say to anyone considering becoming a practitioner, walking with people on a voluntary assisted dying journey to just do it, go for it. It is amongst some of the most deeply moving and intensely emotional, but meaningful and rewarding work that I've ever done in twenty odd years of being a doctor.

Prof. Michael Dooley

Those considering getting involved, I think, need to understand the journey you're going to be involved in. So that's two things. One is understanding the journey of the patient and their loved ones and what voluntary assisted dying means and what is the reason that people are contemplating that. They need to understand that first.

Then, they need to understand their own journey, because I believe when I'm involved in this, I take away a little bit of the people I interact with and I leave a little bit of myself behind.

And so, I think it's a journey that you're involved in for the patients and the journey itself, and you have to contemplate both of those. And then when you've done that, then I think you can be in a place to consider whether that is something for you or not.

Dr Gareth Wahl

I would say lean in to any discomfort that you have, do the training and don't be afraid of having these discussions with patients. They're not difficult. They're not unfamiliar. They are the same things that you're already talking to people about and there is an honesty about having all of the cards on the table that then really allows a patient to talk to you person to person, and help... allows you to then help them troubleshoot and achieve whatever they want.

Meg Plaster

Looking at the legislation in Western Australia, to some degree we can have nurse practitioners as administering practitioners and in Queensland, registered nurses can become administering practitioners and that's weighty. And I think of all the things that I would want people to consider before they step into that space in good faith and for good intent, is­–are you ready?  Have you thought through what this will be like?

And I don't know that any of us can know that until we're there. And I've seen that with some of the practitioners in Western Australia. That it is... it's a heavy load to carry. Fulfilling, but one of my trusted medical practitioners said to me, I don't know that I could have done this much earlier in my career. Would I have had the personal development and professional development to understand the gravity of what I'm doing? I'm not sure.

Dr Clare Fellingham

It is challenging. I'm not going to lie. It's definitely confronting, it's emotional, it's labour intensive and it's... it varies, it fluctuates. So, you need to have a good framework to fit it into your professional life and you need to be aware of your own limitations, your own triggers, and have a great support network around you. But, that through assisting people to access voluntary assisted dying, you will learn so much and you will grow so much, that the balance of energy in versus energy out, provided you look after yourself, is significantly in favour of the positive.

Dr Gareth Wahl

On a softer level, it's enormously rewarding. It's hugely rewarding. And yes, it takes time and it's learning something different and something new and there is discomfort in being a practitioner who's exploring something that's different and new and unfamiliar. But, the rewards in terms of the satisfaction that you get from doing this cannot be overstated. There is always a bit of personal cost with being involved with a patient in this space, but the reward that you get from being involved in this space, vastly outweighs the cost.

VAD Clinician Series - 4. Patient centred care in practice

Transcript for VAD Clinician Series - 4. Patient centred care in practice

Dr Clare Fellingham

I think the fascinating thing about people accessing voluntary assisted dying is that there is no one type of person. Honestly, they come from all walks of life. I've looked after people who've left school before the age of 16, all the way through to people with multiple degrees, holding very significant jobs in positions of responsibility. People are quite united in one thing and it's a theme that recurs over and over again when we discuss voluntary assisted dying.  They are united in their bravery and their courage.

They’re people who are typically quite self-determined and they want to have some control over their lives. And they’re people who are brave enough to acknowledge that the end of their life is coming.

Dr Gareth Wahl

My patients have all been people who have overwhelmingly had cancer. WA has been very similar, and I expect Queensland will be the same as everywhere else in the world, where it's about 75% patients who've had cancer and they've had a lot of experiences. They've had chemotherapy, radiotherapy, lines, hospital stays and they... what they say is that, they've ended up on a treadmill of treatments that have been thrown at them and they want to take back a bit of control at that particular point in their life.

So, they access that control through me and they are... they are overwhelmingly grateful. I've never had patients and their families be so grateful for that ability to take back control of their own healthcare and their own experience and their own life.

Dr Clare Fellingham

Every single person has a story to tell. Everyone has a lifetime of experiences under their belt that have shaped and created them. And, so much about voluntary assisted dying is about not judging people, judging them by our own standards, judging them by our own training, judging them by our own expectations. It's about honouring them as individuals and helping them make the best choice for them.

Prof. Michael Dooley

And patients share a lot. They want to share their journey. They will always tell us why they've come to the decision. And that's because they want to share their decision and they want us to understand that decision. And I think they also want to have a feeling that they're not alone in their decision. They're not the only person in Australia who's making that decision.

So, they share their journey. They share the journey of how they've got to where they are and why they're considering ending their own life. But also, they share what they were and the person they were, before the day we see them. Because often we see patients who are very unwell and they're often very much a shadow of what they were previously.

So we will often... they will often share their previous person, whether they were a lumberjack or whether they were a pilot or whether they were an author, they will share that and share themselves with us first. And that's part of them, I suppose us, building a rapport with them when we're having quite difficult conversations.

Dr Gareth Wahl

No patient that I have seen has come to this out of a desire to die. But they all know what they don't want and they all know how they don't want to die. And overwhelmingly they are a very experienced healthcare consumer who has often planned every degree of their life, has organised everything from their Will to interviewing the celebrant for their funeral, because they know they want to be able to control what's happening at their death, out of a desire to be able to support their family.

Meg Plaster

What is so palpable is their determination. Such determination. Many of them have thought it through for years and years, long before they had a diagnosis that would have been relevant to them in terms of voluntary assisted dying and often they've thought about it long before the legislation was available. And, the patients and people who are not that determined are exploring it and often don't pursue it, but they come to understand that they have some choice and it is then their decision and they can choose that.

Dr Cameron McLaren

My biggest learning through doing voluntary assisted dying has actually been in performing home visits. Now, as an oncologist, this is not something that we do. We sit in our ivory tower and prescribe chemotherapy. But, in doing voluntary assisted dying, many of the patients are unable to attend the ivory tower and I end up having to visit them in their home and see how they're actually living.

And this is really giving me fantastic insight into what they actually face on a day-to-day basis and I think has actually made me a better oncologist as a result.

Prof. Michael Dooley

Look, I think we're used to practicing in settings where it's a hospital. That's where I am used to. And it's very different when we go into patient's homes and 80% of our visits are to the home. And I think then you go into their natural environments. It's a very, very different dynamic. You're understanding more about them, than you are actually the condition.

In hospitals, we often see the condition and we often see the solution, the medications, the treatment... When you go into someone's home, you actually see the... you see the person and you see the impact of the disease on them.

You see the photos on the wall of them when they were, you know, 90 kilos and fit and two months, three months later, they're half the size. You see the family, you see the impacts of what's going on. You see the suffering. You see the suffering in their eyes and you see the suffering of those around them, so, you actually get a better feel for the person.

In hospitals, we often see patients for minutes. When we visit patients in the home, we're there for usually an hour and a half and a lot of that time is understanding their decisions. And I think what I've learned over the journey is that we need to take more… have a greater understanding of why the patient is making a decision, rather than us making a decision and them saying yes or no.

So, I think one of the professional things I've learned is, is more about understanding the why and what the patient wants. And then my role really is to then fit into that and see how I can help them.

Dr Gareth Wahl

So my biggest learning was that, even... it doesn't matter how nice you are and how much you try to do the best thing for your patients, you can only see the world through your own lens. And a big part of this for me has been trying to open that lens for myself to try and see it from another person's lens.  And, I have realised that that's not how most of the healthcare system works.

Dr Clare Fellingham

They reflect back to us, that being able to begin a voluntary assisted dying journey brings them an enormous amount of peace. It reduces their anxiety. It gives them the ability to relax and to know that they're going to be supported. And actually in helping them die better, it helps them to live better. And so, the process of their dying evolving, it typically it's very supportive, very compassionate, very, very gentle and very collaborative, just driven at their pace.

The actual process of the death itself, the vast majority of times, the words that are reflected back to us by the families that are left behind are, that that was truly focused on the person. And time and time again, it was exactly what they would have wanted.

Queensland Voluntary Assisted Dying Implementation Conference

In October 2022, Queensland Health hosted a conference about voluntary assisted dying.

Watch recordings from the Queensland Voluntary Assisted Dying Implementation Conference.

Last updated: 11 May 2023