'I was a late convert to voluntary assisted dying'

Victorian physician James Hurley says working as a VAD doctor has enabled him to give back to the community in a way he did not anticipate

"I graduated in medicine in 1981 and completed my physician training in 1991. I have been a general physician, with hospital and academic appointments in Ballarat and Western Victoria, for more than 25 years. While I was trained broadly in internal medicine, my training in end-of-life care was acquired 'on the job'.

"I was a late convert to the voluntary assisted dying (VAD) concept. I thought my training as a physician was complete, until I faced the end-of-life experiences of four close family members over the past 5 years. For two of these, one in a hospital and one in a hospice, the experience was distressing for all. For two others, a desire to die in their own bed at home in their 90s, pain-free and with their family close by was met, unassisted.

"This experience sharpened my views on VAD as a justifiable end-of-life option in a way that no medical training or work experience could ever do. Two years ago, with VAD becoming Victorian law, I undertook the VAD training in order to facilitate access to VAD for people in towns across western Victoria.

Over 2 years, I have assisted more than 50 patients through VAD, although only some have proceeded to assisted dying. Several patient experiences were memorable in a way that eclipsed my typical general physician experiences caring for complex general medical cases.

"All the patients have been supported by their families. Even though access to VAD is now a legal right across most of Australia, the application processes that patients are required to negotiate are not simple and require expert assistance and family support to navigate. Several have had to overcome conscientious objection from other health practitioners and religious order-owned aged care facilities, which otherwise would have effectively blocked their application by not allowing VAD to happen or to even be discussed in their facility.

"For applications made against the views of the treating doctor or aged care facility, in some cases, this has required the patient to be physically lifted by the family members from their nursing home bed, into a private car and transported long distances for each of the four or so visits required for the VAD application process. Some choose not to proceed, several do not meet the eligibility criteria, and many apply too late and die before their application can be completed – which in my experience typically takes 3 weeks. Fewer than ten patients did not meet the eligibility criteria in my assessment. These patients I referred to either active therapies or other supportive or palliative options.

VAD is not for every doctor. First, training in VAD is required. This is usually done online with occasional face-to-face opportunities. The training is not hard but it is an essential requirement.

"Second, the VAD application process for each patient is time consuming. Each application requires face-to-face consultation time with the patient. Additional to this is the screen time to register the patient’s criteria for eligibility to a level that the VAD Board will approve. In my experience, this requires one hour for each of the initial and written declaration steps and the ultimate prescription.

"Third, some doctors conscientiously object to VAD. In my experience, other doctors genuinely wish to avoid a perception of wearing 'two hats' in their role, even – or perhaps especially – palliative care physicians. I have learnt to respect those views. However, I do ask that doctors who conscientiously object consider the views of the patient and acknowledge that respect is a two-way street.

For the treating doctor to tell their VAD patient that, as a conscientious objector, they will no longer care for them and will not be doing their death certificate is, in my experience, confronting. It is distressing, and several patients seek medical care from another doctor, who, if they live in a one-doctor town, may be in the next town.

"However, more often, I find that the views of most doctors are similar to community views. Indeed, I find that most doctors and health facilties do not object, they simply find VAD to be too awkward.

"Fourth, to be present at the moment of death and stand back goes 'against the grain', even though masterful inactivity may clearly be the right thing to do. This is difficult for any doctor, even sometimes for experienced doctors. Let’s not forget, for the family members, it will typically be their first time and it will always be difficult for them. To be the doctor present in the patient’s own home when this occurs increases the level of the doctor’s discomfort.

Finally, how can assisting a death ever be justified? The justification, in my opinion, comes from the patient. It comes from when a patient looks you in the eye and says 'I want you to assist me to die to relieve my suffering'. Likewise, it comes when the family says, 'we want you to assist our family member to achieve the death our family member chooses'.

"When this happens, it is not difficult to assist. Indeed, in my experience, it would be more difficult not to.

"The VAD training makes explicit that it is never the role of a VAD practitioner to advocate how people might choose to end their lives. For me, the VAD experience has been an unanticipated contribution that I can offer at my late stage of career. Not only can I provide consultant physician opinions for VAD applications as required, I can provide support to patients and families with the initial and written applications and whatever else is required along the way. For the first time in my 30-year career of hospital medicine I have started to do home visits.

"Working as a VAD physician has enabled me to give back to the community using my medical qualifications in a way that I did not anticipate. At the end of the day, is not the relief of suffering for an incurable illness, on the terms that the patient requests, and to likewise provide comfort to their families, part of being a physician?"

Dr James Hurley is a general diseases physician at Ballarat Health Services.

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