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27 Feb 2024, by Amy Sarcevic
New South Wales’ (NSW) version of voluntary assisted dying (VAD) legislation came into effect in November last year, providing welcome relief to people suffering in the advanced stages of illness and disease.
With the legislation now in full swing, what do NSW health workers need to be mindful of – legally and ethically – in their handling of end of life care?
Ahead of the Medico Legal Congress, Informa spoke with Dr Wade Stedman, Clinical Lead for Voluntary Assisted Dying at the NSW Ministry of Health, to find out.
Raising VAD appropriately
Dr Stedman says the NSW laws have subtle, but important, differences, when compared to states where VAD laws are already in effect.
In particular, NSW workers should pay attention to the circumstances and manner in which they raise VAD to patients, he says.
“On the whole, NSW’s laws are less onerous than they are in other states. For example, in Victoria and South Australia, practitioners are not allowed to raise VAD unless a patient specifically asks about it.
“In NSW, practitioners can raise it, but only at the same time as other palliative care and treatment options. In other words, there is more flexibility in NSW, but still some legal considerations,” he said.
Ethically, too, practitioners should be aware of their own biases when having these conversations, Dr Stedman cautioned.
“It needs to be a patient-directed decision, so we want to remove any hint of bias from our discussion. There should be no perception of coercion, for example.”
Similarly, the clinical relationship between patient and practitioner cannot change following a patient’s decision around VAD.
“In NSW, it is a person’s right to access a legally available option. Practitioners can conscientiously object to any part of the process, but they cannot stop providing usual care.
“For example, if I am a palliative care specialist and have a long term patient relationship with someone who has decided to go ahead with VAD, I might disagree with their decision, but I cannot stop seeing the patient or refuse them treatment.
“The law is firm on that and there are no exemptions, even if it opposes the practitioner’s personal or religious beliefs,” Dr Stedman said.
Thankfully, the NSW legislation also has safeguards in place to ensure VAD treatment is only administered to eligible patients in the right circumstances.
“Even if someone raised VAD to a patient who was not eligible, or for whom it was not appropriate, two independent practitioners would still need to assess them as eligible.
“Both of these would need to have done specific training and be a medical specialist or have worked for at least ten years with general registration.”
In addition, NSW has a board approved substance authorisation process that works on a prospective basis.
“After two independent assessments (amongst other things), a formal application will need to be made to a board, which reviews the documents and gives substance authorisation. This approach differs from some other states where these reviews are performed retrospectively.”
“Combined, these measures reduce any harm that can come from ill-intention or misinformation in end-of-life discussions between practitioner and patient.”
Helping patients choose a method of administration
The laws around the method of administration are also more relaxed in NSW, where patients have the option to receive end-of-life medication from a practitioner, alongside the option to self-administer.
“In Victoria, the default option is self-administration, so practitioners need to demonstrate that a patient cannot self-administer before offering the alternative. If the patient’s circumstances change, they will need to re-seek approval.
“Thankfully, in NSW, patients have more freedom of choice and can change their mind at any time. That said, it still needs to be a patient-directed decision, so – just as with raising VAD – practitioners should be mindful about the manner in which they inform patients of their options.”
Complexities can, however, arise in this process, given that practitioners should also be frank with patients about what each option entails.
“A medical practitioner wouldn’t be doing their job properly if they didn’t advise patients about the differences between each administration options and help them understand that it is not a like-for-like comparison.
“However, they need to be respectful of the patient’s unique preferences. For some, it might be an absolute priority to have their medication at home and maintain control of the timing and their environment. If this kind of patient had practitioner-led administration, they might lose that sense of control, as they would have to organise a time with someone external.
“Then, there might be other patients who feel they need more external support. It’s very much a personal choice that practitioners should cater to.”
Further insight
Dr Wade Stedman will share more expert advice around voluntary assisted dying legislation at the upcoming Medico Legal Congress – Australia’s longest running event for medical and legal professionals.
This year’s event will be held 19-20 March at the Swissotel Sydney.
Learn more and register your place here.
About Dr Wade Stedman
Wade is an Intensive Care Specialist at Royal North Shore Hospital. He has a particular interest in the long-term outcomes of ICU survivors and their family members and co-developed one of the first intensive care follow-up services in Australia. He is passionate about end-of-life care and is currently the clinical lead for the implementation of Voluntary Assisted Dying in NSW.
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