GPs often find themselves in the centre of difficult treatment programmes as the patient bounces between home, hospice, hospital and resthomes. Development of palliative care and hospices in most of New Zealand has been admirable, but still has a long way to go.
It is important to know that movements supporting voluntary assisted dying, such as the End-of-Life Choice Society NZ, wholeheartedly endorse these modes of treatment and would see most patients described in the intended Bill as being helped by these services. In Oregon, most patients who have assisted death have been treated in a hospice environment.
In the Netherlands and Belgium, palliative care doctors have been some of the leaders in the voluntary euthanasia movement.5 However, for those who think palliative care is sufficient, there are a number of issues which should be considered including:
1) Relief of suffering from palliative care - It is clear that palliative care cannot always relieve physical suffering or "existential suffering" due to loss of autonomy and dignity, and there are a number of patients who ask for assisted medical death in spite of good palliative care. Palliative care health professionals argue their techniques are becoming increasingly refined, but some patients find the prospect of dying while under sedation repugnant. Figures released from an Australian study widely quoted in 2016 show that, 10-20 per cent of patients on hospice programmes experience unbearable pain/suffering as they die.6 Over 1000 submissions to the health select committee on assisted dying wrote about bad deaths in their relatives and friends, and many of these were in hospice. Some of these submissions were from experienced palliative care nurses and doctors supporting voluntary assisted dying.7
2) Patients not under direct palliative or hospice care - Libby Smales, a NZ palliative care physician, an experienced hospice doctor points out in her submission to the health select inquiry into assisted dying (2015-16), that there is a major shortage of palliative care experts in New Zealand. She also says, that even with the best palliative care, patients can have suffering deaths.
Dr Smales points out that in legalised jurisdictions where voluntary assisted dying has been authorised, mandatory referral to palliative care doctors has often been enshrined in law, which is not the case in New Zealand. Examples of this are in Belgium and Canada.
Lannes Johnson, who has extensive palliative care and general practice experience in Auckland), in his submission to the health select committee 2015-2016, points out that most patients do not die in hospice-controlled situations, but in resthomes (about 4 times as many).
He describes cases where horrible deaths have occurred because of lack of experience and entrenched attitudes about not "giving too much sedation and pain relief, in case it causes death".
3) Integration of palliative care and voluntary assisted dying - Palliative care and physician-assisted death are not mutually exclusive; the former should be universally provided at a high level, and the latter should be available as an adjunct where requested. In Belgium particularly, voluntary assisted dying has been integrated with heavily funded palliative care, and as a result the speciality of palliative care has grown enormously.
The Canadian law mandates growth of palliative care integrated with voluntary assisted dying. The recent Victorian law mandates a major increase in palliative care funding.
There are many other issues which medical practitioners have to work though, including the sanctity of life, the difference between murder and voluntary assisted dying, autonomy of patients, shifting norms in society, the mischievous claims that the aged and disabled are vulnerable to abuse in association with voluntary assisted dying, the difficulty that doctors experience in expressing their opinions when voluntary assisted dying is illegal, and moral issues usually related to religious belief.
In conjunction with an Australian doctors group who support voluntary assisted dying, we in New Zealand have set up a group of doctors who support End of Life Choice in principle. Some are retired, some are GPs, some are hospital specialists, and all are still working through the issues.
We have responded to the Gillett article on euthanasia in the NZ Medical Journal (19 Jan 2018) and sent a suggested survey to the NZMA which they could use for their members. We consult about various issues and share information about voluntary assisted dying.
If any medical practitioners wish to join this group of the contact person is Dr Jack Havill firstname.lastname@example.org. We are careful if a person wants to remain anonymous to those outside the group, and the individual’s name will only be revealed with permission, for example, as signatures to a letter. We correspond by group emails.