ADVOCATES for palliative care and voluntary-assisted dying (VAD) have been formidable warriors, on opposite sides in the public debate about the legalisation of euthanasia.
Now, when there is the prospect of the introduction of VAD legislation in Victoria in the foreseeable future, is it time to explore ways to affirm them both, and to ask whether they are, in some way, complementary?
Palliative care prides itself on being “patient-centred”. Indeed, some prefer the term “person-centred” to emphasise that the individual receiving care not be confined to the dependent status of a patient “under the doctor”, but enjoys freedom to express opinion, to participate fully in decision-making and, as far as is possible, to exercise a sense of personal control.
In countries where it is legal, VAD is also person-centred, affirming autonomy — available only to individuals fully capable of an informed and independent decision about the best management for them when the end of life is threatened by intolerable suffering.
There are, of course, important differences in the two approaches to assistance for a dying person. In its intent and timing, palliative care seeks to maintain the best quality of life in the face of threatening death. It offers a process, a continuous attention to symptom control, and emotional and social support extending, if necessary, for months.
VAD’s intent and contract is for sudden death, a single effective intervention, only minutes in duration.
Palliative care is essentially clinical; its basis is good medicine, demanding of clinical training and skill and, at the same time, proving flexible and responsive to the changing needs and wishes of the dying person and of family and friends.
Some might argue that VAD requires little clinical skill; in some countries, such as Switzerland, Germany, Japan, and Canada, it operates largely outside of established medicine. Where it is legalised, VAD is based in good law and is required to adhere strictly to the law’s demands. It is inflexible; it defines in clear terms who is eligible to request VAD, who may provide it, what processes of explanation, consultation and delay must be followed, and what reports must be supplied to a watchful authority.
Palliative care also takes advantage of good law. A practitioner offering palliative care for a patient with difficult and intractable discomfort in terminal illness may find that adequate relief is provided only with measures that risk hastening that patient’s death. In such circumstances, no criticism or change shall apply if the treatments prescribed accord with accepted palliative care practice.
In a similar vein, VAD can be good medicine, if a request for assistance to die brings to bear an unhurried, thoughtful and comprehensive approach of the experienced clinician. To ensure full attention to informed consent, underlying disease, symptoms, prognosis, other options for care and support of family throughout, VAD needs to embrace that clinical dimension.
Experience from countries that have legalised VAD suggests that requests for VAD for those who have major suffering in terminal illness will be few in number.
Palliative care will continue to carry the greater responsibility to provide relief for those patients, and the demand on its services will continue to increase. Though controversy may continue to bring it significant public visibility, VAD will provide only a very small part of the great mix of medical, social and political interventions that contribute to the public health.
Relatively few doctors may wish to practise VAD or build experience in its conduct. To ensure that it is done well and that it accords with best practice, VAD should seek to place itself alongside palliative care and learn from it.
The brisk legal imperatives that command VAD may be moderated through familiarity and close contact with palliative care. It may bring the doctor who approves a request for VAD an engagement with patient and family in far more than the assessment of a request and the writing of a lethal prescription. It may encourage the offer of a continuing medical presence willing to attend at the time a dose is taken, and to monitor later bereavement support for the family. That would be the way of palliative care.
Emeritus Professor Ian Maddocks is an eminent palliative care specialist, recognised internationally for his work in palliative care, tropical and preventive medicine. He was Senior Australian of the Year in 2013.
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