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Alt Wednesdays webinar series - Voluntary Assisted Dying - what to do when a patient asks

Dr Marina Malcolm: Hello everyone and welcome to our Alt Wednesday webinar series, my name is Marina Malcolm, I am a different face today, I’m co deputy chair of the Vic faculty and the amazing Anita has got another urgent meeting that she had to do tonight, so I am filling into the space. So, we're just waiting as the participants are coming in, which is nice and exciting. So the Alt Wednesday webinar series, it's a series that's run by Vic fac and the amazing Sally Cockburn. Where we look a little bit deeper into the things that they just don't teach you at Med school and so tonight we're having a good look at the voluntary assisted dying and we will look at the practicalities of participating or not participating if you're a GP, which is very important thing to look into. We always, of course, start any RACGP meeting with a welcome to country, so I would like to acknowledge the traditional custodians of the land and sea, on which we work and live and we recognize their continuing connection to land and culture, and we pay our respects to elder's past, present and future and, of course, would like to acknowledge, anyone who identifies as Aboriginal or Torres Strait Islander who is participating tonight. So. I think, Lorraine, is just popped up a few of the things that are coming in the next little while for the RACGP but of course it's a very complicated space so we're not really sure what's going to be there and what's not. The brainy women mark number three, it will happen at some stage whether it happens in October we're not really sure, but keep your eye on it, because it'll be fabulous when it does happen and same with all of the other things that will all be to be confirmed, as we know a little bit more. Okay, so, as everyone has come in, I will hand over to the amazing Dr Sally Cockburn, who will take over.
 
Dr Sally Cockburn: Don’t know about the amazing bit, old, tired. Anyway, thanks very much Marina and it's great to be here with yet another Alt Wednesday session. Oh, stay there, because I want to ask you, oh you've done come back. So, our session tonight is part two, in a series on death and general practice and the first one was on certification of cause of death and that's very relevant because it flows on tonight's really well because there is some overlap. Now tonight's is entitled, what if my patient requests voluntary assisted dying a GP’s guide to understanding Victoria's voluntary assisted dying program. Whether you participate or not, and I want to really stress that, because this is not about that you have to take part to be listening to this, it's probably even more important for those of you who don't want to take part. Unless you graduated in the last couple of years from Med school, I think it's the epitome of stuff they don't teach you in medical school. In 2017 the Victorian Parliament passed the voluntary assisted dying act being the first Australian State to do so, there was a brief sojourn into it in the Northern Territory in the 1990s. But since then, since ours was passed three other states have also passed similar laws. And in Victoria, the law became active in June 2019 so we're into our second, third year now we've done two years and while there's been lots of education and information published, there are still some misconceptions that even amongst medical practitioners and I’m well aware of that. So tonight's session is not about the ethics, the rights and wrongs or the morals associated with the law or its practice, the fact is, it exists and our patients may approach any of us to assist them in the in the with their access to the Program. Whether we do or don't wish to take part in the program is entirely a decision for each individual, but as a medical practitioner we have to be mindful that we should not obstruct our patients or trying to dissuade our patients in their access, we need to bail. This can be confronting for some doctors and we'll talk a bit about this, but please know that you can ask any question anonymously in tonight’s thing if you feel you don't want to be identified there's an option in the Q&A for you to choose anonymous, but please we're not judging anyone on anything but please don't ask or make moral statements and stuff like that that's not what tonight's about, we have a law, we have to live with it and we're just trying to work it out. The most moral I’d say would be reasonable would I’ve got a moral objection to doing VAD well how do I deal with one of my patients when they asked, that's exactly the sort of thing that would be useful. So you can ask them anonymously I’d like to keep it to practicalities and myth busting if you've heard argh but you know is this true? We can deal with that. To assist us on our journey tonight is former GP and now palliative care physician also former member of the implementation committee they spent 18 months after the law was passed in getting through the practicalities and setting up the process, I refer to associate Professor Greg Mewett. Greg describes himself, you can turn yourself on if you like, well that's a bad thing to say, turn on your camera Greg. Greg describes himself and I love this there's a conscientious participant in voluntary assisted dying and he is experienced in navigating the program and educating GPs. I also need to declare my interest, I am a member of the voluntary assisted dying review board, I won't be speaking on their behalf, and I can't really speak about them. The main role of the voluntary assisted dying review board is twofold one is to audit all completed cases after death and produce six monthly reports for parliament. We had been hoping that the six-monthly report would have been tabled already but parliament's not sitting because of COVID until next week so I really urge you in the documents that i've sent out to you you'll find a link and you it's a safer care website, please read that and you'll see how the program is going. And so, before we start I just thought we might do a couple of polls, but first Marina what's your personal sort of experience with the VAD program, have you had any experience with it?
 
Dr Marina Malcolm: um I have, I have been to a workshop that they ran locally, for me, and I, I went because I had about four patients at the time that I thought Oh, I think, thinking through my patient list, I think that they might approach me and I wanted to be ready, so that when they approached me I was across it, and so it was actually it was an awesome session.
 
Dr Sally Cockburn: I think you are probably quite typical of people who say look, I want to be prepared, I want to be ready, but Greg would it be fair to say that the only way, you can really be ready when someone approaches you is to have already done the training because, especially if they're imminently terminal it takes a bit of time to do the training program.
 
Dr Greg Mewett: Oh yes and no. First can I correct a missive, I’m not an Associate Professor, or, as we call them in the business aspros.
 
Dr Sally Cockburn: They did say you were an aspro on one of your bios.
 
Dr Greg Mewett: Not an aspro no. Just a Dr. Thank you yes, um, secondly your question about being asked. Now look I don't think you have to have done. To do the VAD online training is mandatory if you wish to become involved in assessments and helping and assisting patients through the whole assessment and approval process. But I mean I think tonight it's fair to say that we're trying to get people at least to have some framework for coming up with that answer rather than sort of stumble and bumble if someone says ah look by the way, um and you know, as I said earlier on what to you, I wanted to make a couple of sort of overarching statements about VAD that people need to understand before we even go into a saying well how do I approach a patient who asks and how what are they because. Can I just say that most people think well VAD gives people this some inalienable rights to VAD but it doesn't there's no inalienable right to VAD under the legislation. What the legislation does do is give people the right to ask to be assessed for their eligibility, that's what it gives them the right to it, doesn't give the right to die or right to have VAD, they can’t demand it like they can't demand any other form of treatment that is not that is not appropriate, so that they can be a request assessment. The other thing is that the very important crux of the issue is that legislation in Victoria specifically and explicitly prevents health professionals, being able to initiate a discussion or suggest VAD as an option in the course of providing our professional services to patients. That could be deemed as unprofessional conduct under the act. So that's a very important thing and that's why we're going to talk about how to respond, is a patient actually asking me about VAD or are they asking me about something else. The other important thing to remember is also that patients, the families, cares, friends cannot make a request on another person's behalf, the person has to make a request themselves. The VAD cannot be requested an advanced care plan of directive as another thing and I often get patients or families, say look, I’m the medical treatment decision maker previous legislation the medical power of attorney you know don't I get a say in this? Well, no, because medical treatment decision makers or powers of attorney only become relevant when the patient loses decision making capacity and under the act the person has to have decision making capacity with respect to VAD right up until the time of administration of the medications.
 
Dr Sally Cockburn: And Greg, what is really important from the perspective that, as you say, if someone has, tries to waive that I’ve got medical power of attorney, then you can't do it because the person is obviously lost capacity for you to have power of medical attorneys.
 
Dr Greg Mewett: Yeah, medical power of attorney is irrelevant under the act, but that doesn't mean a person who has medical power of attorney is a support person that can’t be involved in discussions and supporting or agreeing or even disagreeing with the person's choice. But they don't get a say under the act.
 
Dr Sally Cockburn: No, exactly. So I wanted to put up a couple of polls and one is a bit of an overlap with last week and so I’d ask around our audience, if you would. do me the honour of answering this poll, it's if you were there last month, then you'll recognize what I’m talking about I’m just launching it now, you should be able to see it. If you like to you, we don't know who you are you won't be named, I just want to know: when you complete a certification of cause of death I use, VDM online MCCD, the old paper forms in triplicate colour coded you know the pinky, the bluey and the greeney or I haven't had to do this, yet, and if you recall from last month that was the first time in 40 years that I’ve actually had to do an MCCD and it was quite interesting. And the reason I’d like to know is, because there are some issues, Greg, with the paper based ones in that am I correct that so the one of the changes in the MCCD has been the addition of something that you have to answer a question about whether you know the person was a VAD participant.
 
Dr Greg Mewett: Well on the electronic version, which is what I use of the death certificate there's a drop down section on every death certificate that says, are you aware of this person being the subject of the VAD permit? and you say yes or no, for most people it’s no when nothing else happened you just continue on with the death certificate and if you say yes, then it drops down box comes your way and it asked you to state did the person die by taking the VAD substance or did the person die and not take the VAD substance or did the person die by having the VAD administered to them by a practitioner so, it's a tick box approach to the death certificate. The other part of the act requires a GP or whoever's involved, instead of on the death to notify the coroner, it's on a reportable death under the coroners act. it's a notifiable death, so you ring up the coroner's admissions office and they take a few details and that's the end of the story, it was an amendment put through parliament but really I think it's an extra layer of in my opinion, nuisance value statistics, but it is required it's a very simple thing you don't have to fill out any forms and you can do that, during you know, within the next day or so after the death. So, it's very straightforward that certification.
 
Dr Sally Cockburn: But of course, if you don't know where that, like it could be that you're a local doctor just being asked, because, in fact, we learned last month that you don't have to be the usual doctor to write the death certification, you just have to examine the body after death. So you could be called in to do it and there may be some issues with the family, not wanting to tell you, and that's the common reason for that would be if they thought that VAD was going to be written on the death certificate which I think is one of the myths we need to bust because it's not.
 
Dr Greg Mewett: It's not written on the death certificate, but if you get the death certificate is a public document and, of course, a copy gets sent the to the to the family and next of kin. Basically, the death certificate, like any other death certificate states the underlying cause of death, i.e. the disease, medical condition or illness that led to the person requesting VAD and also caused the death. VAD is the manner of death, how did they die, so you know that is the manner of dying. Just like the manner of dying for all people’s cardiac arrest well you don't put cardiac arrest hopefully on a death certificate because that's meaningless. So basically, the manner of death is conveyed by that drop down box, I was talking about, but the cause of death is the underlying disease that cancer or the renal disease or whatever.
 
Dr Sally Cockburn: Now I’m just going to share the results. Hopefully they've come up, so interestingly, nearly 50% of people who responded are using the online MCCD system which does have that question about VAD. And 11% of people are still using the coloured triplicate ones which doesn't have the VAD question on it so that sort of throws things data collection wise out of it, but you know, there are ways to get around there, and of course 41% of people said I haven't had to do this yet, so you can register on BDM for MCCD in advance you don't have to be needing to do it, so I would encourage everybody to register on BDM’s online MCCD form, so when, if and when the time comes, you're already online because they're not open on the weekends and invariably this happens on the weekends. So, there you go we've digressed and gone right to the end of the process there so we're going haul it back. And I do have a second poll that’s more relevant to find out who in the audience is actually participating, let me go to poll number two. Hold on, there we go, launch. So, this is just regarding Victoria’s voluntary assisted dying program. And just you can just choose one, I’ve completed the training course, I actually we should have let it open for more but anyway, I’ve completed the training course, I’ve been involved in a patient's application for VAD, will be nice if I don't know whether I think we can change it now. It it's only going to let you do one I should have let it do all. Anyway, doesn't matter, I just don't want anything to do with VAD, that's fine too we just want to get a lay of the land of who we're talking to and what your questions might be. So Hopefully, you can see those we'll just wait a few moments. And do you I don't have the numbers in my head Greg you're also the Chair of the Community of practice I think aren't you, which is a group of doctors who practice in the area, do you do you have a great membership of your community of practice. People are involved.
 
Dr Greg Mewett: It’s a slowly growing area I’d say we'd have about 45 to 50 doctors who are members of the community of practice so it's an online community of practice in VAD. I was going to make some comments about that later it's almost as if, the one of the, PHNs and we have an administrative coordinator or convener and I’m the Clinical Convener moderator I think is the terminology that’s used. So that's a very important part of us and that's people from you know all GPs, the whole lot whoever is involved in doing VAD in Victoria or helping patients with VAD.
 
Dr Sally Cockburn: And if someone does the training course, doesn't mean they have to actually practice, necessarily.
 
Dr Greg Mewett: I know doctors who have done the training, particularly in the early in the piece, because they wanted to be across all the issues but are not involved in the VAD. It's an interesting process, I mean if you want to be involved, you have to pass, have to get a 97% pass rate at the end. And there are options for repeating and it's an open book exam, so it’s not that bad, but yeah so, it's really a community of practice for doctors who've done the training yet and involved in assisting patients.
 
Dr Sally Cockburn: And I suspect that many people who are considering doing this, who may not know about the community of practice, it must give a lot of support to doctors who are on their own and thinking, who do I talk to.
 
Dr Greg Mewett: Well, there's absolutely there's a lot of exchange of ideas, a lot of we also you know have I guess not only peer support but it's about developing best practice about advocacy all that sort of those things that a good Community practice does.
 
Dr Sally Cockburn: And also, a good resource for voluntary assisted dying review board because I didn't mention the other role of the review board is to make recommendations, when the time comes, and I think it's a 6 year mark as to whether there needs to be any changes, the last five years as a changes here, how good I am, making the changes in the legislation. I’m going to share these results, but Lorraine tells me she's made another slide that will show us, give you more than options, for more than one. But just this one, because i'm thinking it tells you it says you whether you have completed the course but it doesn't tell us how many of those ones who've completed the course have been able to do it, but it just gives you a bit of an overview and obviously we do have some people who don't want to be part of the program and they've said they'll refer on to someone else so we'll talk about how you organise that as part of the what to do when a patient asks, and it is fair enough, Greg, conscientious objectors the laws pretty specific on conscientious objectors they're allowed to be a conscientious objector.
 
Dr Greg Mewett: Of course, in fact, under the VAD act it’s very generous allows conscientious objection a doctor or health professional that are particularly doctors were talking about tonight do not have to be involved in VAD, unlike the abortion law in this state you don't even have to refer someone to someone who can help the patient. I think good medical practice and good you know good standard of care would say that you would hopefully point someone in the right direction of further information either to the care navigators or to another doctor even maybe in your own practice, who is prepared and sit and talk to the patient in more detail, than perhaps you are. But no, there's no, conscientious objection very, very wide allowances in under this act.
 
Dr Sally Cockburn: However, conscientious objection is one thing, but, but you would have to dispose that to the patient and not trying to dissuade them from their access.
 
Dr Greg Mewett: Well that's right, I mean. I think one of the. I don’t know what I’ve done with my slides now, they probably disappeared, but one of my things that I am what that I talked about is you know, there are a number of responses and number of roles that GP is can have it all this. But I guess from the basic wrong, one thing I do want to get my slides up at some stage.
 
Dr Sally Cockburn: Get your slides up now because I’m just going to interrupt and say that this is the same same poll, that you can answer multiple you can pick multiple boxes so. What i'm trying to pick up here is people who have completed the training course and have been involved in patients' application, because you couldn't have been involved in the, oh you could be involved in the patient's application by finding the coordinating and consulting doctors, I suppose. It shouldn't be any different to the last one largely.
 
Dr Greg Mewett: I don't know what's happening with my slide so I’m afraid I’ve be looking at them all night and then they're just it's now done a bunk so what I would like to say is that. When we talk about, we're not allowed to introduce the situation with voluntary assisted dying, but a patient might come in and make certain comments I’m going to just try and here we go.
 
Dr Sally Cockburn: You can find them if you want.
 
Dr Greg Mewett: Okay.
 
Dr Sally Cockburn: I can, I can just we can do the poll while we're waiting and we're all used to technical foibles. So now, whoever was a tick the boxes, did they are involved, last time it hasn't ticked the boxes time I think I’ll get rid of the poll thanks for doing the poll off it goes. I suppose, while you're looking for your slides Greg it might be good to just do a bit of a you know, you want to, you want to share them did you want to share.
 
Dr Greg Mewett: Yeah, I just want to share a couple.
 
Dr Sally Cockburn: Yeah sure. You want to do you want to put it on slideshow.
 
Dr Greg Mewett: Okay, thank you just that I can probably a bit of.
 
Dr Sally Cockburn: Leave it there, we're fine.
 
Dr Greg Mewett: Okay, so what I wanted to say a couple of things is that your responses as a GP and as we as doctors really depends on a number of things, I guess, one of them is obviously your level of comfort discussing end of life stuff anyway death and dying anyway. What are your skills like in end of life, discussions and palliative care type discussions, what is your I guess level of knowledge about the act if it is in fact something you're interested in and what are its implications for the practice, what is your moral and ethical stance on assisted dying and are you a conscientious objector. Are you prepared to work with the patient exploring all end of life options, including VAD so there's this I mean the idea my view is an end of life option amongst a number of other options that people consider near the end of life. What do we understand about the patient's medical condition, including their prognosis and how willing, are we to be involved as the patient's coordinating medical practitioner having needed to do the training to get the point. So, the roles of GPs are really varied and many, and I think what I wanted to say was people say, well, how do you know where to patients actually asked you about VAD, because under the act you're not allowed to bring it up, so what if a patient comes in and says. One of these things which patients in various guises, have said a lot of these things to me over the years, both as a GP with a special interest in palliative care analysis specialist. You know, things like these are questions that really are not specific enough for us to say, well, these justify a VAD discussion now the patients ask me about VAD off I go. These need further clarification, and they are I’d have to read all those out the classic would be you know I think I've had enough, I just want to die. Look, if I was a dog they would take me out and shoot me, you know just give me the magic pill or the green dream and I’m out of here Doc. These are clearly not specific enough statements, in my view, for you to say well they're asking me about VAD. So, what I do and being you know I think something I teach certainly our students and young doctors is answer a question with a question. And, someone said, why, well why not, but why are you asking me this question now. You know, in other words, in whatever words you would like to use with your patient, well that's interesting why are you asking me that can you tell me more about what you mean and how you're feeling. Explore the issue, what exactly are you asking me about it sounds like things are pretty tough for you now, why don't we haven't been more of a talk about it. These are the sort of responses that I would come up with. Now this then may give the patient away of you, the doctor and the patient a way of teasing out the issues. But for many of these patients who asked these sort of things they're not necessarily asking for you to end their life for them they've just it's actually often a call for help, if you like, a call of their distress in their suffering and for many patients that can be addressed proactively with good palliative care measures with good discussions, etc. But then of course we have people in this group, and like explicit instructions like Dr I’d like you to help me to die, I’ve heard about the new euthanasia law, how do I go about getting assistance to die, how do I get the pill, they say and dah dah dah, people will use different words but don't actually have to use the term voluntary assisted dying, but if they use statements like these that are showing here then they're clearly asking you very specifically about their desire to die and their desire for you to help them die. And that then gives you permission, in my opinion, with very little more clarification you'd still want to ask a lot more about it, then, to have a more open discussion about voluntary assisted dying. Again, getting to the underlying motivation for people to ask about this stuff is important because, as I said a lot of these patients will talk like this. But once their sufferings address may not wish to proceed, but there will be always a small percentage of patients who will want to proceed, despite your best of intentions, despite world's best practice palliative care some patients will wish to proceed down this path, or at least have that option available to them at or near the end of life.
 
Dr Sally Cockburn: Just on that. And someone's put this up as a question Sujeewa said as a GP can I independently, assess and take a decision that the patient is eligible for assisted dying. I think it is a really important question, because if you do get asked by a patient, you know, how do I access VAD let's say or words to that effect. And you haven't done the training, how far should you, can you go with making an assessment.
 
Dr Greg Mewett: Well, you would need, I think, to be on fairly short ground about what the act says, and what are the criteria, upon which patients are permitted to get a permit for voluntary assisted dying, in other words, you need to know the qualifying criteria for VAD. That all there's you know, obviously demographic criteria such as being a resident dah dah dah dah, permanent resident or permanent citizen of Australia. Things like that you have to live in Victoria for at least more than 12 months that, you have to be over 18 and then there's the important the difficult prognostic criteria which for GPs and even often for myself as a palliative care specialist I’m not always necessarily clear about and I need to get out of you know I’ll just phone a friend. You don't have to start a person down the path of VAD to say well look I’ll get more information about it, and I think this is the other thing that I put up on some of my slides is that don't fluff around and say ah I don't know anything or no yeah I can do that, find out, the patient will appreciate, you finding out more about it or putting you in the direction of someone who can give you more information. And it's the same with anything in general practice patients bring stuff up out of left field, quite often, we don't have all the answers we need to at least be able to you know, be able to give them some direction at least and how to find out more information for themselves, because a lot of these patients in many cases, have looked up stuff on the Internet and give them some suggestion. And there are some patients that I will say I don't think you're going to qualify under the act because dah dah dah dah, you could have a prognosis, your oncologist told me that your prognosis could be two years and your prognosis needs to be less than six months except if you've got a neurodegenerative disorder to 12 months so there's a lot of things that depends on your confidence about how much you can do. But yes, some patients are clearly eligible when you see them, and other patients are clearly not going to be eligible. And then there's a group in between, you know not going to be sure, so having, doing the training gives you a lot more skills and knowledge about that, but also allowing patients to see or talk to someone who has more knowledge or you get more information and get them back.
 
Dr Sally Cockburn: Of course, one of the things that was front and centre in the legal in I don't know if anyone followed the actual parliamentary debate, I was there every day, one of the big things was the safeguards and one of the big safeguards is competency, as you mentioned before, the ability to be able to make a decision and not being coerced and can I just there's two questions up here that I just think we can address very quickly. Parvathi says and Parvathi the answer to your question, which is sort of a statement is no and we've already said at first, they said a patient's carer having enduring power of attorney for a terminally ill patient can raise the question of euthanasia of the patient. No they can't, no
 
Dr Greg Mewett: Sorry, they can raise it. But they can't, you can't discuss it with the patient until it actually comes from the patient. Now if the patient can’t speak or communicate then you use whatever means of communication, like you would in any consultation to have that conversation, for the patient to say, but you can't be in turn to the patient, so Will I brought up do you want to talk about it, the patient has to raise with you.
 
Dr Sally Cockburn: And that actually brings on the second question, similar to that, how do you deal with families who just want to get rid of their parents and demand not that they want, not what they want, but because they may be stressed. And I think this is an interesting issue because doesn't actually happen, it was always the big fear that people have you wanted to knock off Nana.
 
Dr Greg Mewett: I think this is one of the big furphys, Sally, that I’d like to address, and we've talked about this a lot in our community of practice and there's a lot of experience in that community of practice of a lot of cases, a lot of patients have been helped and assisted and a lot of patients who haven't made it through the process, but still needing good care. And really coercion, is not something we see, and it is, it is not something we see. The vast majority of patients, I’d say many, many of the patients, the families don't want them to die, they don’t want then to die they'd rather that they didn't die, but most of them will support the patients right to take their legal option, doesn't mean they want them to die they're not hassling them. Coercion, I see coercion in non VAD situations commonly. Families coercing patients to continue futile palliative chemotherapy, patients being coerced into having horrendous surgery in a futile attempt to cure them, these are the sort of coercions I see in clinical practice, I practice in our patients here my oncologist department as well. These are the types of coercion we see, we don't see people being coerced into VAD now I’m sure there may be some cases. That might come to life, but it is, it would be miniscule and certainly not in the experience of all the doctors that we've worked, and we are, part of the training is recognizing coercion, we do it all the time, just like we're trained in recognizing patients clinical decision-making capacity in everyday medical practice, it's the same thing.
 
Dr Sally Cockburn: What about someone who, you see in an age care setting who says I’d like to access VAD and they're in a faith based, it may not be a faith based, but in an institution that doesn't allow or has a conscientious objection but you're the GP, what do you do?
 
Dr Greg Mewett: Well, there are of course, there are a number of cases that are coming to light about that. I think the first thing to say, and I would say it is from GPs as well as any organisations if you're a conscientious objector and you don't wish and you don't want to be involved tell the patient, inform the patient, if you have a conscientious objection to VAD don't dismiss their concerns and quieten their level of suffering by saying oh no that's rubbish, I wouldn't do that, you can't do that, that's just silly. Take the discussion seriously but say, look that's not something that I can consciously be involved in, but I can direct you for further information. Now you don't have to do that by law, but I would hope that for most people they would see and take the concerns of the suffering patient seriously enough to do that. And it's the same with institutions, they have to clearly give all of their residents the clear message that this is not something that they're prepared to do and then unfortunately when those cases come up other arrangements need to be made and that varies, we've had lots of different experiences with different faith based and occasional nonfaith-based organisations that don't want anything to do with VAD. Now, that is their right to some extent, but it's also something that needs to be very carefully thought about because you know impeding a patient’s legal right to a legal sort of process if they've been assessed as being eligible, not just because they've asked but they have been assessed as being eligible. You know I think impeding a person's access to that is ethically very questionable, but if people want to do that, they need to be clear about it and not impede a person's eligibility. So sometimes the patient has to be removed from the age care facility to somewhere else, where they can complete the VAD if that is their wish.
 
Dr Sally Cockburn: hmm um there's just you've put those interesting things up, especially about the VAD care navigator which will bring up in a minute, but, this question, I think, is really important, because there is something in the process, about this if a patient,  if, this is from Penelope, if a patient elects to have the VAD and it is part of the process for the GP, their GP to be informed even if the GP is not involved, this would help us with the medical certificate if we ended up having to fill that task in. There is something about this in the forms isn't there Greg? You have to tick a box, as to whether you know whether the usual doctor is notified is aware, I believe.
 
Dr Greg Mewett: In what sorry.
 
Dr Sally Cockburn: When you fill in the assessment forms, there's a box that you tick that says, whether you're aware that the usual doctor has been involved, of course, we're caught up in the privacy thing if the if the patient says, I don't want my GP to know what do we do?
 
Dr Greg Mewett: Well, I think, on the form that we put down through the portal, it says to your knowledge has the patient informed you know the relevant people and doctors, I tick yes.But I think all my patients have at least told the GP whether the GP approves or not, along with the decision. is another thing that they've all told them and that's not an impediment to proceeding.
 
Dr Sally Cockburn: Penelope’s point is very important, because if you do fill out the MCCD which a lot of lot of time, you may not have been involved in the VAD but you may do the MCCD if you don't know that they've been on the program, then you can't tick that box.
 
Dr Greg Mewett: Correct, I don't know of many cases or any cases personally and there may be, where a doctor doing a death certificate it hasn't known that the patient’s been a VAD subject. Now there is a case, there is always a case of exception, but if they don't know, they don’t know.
 
Dr Sally Cockburn: I was speaking to a funeral director about this exact thing, and she said to me, there are families again coming back to they don't tell a certifying doctor because they're worried that VAD is gonna be on the death certificate so it's almost worthwhile if you're filling out an MCCD of someone who you don't know who's on the program you can always say. Look I’ve got to answer this question don't be worried it's not going on the death certificate it's probably worth bringing it up, but there needs to be more education on this area.
 
Dr Greg Mewett: Well I think one of the things I always do when I’m seeing a patient is, that is one thing I mean it's the post death stuff that I actually discuss with them. So what happens when the, do I have to call an ambulance or no, what happens when the patient in most of our patients die at home would be that you call most, and I would say Sally over 90% of these patients have palliative care involved so it's another furphy that people say or people are doing this because they don’t want palliative care or you know they can't get palliative care. 90% I think of the latest figures from your review board, the people are involved with palliative care now that varies and dawdle extent. But it's a furphy to say that people are doing this because they can’t get palliative care. What part of the process is to deal with the family and the patient, what happens after death, I actually talked to them about what happens, when they take the medication and the pharmacist, state-wide pharmacy service goes through that, what happens after death, who can sign the death certificate what appears on the final death certificate you get a copy of so patients are prepared and understand that.
 
Dr Sally Cockburn: Parvathi has asked another question that is quite clear in the legislation and Parvathi I’d really urge you to read the references that I put at the bottom of this because a lot of these questions are answered there, what happens if a child is below 16 years of age terminally ill and in a vegetative state?
 
Dr Greg Mewett: It's got nothing to do with voluntary assisted dying the voluntary assisted dying act is clearly for patients over the age of 18 with decision making capacity with respect to the involuntary assisted dying.
 
Dr Sally Cockburn: And, and the other most important thing is, they have to have a terminal illness, with a prognosis of less than six months or in the case of a neurodegenerative disorder up to 12 months and there's some special stuff around that last one, because they have to get another doctor.
 
Dr Greg Mewett: So Sally a couple of other really important points people get confused about. Firstly, the term euthanasia, so voluntary assisted dying is a term that covers two specific types of assisted dying. The most common type and the default position under the Victorian act is that a patient is given a prescription and it's dispensed to a lethal dose of medication and the patient elects to take that at a time and in a place with whom they wish in that situation that's called self-administration permit. That is not euthanasia, that is in other jurisdictions call physician assisted dying, voluntary assisted dying covers that but also covers the in minority of cases in Victoria what's called practitioner administered voluntary assisted dying so practitioner administered is in other words a doctor is able to apply for a permit to administer a series of medications to a patient to bring about their death in the case where a patient is unable to swallow absorb or keep down the oral medication so it's a, so these are two types of practices that overseas is called voluntary euthanasia, where a patient has administered to them a series of drugs to bring about their death at their request of the request and self-administration where a patient has the lethal medication and takes it at a time and in a place that's convenient for them. So these are two different types of permits and two different types of practice, so this is not a euthanasia act. Euthanasia is part of it, and there is an allowance for voluntary euthanasia and I always emphasize the word voluntary because what that question before about the 16 year old and an entity status talking about is that well, what do we do in that situation well that's a different ball game and decision making process and involuntary, V for voluntary assisted dying. People are worried that voluntary assisted dying and euthanasia will mean that people will be bumped off by stealth. And that doesn't occur, it can’t occur and won’t work, if it occurs it's probably been occurring for years it’s got nothing to do with this act. And I would say, you know I don't even know of any cases of that, and I’ve been around a long time. Now I’m not saying that hasn't been and they probably have, and they would be overseas, but this has nothing to do with voluntary assisted dying act.
 
Dr Sally Cockburn: And that brings up one of the really important points, which is just because someone ends up going through the system, their doctor gets the permit, they write the prescription, the state-wide pharmacy service delivers the substance in a locked box to the person they don't have to take it.
 
Dr Greg Mewett: And some of their patients decide not to take it, they are recovering in their suffering actually reduces once they get hold of the medication. It's part of that having control and I don't I’m not trying to use the word control in a pejorative way I’m trying to use it as a way where people feel they have regained some control over their dying that they've not had. And people feel comforted by that and some patients, and in fact in Oregon in the USA, where this legislation similar legislation is made available for some 22 years around 30% of people don't either get the script filled or get the medication, take the medication themselves so 30% people die, despite having a VAD approve, without accessing the VAD.
 
Dr Sally Cockburn: Just on that we've got a question from Sujeewa and then Marina wants us to go through more of the eligibility stuff. Who is going to give them, we've already sort of hedged around this, who is going to give the medication to assist dying to the approved patient?
 
Dr Greg Mewett: Okay, so in the common case, as I said, is self-administration, where the patient is dispensed an oral medication, that is made up immediately prior to administration, the patient must self-administer. That means the other person, the family or friend can help mix up the medication because comes into powdered form it's mixed up in 30 mils of liquid, but the patient must drink the medication.
 
Dr Sally Cockburn: Or suck it up a straw.
 
Dr Greg Mewett: Whatever they take they have to, be at, they have to self-administer. We had a patient die in our palliative care unit and if he self-administered their VAD medication down her peg tube which she was able to do. So, you know, in the practitioner administered VAD it's the coordinating medical practitioner because remember, there are two doctors, the coordinating doctor who does a lot of the legwork and I do a lot of those cases where you help the patients are then there's the consulting practitioner who gives an independent opinion but it's the coordinating doctor that applies and is granted a permit if that's granted, who then has to administer the medication in the practitioner administration.
 
Dr Sally Cockburn: There's one step in between that and that is, they have to apply for a permit to the secretary, and so they have to have all our ducks in a line, have everything done everything finished and then they write a permit. The Secretary looks at all the documentation checks at all it's all correct and then write a permit, then they get the state-wide pharmacy, then write prescriptions state-wide pharmacy service at the Alfred dispensed goes wait for the patient to ring them, and this is the other steps we need to tell our patients, by the way you have to you have to instigate this and I think-
 
Dr Greg Mewett: That happens, if you're the coordinating doctor and so I’ve done that's my main role in VAD over these last two years, you must inform the patient that either themselves or the next of kin or whoever has to ring and arrange for this, at a time that's convenient that pharmacy will come up and go through the whole process and dispense it. So as far as who gives I,t the patient themselves or the coordinating doctor if it's a practitioner administer intravenous medication.
 
Dr Sally Cockburn: Now Penny has asked a very important question and I want to come back to the eligibility criteria in a moment, but who police's this? The voluntary assisted dying review board do it after the fact, but who police's it, the doctors
 
Dr Greg Mewett: What I mean, you, who polices, you have to pull it, obviously the act any act requires you to practice within the law. So, if you've done something that's obvious in your paperwork and all the things that is obviously not according to the act, you can be charged with an offense or you can be cited for unprofessional practice, for example, if you raise voluntary assisted dying with someone before they bring it up. But having said that its compliance is part of the training, is to learn, in fact, the training really is about how to comply properly with the law and how to do this properly, so that people are being dealt with fairly and squarely and not through the back door, believe me that you know, that is, that is not a practical concern, but if someone greedy just enough to do something ridiculous will then it'll be picked up in the paperwork and it can be referred by the review board to the police to AHPRA if necessary. And it would have to be deliberate, you know, a deliberate act, not an active, you know minor mistake or something like that.
 
Dr Sally Cockburn: Exactly, and I think again, that’s evil, but you know I hope we haven't got any practitioners, who would even try it because the whole process, you have to put all the information you know, in a portal online it's checked by the secretariat it's been checked by the Secretary and then everything's okay after the fact it's checked again by the voluntary assisted dying review.
 
Dr Greg Mewett: That reminds me another really important point I’m happy to answer a couple more, a lot more questions, but one of the things is Sally is that people often say, and I was reading about this in a paper that was published just recently, doctors in Victoria, who are objecting were saying that doctors like myself who are involved in voluntary assisted dying will then become fairly routine about it. And it'll be a routinisation of VAD that patients will be assessed or encouraged to come in for assessment and that they shuffle down the course and off they go and so will become sort of you know, just a conduit for death and, in fact, all of my colleagues on the Community of practice we all actually what to say one thing. And as a palliative care doctor I hope they don't ask for VAD, I mean if they genuinely want to, we will help them, but if they don’t, I mean the things we have to go through to get them through that the safeguards, important as they are and very important are doable but, it's time consuming and I’m not trying to downplay it or to put people off, but to sit there and think, ah we do it because it's an easy way to bump people off, it is just not the case. It's hard work and each of these cases, take a lot of us both mentally and physically, but they can be very gratifying, and they are some of the most grateful families and patients.
 
Dr Sally Cockburn: And that's why, having the community of practice is really important for anyone who is considering doing it, so if you've got someone to debrief with it is, it is, can be very gut wrenching with some of them. Penny just wants to clarify, I sorry Penelope I don't know whether you like being Penny, I do apologise, she said, I mean who police's that the patient self-administered at a time of their choice in the patient's home? Would I be right in no one actually has to police?
 
Dr Greg Mewett: I mean this it comes up, it came up time and time again in a lot of our talks to health services and practitioners and health professionals who polices it? Well, who polices, my answer is that who polices, I mean we give patients in palliative care and in other areas of medicine huge amounts of potentially lethal medication. If you prescribe someone 50 times 50 of amitriptyline or enormous amounts of opioids, patients can potentially do mischief and some patients do. So, it's not, we don't, our role is not as policeman in patient’s, the privacy of the patient's own home. Our job as doctors is in good faith to help patients in whatever way we can and I combine you know, regardless of what people think I combined my palliative care skills, with VAD that they are intermingled in my practice, inextricably linked and but we're not there to police what people do once they've been prescribed a legal medication.
 
Dr Sally Cockburn: And it's none of our, it’s frankly none of our business when they choose to take it, that's their business and some people don't ever take it, but if they die of something else, or they don't finish it, there is a failsafe, safeguard and that will a safeguard, and that is that form four which the applicant has to appoint a contact person, this was a lot of debate around this I’m sure you remember Greg as a what happens if this lethal drug is left in the Community, what if someone else takes it, so the contact person who the applicant will appoint has to bring that back within a time frame.
 
Dr Greg Mewett: If the contact person is just a person, it's usually a close relative or friend who agrees to within 15 days of death, arrange for the medication to be returned to the pharmacy if there's medication leftover or not taken so they ring the central pharmacy, the state-wide pharmacy, the Alfred, they arrange for it to be picked up, that's all and that's checked on if that and that's that is actually another contact person who doesn't do that could be charged, unlikely, but it is part of the act and I have to comply with that within 15 days they have to return any unused VAD medication so yeah.
 
Dr Sally Cockburn: And it's important, I suppose, if people are doing, if they are the coordinating medical practitioner is to talk to the applicant about who you choose to be a contact person, because it doesn't have to be a close friend or relative and especially if the close friend or relative is a bit, I don't really want to do this.
 
Dr Greg Mewett: Yep, we've had other people appointed as the contact people, even within the health service.
 
Dr Sally Cockburn: let's just go right back to again when someone asks you to do VAD just if someone is sort of thinking, maybe I need, the first thing is, if you really don't want to do it, you can refer them off to another person, if you want to find out who someone else might be that can do it, you can ring the care navigator if you don't know the likes of Greg or you're not near him. But what about someone who's clearly not eligible, that is, they're sitting there, and they can't and they've got a mini mental that's just not good and they're not competent. And you think well, look, I don't think I should refer your on because you're ineligible or should you refer them on and let someone else decide that.
 
Dr Greg Mewett: It look, you know, it depends on your comfort in that area, I mean if it's clear to me as an experienced practitioner that someone doesn't have the capacity to make a consistent enduring decision about VAD then I'm not going to, and I will then have to talk, then talk to them and their family about this, the common situations where a patient comes in, fully competent but their prognosis could be two or three years, you know, let's say a guy with metastatic prostate cancer, a woman metastatic breast cancer, these patients live for some years even with metastatic disease and these patients are going to have to be told sooner, sooner or later that they will not qualify under the prognostic criteria. But they might at a later time that we're not dismissing the request, but we will not take it any further, and this is why now some of these basically quite distressed and upset about that but, and we actually, I was actually played the part of the doctor we recorded a video on the training program that you can see, on Dr Gary for anyone and it's what my children now call me, is Dr Gary being confronted with a patient who is not, has been found not eligible and how we take a patient through that without dismissing them and being able to deflect their, more their anger with a very strong disappointment that you aren’t able to help them.
 
Dr Sally Cockburn: But it would be very important at this point to have the usual GP involved because we're the ones who, if I mean, if we don't know that they've been deemed ineligible we don't know what's going on, but if say if I’ve referred my patient to you Greg and you find them ineligible I would want you to tell me that they're ineligible, so I could debrief with them and send them back in X amount of time.
 
Dr Greg Mewett: That's exactly right yeah. And, of course, you know I mean there are situations where a patient is deemed ineligible by the consulting doctor and they go back to their coordinating doctor and their coordinating doctor has the right under the act to refer them to someone else. But that would turn up as doctor shopping, if you want, if you're repeatedly referring someone because you're being knocked back, that would be picked up quickly by the board and you'd be counselled as to that and they'd be more, but I think if there are any doubts about a patient prognosis. Though their capacity to make decisions about VAD or anything like that, then you gotta get another opinion and I often ring even before I start the process, ill ring the oncologist and say this woman's actually considering dah dah dah, oh yes she told me about that, what do you think of the prognosis well I think they're not having any further treatment I’d say the prognosis is maybe nine to 12 months, so I said well okay, well then I’m probably gonna find them ineligible and I’d say yep, but come back later. And that's one of the, you need to have the communication skills to talk patients through that and then divert them if you can from the VAD focus back onto the palliative care, quality of life, all the other things that you can put in place to improve their quality of life for, however long they've got left.
 
Dr Sally Cockburn: I’m mindful that we've probably only got what about six minutes left, and I know people leave their questions to the last minute, so quickly get your questions in if you if you want, but I suppose on that Greg there's some legwork that people can do if someone comes and asks you for, asked a GP, you know, want to get involved VAD and, meanwhile, while you're out there, trying to find someone to do it there's documentation they can get together, what of the pivotal pieces of documentation that they need to be able to progress in a timely fashion.
 
Dr Greg Mewett: Well you've got to be able to prove that you're either Australian citizen, so therefore you must have an original, a copy of a birth certificate and now there's other, there's tricks of the trade here and I don't take up too much time or a current or expired Australian passport or a certificate proving that you're a permanent resident. And you also have to have some sort of documentation to say that you've been permanently resident your place of residence within Victoria, for more than 12 months so that might be an electricity bill from last May, for example, it still has-
 
Dr Sally Cockburn: But it has to be more than, it has, I’m not getting any cats out of any bags but not from January this year, it has to show that you've been there for 12 months.
 
Dr Greg Mewett: But that's the, that's where it can be a good coordinating practice gets it's all that in place, often with the help of our VAD coordinator and our hospital or care navigator if you'd like, to call that in our in our hospital as well, so.
 
Dr Sally Cockburn: And what about writing up your assessment, the importance of keeping good notes, as well as ticking the boxes in the portal.
 
Dr Greg Mewett: Just like any good record keeping I mean it's gotta be you should document if a patient's actually making the genuine first request to you and you're accepting as the coordinating doctor, I always write exactly what they asked me, in whose presence that was asked, what my response was, and I mean it's no different to other good record keeping. But you know, and I think that's important because you want to be able to show that you've acted in good faith here if, if anything, does go on this, which is unlikely, but if it does.
 
Dr Sally Cockburn: Greg in the perfect world, if you know there's you and you can find a or someone finds a consulting doctor, the second doctor and it's a clear cut prognostic thing and they've got all their ID what's the time frame, because I’m wondering do some people leave these too late?
 
Dr Greg Mewett: Yes, and I think that's improved I mean. The short answer to your question is depends on where you live, what the time frame is. Us in the rural areas and we deal with, it can take longer because you got to get patients to somewhere where they can have a consulting assessment. Most of us would say the average time is about three to four weeks from the time the person make their first request to the time that they might get the medication if they say we ship their time dispensed so three to four weeks. There is a provision in the act to compress that if both practitioners are able to say the patient has less than nine days to live. So, patients were leaving it, and now I think we're starting to get people at least down the track of it earlier. So that there's not a mad flurry at the end, and these are patients who we've got a bit more time to take through and some of these patients eventually decided not to go ahead so.
 
Dr Sally Cockburn: Now you touched on in the country, getting people organized to go and see a consultant, this is an issue. I understand, with the criminal code in the federal government saying with issues about whether you can use a carrier service, a telephonic whatever, this sort of thing to have a meeting with a patient.
 
Dr Greg Mewett: It’s a complex situation Sally and I’m aware of the time. If there are other questions. That’s something you will have to deal with if you become a coordinating practitioner or a consulting practitioner, so that's a difficult thing to answer in a couple of minutes, but it does mean a federal law can override the VAD act, theoretically it's never been tested and I’m quite clear that I’ve actually done it three times, I’ve actually done an assessment, I wouldn't do competency assessments but i've done other straightforward assessments by telehealth purely because, A, COVID, B, distance and C the infirmity of the patient.
 
Dr Sally Cockburn: And talk to your local Federal Member everybody, you know, that’s the thing. I see Marinas come on board, but there are two very important questions and I knew they would come in the last two minutes so quick answers for those ones. Megan wants to know so if a patient moves to be with family for care needs does change of address within Victoria make them ineligible for VAD.
 
Dr Greg Mewett: No, but you have to have the, but you have, to play the game, you have to have the consistent address that they've been at that address within Victoria, they have to have been within Victoria, for the last 12 months.
 
Dr Sally Cockburn: Can I just clarify that. I think the wording of the act is that they have to have been a resident of Victoria, not necessarily at the same Victorian address.
 
Dr Greg Mewett: That’s right, there has been a number of test cases about that for people who travel interstate for four or five months of the year, but they are still found to be eligible, if you really want to press the case next question.
 
Dr Sally Cockburn: 30 seconds, Penny, Penelope, sorry Penelope, I’ve heard that there is no Medicare rebate for these assessments does it mean that the doctor has to do this work pro bono, there you go Greg.
 
Dr Greg Mewett: Well, in the community of practice there is a lot of discussion about that, I personally work in a public health system, I don’t charge. Some GPs charge normal fees, the only thing that's not covered under Medicare other than your home visits, and that is actually the procedure of practitioner administering VAD if that occurs in a private facility or at home. So that's not covered, but a lot of the private doctors in our community practice have their own scale of fees that they feel are reasonable and are usually no problem.
 
Dr Sally Cockburn: More work for the Faculty Marina, in that you know, why isn't there a Medicare rebate for a perfectly lawful treatment.
 
Dr Greg Mewett: Most of the consultations, the problem is, of course, is quite a lot of after, away from patients faced work that you have to do on the portal, but the actual patient face works should be billable.
 
Dr Sally Cockburn: And Greg, as always, these topics we've got more questions, oh Charlie Cork, I have to say, Charlie Cork is in the audience and Charlie is the acting Chair of the voluntary assisted dying review board and Charlie intensive care specialist from Barwon and Charlie said, and thank you for this Charlie I’m glad you're saying it, the new portal let's patients have an original residential address and a current residential address, and I can say I’m sure Charlie will be happy for me to say this there's a lot of work going on with the nuts and bolts of fixing the portal to make it more user friendly. We better wind it up because Marina is there, looking at me and Greg, look, thank you for being so candid tonight, and I hope it's made people feel that they can talk about this issue and we might do another one of these just to cause there always is more.
 
Dr Greg Mewett: There's a lot of stuff going on, I hope that gives GPs is a bit of an idea about how they can respond without just getting stuck and not being and feeling frozen in the moment.
 
Dr Sally Cockburn: Exactly and can I ask people if, you would have received a whole lot of information with a whole lot of references that you can use to go and find out the answers to a lot of the questions that possibly weren't even asked today and Marina I realised we've gone over time that's naughty. Oh, can I just tell everyone that next Alt Wednesday in October is team building and it's optometry and we've got an optometrist coming on, so how can we can we can utilize optometrists better in a general practice team way, I declare my interest, my dad was one of them, but anyway so Marina I’ll hand back to you and thank you so much again Greg.
 
Dr Marina Malcolm: Thanks Greg and Sally we really, really appreciate that the one-on-one time that you gave us to really answer our questions and I didn't really have very much more to add except for to look out for next Alt Wednesday and also the Department of Health COVID ones coming up and that's about it and just remember that when the meeting ends it abruptly goes poof and we're all gone, but thanks very much.

Other RACGP online events

Originally recorded:

1 September 2021

Well known media commentator and respected GP Dr Sally Cockburn will be deep diving into various GP-relevant clinical topics with guest panellists to address “stuff they didn’t teach you in medical school”.

Hosted by RACGP Victoria Faculty and Dr Sally Cockburn, these will be interactive panel discussions and promise to be entertaining and educational events!
This event attracts 2 CPD points

This event attracts 2 CPD points

This event is part of Alt Wednesdays webinar series. Events in this series are:

Presenters

Dr Sally Cockburn

Dr Sally Cockburn is a practicing GP and health educator. She graduated MBBS from Monash University in 1982 and recently completed her Masters of Health And Medical Law from Uni Melbourne. Sally has also been a high-profile media presenter (Dr Feelgood) for over 30 years on radio, tv and in print. She has a strong commitment to Medical Education and has held various teaching positions. She is currently an adjunct Senior Lecturer in Department of Public Health and Preventive Medicine at Monash University. She has a strong commitment to better health outcomes and social justice and behind the scenes has been involved in health policy and legislation reform. She has sat on some high profile not for profit boards Sally has received numerous accolades throughout her career, including a radio industry award for best documentary , the Monash University Alumni Service Award and in 2010 was inducted into the Victorian Women’s honour roll for harnessing the media to improve health communications. She is a sought after public speaker, MC and panel facilitator.

Dr Greg Mewett

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