Serena Chu
Welcome to this evening webinar Voluntary Assisted Dying Implementation. My name is Serena, your RACGP representative for this evening. We are joined by our presenters Dr. Kerry Chant, Dr. Wade Stedman and Dr. Ramanan Chandrabalan.
Before we get started, I would like to make an acknowledgment of the country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders’ past, present and emerging. I would also like to acknowledge an Aboriginal and Torres Strait Islander colleagues that have joined us online this evening.
I would like to introduce you to our presenters for this evening. Dr. Kerry Chant is a public health physician, Chief Health Officer for New South Wales and Deputy Secretary of Population and Public Health at the New South Wales Ministry of Health. Dr. Chan has extensive public health experience, having held a range of senior public health positions in New South Wales since 1991. Dr. Wade Stedman is a clinical lead for the implementation of voluntary assisted dying in New South Wales, including development of clinical guidance, education and training and clinical pathways. Wade is also staff specialist in Intensive Care Medicine at Royal North Shore Hospital, and has a particular interest in long term psychological outcomes of patients who have survived a severe clinical illness. Dr. Ramanan Chandrabalan is a visiting medical officer with the New South Wales Voluntary Assisted Dying Care Navigator Service. Ramana is a general practitioner and practices in Inner West Sydney, and a further staff specialist with the Hospital and Home Service at Royal Prince Alfred Hospital. Ramana has a mix of clinical roles, allows him to enjoy the vast breadth of medicine that is general practice and finally, before we head over to our presenter, I will quickly run through the learning objectives. By the end of this online activity, you should be able to describe the process of becoming a voluntary assisted dying practitioner. Second, outline how Voluntary Assisted Dying Services such as the Care Navigator Service can be assessed. Third, outline the rights and responsibilities for practitioners. I will hand over for Kerry to present it. Thank you.
Dr Kerry Chant
Thanks very much. The next slide. So good evening everyone, and thank you very much for attending the second webinar on the Implementation of Voluntary Assisted Dying in New South Wales. My name is Dr. Kerry Chant and I am the Chief Health Officer for New South Wales. I would like to start by acknowledging the traditional custodians of the land and lands of which we are meeting from. And we honour the ancestors of yesterday, the custodians of today and those of tomorrow. We recognise the continuing connection to land and waters and how culture is held, nurtured and shared. We pay our deepest respects.
It is really pleasing to see so many GP’s join with us tonight. Voluntary assisted dying represents a significant change in our health care system. It is important to understand the services that will be available and what role you may play. Some of you will choose to be authorised voluntary assisted dying practitioners, whilst others may decide not to play a formal role, however still receive questions from patients in the course of their care and treatment, and we recognise the pivotal role GP's play in providing coordinated care and voluntary assisted dying will form part of that end of life process for your patients. In the second webinar we will discuss voluntary assisted dying in the context of primary care and end of life care more broadly. We will also explain how you will become involved with voluntary assisted dying as an authorised practitioner and the role and functions of New South Wales Voluntary Assisted Dying Support Service. It's also an important opportunity for you to ask questions, and we have reserved time for this at the end of the presentation. So, if you have any questions, concerns or observations throughout the webinar, we would really like to hear from you. So please ask any questions or type them into the chat box. A critical part of voluntary assisted dying is that patients must maintain decision-making capacity for the duration of the voluntary assisted dying process. If at any point they permanently lose decision-making capacity, they are no longer eligible to access voluntary assisted dying. This is an important safeguard to ensure that a patient's desire to pursue voluntary assisted dying is voluntary, enduring, clear and unambiguous. As you know, patients with capacity can already make informed choices that may result in their death for example, refusing life saving treatments. These sorts of decisions should be made following end of life discussions that many of you are very practiced in. These are avenues open to individuals to determine their care for pathways. Currently involuntary assisted dying will be again patient centered. It's an option for a patient where it aligns to their goals of care and where they meet very specific eligibility criteria.
Our goal in implementing voluntary assisted dying, is to embed voluntary assisted dying as part of broader end-of life care, where this aligns with a patient's goals of care. Our commitment is to putting patients at the centre. Data from other states that have already implemented voluntary assisted dying shows this would be especially important for oncology and haematology patients, neurology and respiratory medicine patients, which are the key clinical streams for patients seeking access to voluntary assisted dying. Around 70% of those accessing voluntary assisted dying fall within the oncology stream. I will now hand over to Dr. Wade Stedman, our clinical lead to expand further on the incorporation of voluntary assisted dying into end of life discussions and planning. Thank you. Wade.
Dr Wade Stedman
Thanks, Kerry and thanks again, everyone for joining us at the end of you're probably very long clinical day, so thanks.
As Kerry said, voluntary assisted dying is a choice available to an eligible person who is approaching the end of their life, and this is in addition to other choices that people may make about their end of life care, including palliative care. The voluntary assisted dying process is entirely patient driven, and at each stage the patient can decide to pause or stop the process. A fundamental part of the legislative framework is that voluntary assisted dying should complement a person's right to access high quality palliative care and indeed, it's actually a requirement of the legislation that conversations around voluntary assisted dying also include other end of life options available to that person. Importantly, where it aligns with the patient's goals of care, the discussions about voluntary assisted dying should occur as part of routine decision making. This includes having respectful, honest discussions summarising the current clinical situation and estimated prognosis, listening to patients and doing our best to understand what is truly important to them at this difficult time in their life, building a shared understanding of people's psychosocial and physical needs so that available treatment options can be tailored to best meet these needs. At the same time recognising that each individual will have unique goals of care and their reasoning for this will also be unique. As mentioned, ensuring that there are appropriate options such as palliative care and voluntary assisted dying are included in this conversation. An advanced care directive is an important way to document a person's wishes about health care and treatment, should they lose capacity in the future. However, it is important to understand that once a person loses decision making capacity, they are no longer able to access voluntary assisted dying, even if they have previously expressed wishes to do so. This is because, as Kerry mentioned, a person must have decision making capacity throughout the process for voluntary assisted dying. Voluntary assisted dying will be available in New South Wales from the 28th of November this year, which is just six weeks away, and one night, that all counts. And it is important to note that voluntary assisted dying services cannot be accessed before the 28th of November. In order to support the implementation of voluntary assisted dying and build a system that is accessible to all eligible people, we are collaborating closely with the local health district's, executive leads, who are working within their districts and with local health services such as your own, to develop care pathways and local linkages and processes to support their communities. If you have not yet had discussions with your local health district about voluntary assisted dying, I would encourage you to do so and we can help facilitate connection if needed. We have been engaging with private hospitals, aged care providers, disability care organisations to ensure that their needs are considered and we have been consulting widely, including with our priority populations, including multicultural and Aboriginal representatives. In addition, there are a number of key systems, services and frameworks that are needed to be established to support the implementation and I will give a brief update of those now.
The implementation team has been working closely with local health districts and other health agencies to establish care pathways to support eligible patients across New South Wales in a range of settings to access voluntary assisted dying with a special focus on, but of cause not limited to, as Kerry was saying, oncology, haematology and neurological settings. These pathways include transfer of patients to and from private providers if required, which should occur through usual mechanisms that are available today. The implementation team has also developed resources on health pathways which can be accessed today, and these resources will receive additional information as it becomes available. The New South Wales Voluntary System Dying Clinical Practice Handbook has been developed by our Clinical Advisory Group, and that is a detailed guide to support authorised practitioners through every step of the voluntary assisted dying process. The Clinical Advisory Group was selected following an open expression of interest process and it includes representatives from across the state and also many specialties. We also feel it was important to include conscientious objectors in the group, so we had a broad range of views and expertise. The Clinical Practice Handbook is now available to you to view and can be accessed via the QR code that is on the screen. The implementation team has also worked closely with the New South Wales Registry of Births, Deaths and Marriages and the office of the State Coroner to develop the revised Medical Certificate of Cause of Death to include reference to voluntary assisted dying. The updated medical certificate of Cause of Death is marked Voluntary Assisted Dying Compliant on the front cover. They will otherwise actually look very similar at a glance. From the 28th of November 2023, all voluntary assisted dying deaths must be recorded in the updated medical certificate Cause of Death and state both that the person died as a result of administration of the voluntary assisted dying substance and the disease, illness or medical condition which made the person eligible to access voluntary assisted dying as per the act. There is a tick box that is very clear, that said, did this patient die as a result of voluntary assisted dying? And then in a separate section that is where you would write for example motor neuron disease or metastatic pancreatic cancer. All of our work has been informed by the learnings and experience of other states, have been absolutely, incredibly generous with their time and their resources. Having a sufficient workforce to provide voluntary assisted dying services is actually critical to implementation. Medical or nursing practitioners who meet the eligibility requirements and wish to become authorised voluntary assisted dying practitioners must register via the Voluntary Assisted Dying Portal, which is available on the New South Wales Health website. When registering, make sure you have your APA registration, your HPII number which can also be found within your APA registration and an up-to-date CV. You will also need two valid forms of ID and more information is also available on the New South Wales Health website. It is very pleasing that we see over 100 GP’s have begun the registration process to become an authorised practitioner. Once you have registered and have been assessed as eligible to become an authorised practitioner, you will be directed to complete comprehensive mandatory training. This training is now available both online and in person at several face-to-face training days across the State. And the weekend just gone. we just hosted our first two training days, one in Dubbo on Saturday and then in Saint Leonards on Sunday. Spaces are very limited for the in-person training, so you'd like to access this training in this manner, I would recommend registering shortly. Remember the face-to-face training and the online module are equivalent, in that it is the same exam and the same qualification. It is just we know that some people would like the option of face-to-face training and they are certainly providing both options. We are also developing a shorter awareness raising module for all other health professionals, including those who may support patients seeking access to voluntary assisted dying, but who do not have a formal role in the process. This will be accessible to anyone interested.
Now, I would like to now go through a case study to illustrate a little bit about the process of voluntary assisted dying in New South Wales. So, let's talk about Martha and she is a 68-year-old woman who was diagnosed with metastatic bowel cancer two years ago. As part of Martha's treatment, she underwent a hemicolectomy, a hemi hepatectomy and had chemotherapy. Her treatment was initially effective and initial surveillance imaging did not reveal any new metastatic disease. Unfortunately, 12 months later Martha was noticed to develop hip pain and imaging showed bony metastatic disease. Despite undergoing further radiotherapy and a trial of immunotherapy, her disease progressed significantly. Martha then approached her GP after her worsening diagnosis, stating that she doesn't think she can do it anymore and wants to learn about her options. The GP acknowledges Martha's distress and discusses her goals of care. As this is a general conversation about end of life care, the GP is able to explain voluntary assisted dying as one option of care for her. After ensuring that Martha is aware of all her treatment options, the likely outcomes of those, including palliative care, the GP provides the necessary support and information. Martha then makes a decision to access voluntary assisted dying or to start the process as her GP has completed the mandatory training and is an authorised practitioner and the GP accepts Martha's first request. You can see an overview of the voluntary assisted dying process now on that slide. So you can see on the left hand side, Martha has made a first request, which is the first step of the journey through the voluntary assisted dying process. Martha's GP is required to complete the first request form even if they are not accepting the first request because they are not an authorised practitioner or for another reason. So if you receive a first request, you still need to complete a first request form on the portal. The form will be accessible on the voluntary assisted Dying portal from the 28th of November. Martha’s GP upon accepting the request, becomes the patient's coordinating practitioner and completes the first assessment to determine her eligibility. Martha's GP assesses her eligibility and she will be assessed also by another practitioner if she meets those eligibility and that second practitioner, will be known as the consulting practitioner, also needs to have completed the mandatory training. If Martha's GP and the independent assessment by the consulting practitioner are both in agreement and Martha wishes to continue, she may then make a written declaration and submit a final request to the coordinating practitioner, who will then undertake a final review. It is important to remember that Martha is driving this process and she can pause or withdraw the process at any time. If she was to take a break for a week or two to think about it, she would just re-enter it the same point of the pathway in which she left. Martha’s GP or the consulting practitioner may refer her to a specialist or other registered health practitioner with appropriate skills and training. If there is a need for an extra opinion about eligibility such as, for example, an opinion about prognosis or decision-making capacity. The people providing that opinion do not need to be authorised practitioners under the VAT Act, they just need to obviously have expertise in that field and they are providing just an opinion on that particular question around the eligibility. Following the final review and submission of the relevant forms to the Board, the Board considers the application and may approve or decline the application. If approved, Martha's GP, in their capacity as her coordinating practitioner, is able to write the prescription for the authorised substance, which is then sent to the Voluntary Assisted Dying Pharmacy. In New South Wales, Martha can choose to self-administer or have the authorised substance administered by an eligible practitioner, which is defined by the Act.
I would like to stop here now and hand you over to Ramanan who will talk about being an authorised voluntary assisted dying practitioner as a GP, and to talk about Voluntary Assisted Dying Support Services in more details. Thanks, Rames.
Dr Ramanan Chandrabalan
Thank you, Wade, and thank you to everyone for joining us here this evening. So as GP’s, being a GP myself, we are incredibly privileged to be able to get to know our patients on a deeply personal level and over the years, I have accompanied a number of my patients on their cancer journeys, and a handful of these patients have had a profound impact on how I continue to practice and how I approach conversations around end of life care. And these experiences, and I guess the general trust that patients put in me, what encouraged me personally to become an authorised practitioner so I can support my own patients who wish to access voluntary assisted dying. But I do acknowledge that becoming an authorised practitioner is a deeply personal decision and respect the personal opinions of all of those GP's here tonight as to whether voluntary assisted dying is something that they would want to become an authorised practitioner for.
As is clear from the journey described by Wade, being a coordinating practitioner requires a significant number of consulting and administrative hours to support the patient along their journey. Furthermore, in the context of the Criminal Code, a Federal piece of legislation, several consultations, especially those pertaining to discussing the voluntary assisted dying substances and the routes of administration of the voluntary assisted dying substances, need to be undertaken face-to-face and cannot be undertaken utilising telehealth mediums, and we recognise that this adds further complexity to providing voluntary assisted dying services to your patients. In regards to remuneration, patients are eligible for their usual Medicare attendance rebates for each step of the journey, except for consults pertaining to voluntary assisted dying substance administration, which is not eligible for a Medicare rebate as per MBS stipulations. Acknowledging all of the above that I' have just mentioned, not all GP's will be able to or want to provide voluntary assisted dying services to their patients. We suspect perhaps only a small portion of GP’s will become authorised voluntary assisted dying practitioners, and such patients may contact the Care Navigator Service seeking to access voluntary assisted dying and will be first encouraged to speak with their existing treating team, for example their medical oncology team, and to prepare for this, all local health districts will be able to support eligible patients to access voluntary assisted dying. Any service gaps, for instance, particularly in remote areas of New South Wales, will be supported by the New South Wales Voluntary Assisted Dying Support Services. If a patient is not already connected with the public system or prefers to access voluntary assisted dying through a different practitioner, the Care Navigator Service can connect that patient with an alternative coordinating practitioner who may very well be a general practitioner. As Wade mentioned, coordinating or consulting practitioners may refer patients to other health practitioners to assist for advice when determining eligibility, for example, around prognosis, and as a GP you once again may be approached regarding this. Health pathways are in the process of being developed and updated and will continue to be updated to reflect these referral pathways and provide contact details for your local health district services. So, the Voluntary Assisted Dying Support Service aims for all people seeking voluntary assisted dying information and services to receive compassionate, safe and timely support in patient centered care. The service is hosted by Northern Sydney Local Health District and it is one service, but it comprises of three operational arms, The Care Navigator service which I alluded to before, the Access Service and the Pharmacy Service. Our roles span provision of call service, liaison and referral, provision of clinical expertise and services, outreach services, substance dispensing, advice and disposal and also hosting a communities of practice. The Care Navigator service will provide advice, information and support to patients, their families, loved ones, the community and clinicians like yourselves. Really, anyone who has questions about or would like to access support around navigating the voluntary assisted dying process. The service will also connect people who have requested access to voluntary assisted dying with participating practitioners. The Care Navigator service, as I mentioned, will also host two Communities of Practice, one for authorised practitioners and another for all other health professionals active in Voluntary Assisted Dying Service delivery. The Voluntary Assisted Dying Access Service is a small workforce of registered voluntary assisted dying practitioners, primarily GP VMO’s, providing second tier support to local health districts where there is limited or delayed access to local voluntary assisted dying practitioners, and we envisage this would particularly be of importance for rural and remote regions. Recruitment of practitioners to the Access Service occurred earlier this year, and I am one of the practitioners, and they are making significant contributions to service readiness, and an additional round of recruitment has recently been finalised with a focus on GP's who live and work in regional and rural areas of New South Wales.
Finally, the third arm is the pharmacy service, which is a team of experienced pharmacists whose roles include the central procurement and dispensing of voluntary assisted dying substances, adjuvant medications and administration equipment, outreach medication delivery services to patients and authorised practitioners, providing advice, education and assessment for patients, caregivers and authorised practitioners and liaison with authorised disposes to facilitate safe destruction of any unused substance. For further information about voluntary assisted dying, you can go to the website as shown to you by Wade earlier and sign up to be on our mailing list, where we can provide you with regular updates on the implementation process, which is Wade mentioned is only now six weeks away.
Tonight we have discussed End of Life and Dying and we know for many of you as GP's were accustomed to discussing end of life options with our patients, but understand that some parts of today's presentation may have been upsetting and if you found anything particularly distressing, I encourage you to please reach out to a friend or colleague or contact a support line services displayed on the screen. Thank you.
Serena Chu
Thanks, Ramanan. Just opening up for some Q&A for this session. I'm just going to start from the top. Will there be a register of GP's who will participate actively in VAD?
Dr Ramanan Chandrabalan
So, we will all be authorised practitioners in New South Wales who have completed training there. Their names will be available to the Care Navigator Service, but it's not a publicly available list, so only people within the Care Navigator Service would be able to access who that those people are. We would also expect local health districts who have local sort of VAD project officers who will have a list of practitioners within their local health district. There will obviously be overlap there. So the care Navigator will have the entire list and then the local health district will have their local list. We would hope then that if you wanted to contact an authorised practitioner, you could do that locally and then as Ram said, we have worked on other backup options with the access team so that if you can't find an authorised practitioner locally, that you can call the Care Navigator Service and they could then put you in touch with somebody who who could help through the voluntary assisted dying process.
Serena Chu
Thank you. Second question, what is the process of completing death certificates for consultants objecting GP's?
Dr Ramanan Chandrabalan
That's a good question. So I guess in the process of a patient going through a voluntary assisted dying process, they would have a coordinating practitioner who may or may not also be the administrating practitioner if the patient has chosen a intravenous substance to be administered. So, I guess during that voluntary assisted dying process, we would hope that that coordinating practitioner and/or the administrating practitioner would be able to complete that Medical Cause of Death Certificate for the patient. We do appreciate that there are other instances where the patient's usual may be contacted to complete the death certificate, and as Wade mentioned, there is an updated medical Cause of Death Certificate that has been designed and will be delivered, which will you would tick to say that the patient has died as a result of voluntary assisted dying, but in the actual cause of death, it would be the disease process that led to their being eligible for voluntary assisted dying. So, we do appreciate that this is an incredibly sensitive topic for practitioners, but we would hope in the process of the patient going through the journey, that there is a solution for that process, the medical certificate to be completed, but we do hope that otherwise the general practitioner would be able to complete that given that it is a very specific certificate being completed.
Dr Wade Stedman
As Ram said, the Medical Certificate Cause of Death is really very similar to the current one. So, there are no significant extra burden of work. But as a conscientious objector, it is important to know within the Act, the Act really spells out clearly that people have a right to contentiously object, but it also does comment that people need to continue to provide their standard care to patients and people who would normally get a certain service, you can't withdraw that service and I must say completing a Medical Certificate Cause of Death when the patient's already died and you're their GP who's known them for many years, I would consider that standard care. So, I would expect as a conscientious objector that you would complete the Medical Certificate Cause of Death as per your standard care.
Serena Chu
So, if a person makes a VAD decision when their capacity is full and clear and then develops dementia in the future, their original VAD decision is void?
Dr Kerry Chant
That's correct. Remember that the eligibility criterion for voluntary assisted dying is six months and 12 months for the neurodegenerative conditions. So, we are not talking about a decision made when the prognosis for the patient is a very long one. Notwithstanding that, we know that people's level of capacity can change. Dementia can get worse and that people can lose capacity and you can also have temporary capacity loss. So, anyone without capacity, if it is permanent loss of capacity, the process cannot continue.
Serena Chu
What is the substance?
Dr Kerry Chant
We are unfortunately not able to discuss that in this route, but I think the most important comment is that we have a lot of experience across Australia in using this substance, and we therefore have confidence that it is the best product to be used for the effect, and there the pharmacist service will take people through how it is used and what is to be expected. There is also a patient information booklet, but Wade did you want to say anything else about that?
Dr Wade Stedman
I think that's a great summary. In Victoria they have been going for over four and a half or four and a bit years now, and they have used the substance around nearly a thousand times for self-administration and around 200 times for practitioner administration, and as you would expect, we have stuck with a protocol that has been tried and tested and our protocols don't deviate from what is already known to be effective.
Serena Chu
Will the official death certificate issued by video include a VAD as the cause of death, or will it be just the underlying disease cause of death?
Dr Wade Stedman
The certificate that will be issued by Birth, Deaths and Marriages and will just have the disease process that made the patient eligible for voluntary assisted dying and won't specify voluntary assisted dying on the formal certificate.
Serena Chu
Next, is it easy to understand that some practitioners will be opposed to VAD and what obligation is then on them not to stop patients seeking to assess this option?
Dr Wade Stedman
Essentially there a couple of parts to this. As I mentioned before, if you're providing care to a patient currently and you are a conscientious objector and they raise voluntary assisted dying, then you don't have to participate in the voluntary assisted dying process unless it is a formal first request and then you need to complete the first request form on the Voluntary Assisted Dying portal. What is really important and sort of relevant to this question is that you would then continue to provide the support that you would usually provide to that patient, and that is where I mentioned before about the medical certificate cause of death. It is expected that whatever care you are normally providing, you would continue to provide that even if that's in parallel to while this person is going through the voluntary assisted dying process. So, conscientious objectors cannot stop providing, the same level of care that they were providing before, but obviously when the specifics of voluntary assisted dying they can object to, but we would hope, you know, if they felt comfortable or found a set of some language that they could use or some phrases that they can use when they're approached about voluntary assisted dying, then that will allow them to respect their own sort of moral opinion or ethical standpoint, but at the same time be able to answer a patient in such a way that you know the patient doesn't feel abandoned and support the patient and help that patient on their journey. But appreciate that can be difficult for some people.
Serene Chu
Are our New South Wales regulations same as Victoria or other states? If not, what are the differences?
Dr Kerry Chant
I think one of the key factors is Victoria was the first state that legislated voluntary assisted dying and they have requirements which our voluntary assisted dying has to be initiated directly by the patient. Whereas a number of the other states, including New South Wales, has the fact that voluntary assisted dying can be discussed in the context of end of life care, in the context of mentioning treatment options, palliative care and the full suite of end of life life care and as part of holistic care. That is a clear distinction and so it does mean that some of the way in which voluntary assisted dying in Victoria is implemented will be different and so you might hear from your colleagues different experiences. We are very much embedding end of life care within the usual care pathways and trying to support this being integrated, wherever it aligns with patient's goals of care. So, clearly we are not saying in every context it needs to be raised, but again, where this aligns to the articulated goals of care, where they have been teased out and the patient meets the eligibility criterion, it is appropriate that a clinician providing holistic care do provide this option to patients.
Serena Chu
Thank you. Any waiting time for VAD?
Dr Ramanan Chandrabalan
I guess VAD will be accessible from the 28th of November this year and I guess a lot of work has gone into implementation of voluntary assisted dying across the state from a local health district perspective, but also with the New South Wales Voluntary Assisted Dying Support Services. We do anticipate that patients may have been planning to access voluntary assisted dying and that there may be an influx of patients wanting to access information around voluntary assisted dying and seek voluntary assisted dying. So, I guess we are expecting that there will be many patients wanting to access this, but guess hard to know exactly what the waiting times will be like, but that is why local health districts and the voluntary assisted dying support services are trying to prepare as well as we can to help patients access voluntary assisted dying if eligible.
Dr Kerry Chant
I think I would just add that, as Wade had said, it is patient driven, the time taken. We are aiming to meet demand in the sense of trying to provide good quality access to care, but it is patient driven in terms of the time frames. There can be expedited in urgent situations and that can probably be affected, Wade help me here, but probably in the vicinity of a few days in very extreme circumstances, but usually the process would take probably about a week, if someone really wanted expedited access and was very aligned.
Dr Wade Stedman
That is exactly right Kerry. We had a meeting recently with some of the other states and somebody in WA said that they managed to get an expedited person through in three days and the other state said that's amazing. So you know, even on an expedited pathway, you know, as Kerry said, three days would be the shortest. You know, it's probably going to be 4 or 5 even for an expedited pathway and then as Kerry also said, you know, 7 to 10 days is probably a fast way through without formally expediting the pathway. When we say expediting, if the coordinating and the consulting practitioner agree that the person is likely to lose decision making capacity throughout the pathway, or they are getting acutely unwell, if they both agree, they can shorten what is a standard five-day gap between the first request and the final request. That has to be five days. But if the coordinating and consulting practitioner agree, they can shorten that completely.
Serena Chu
Will medical indemnity providers charge higher premiums for doctors to participate in VAD?
Dr Wade Stedman
I don't know what you've found. I spoke to my indemnity and they said thanks for letting us know. So yeah, there wasn't a significant increase in fee, but I think if you are going to be an authorised practitioner, it just makes sense to let your MIPs or equivalent know just for, you know, open disclosure.
Dr Kerry Chant
Now none of us are lawyers, but I think one of the things is this is a very structured process. You have got two independent practitioners and you have also got a Board who is checking the paperwork and signing off on this for the to permit the prescription to occur. So of all the things that probably general practice is involved in, this is a very structured process. So, generally that is a factor which would decrease risk associated with it because of the fact you have got multiple steps and multiple safeguards in place.
Serena Chu
Does the consulting practitioner need to also be nominated by the patient or is it someone the coordinating practitioner refers to?
Dr Kerry Chant
It can be someone if the coordinating practitioner has a consulting appropriate practitioner to a consulting practitioner that may be part of the care team at the hospital, that they are aware of, then that can occur there and obviously the navigator service can identify a consulting practitioner where that is where that isn't known to the to the coordinating practitioner.
Serena Chu
Will there be a uniform criteria for assessing VAD throughout New South Wales? Will every LHD or local VAD service have equivalent or same current criteria?
SPEAKER: Dr Ramanan Chandrabalan
The criteria to access voluntary assisted dying is as per the Voluntary Assisted Dying Act. So, it is a very clear criteria that is set out in the Act and that will be the criteria that will be used by all the local health district and practitioners. I guess if that question was perhaps referring to access to the service, then that's where the local health districts are trying to prepare to be able to provide that access and the voluntary assisted dying support services will be able to step in, particularly in rural and remote communities, to help provide access to patients.
Serena Chu
When discussing advanced care directives or palliative care with patients, are GP's able to mention VAD will be available or do we specifically have to not mention it until the patient asks?
Dr Kerry Chant
The concept of events care directive is really we are encouraging advanced care directives to be constructed, very wise that it is very early on in the early on in the process. So that is probably the context for advanced care directives that that would be an early discussion when the patient's relatively well and talking about how they might want it if there was a sudden, unexpected event. Obviously, we want everyone to have advanced care directives in terms of talking about their wishes and progress, if they certainly have that as they develop any chronic illnesses. So, in the context of when a general practitioner or anyone would want to talk about voluntary assisted dying, it really is when people are in the context of being eligible for voluntary assisted dying. So, we really were talking about people with, as we have discussed, a cancer diagnosis where their prognosis is very limited and they are approaching that sort of end of life pathway or where they have got a neurodegenerative condition like motor neuron disease. Obviously in those contexts we would be suggesting that their care team as part of, and that includes the general practitioner, talks through the full range of options as they're caring for that individual. And again, if voluntary assisted dying does not need to be raised or may not be appropriate to be raised in some circumstances where it clearly does not articulate with the patient's goals of care, that they've articulated to you. In the usual way GP's will know and ask their patients about what their goals of care are, but where it aligns to their goals of care, then it is appropriate if they're in that sort of context of eligibility for voluntary assisted dying that it would be discussed.
Dr Wade Stedman
One thing that is separate to that or slightly related, someone asked me on the weekend, which was a good question. So, we have been over, and Kerry's made it very clear, that you can't use advanced health directives to ask for voluntary assisted dying, and that is absolutely true, because you lose decision making capacity. However, if somebody was creating an advanced health directive and they wanted to put voluntary assisted dying in it, you know, they could, and then I suppose that still is helpful because when a practitioner was assessing a person talking about goals of care, they have already got this advanced directive that says, it aligns with their goals of care. So, it meant that when you're assessing for pressure or duress, about a person's willingness or want to access voluntary assisted dying, you know, the GP could tell the authorised practitioner… Yeah, they put it in their directive, they have been talking about it for a year or two.
Serena Chu
What is the medication and what will be the process for the patient on the day itself admitted in the hospital with family around? How will it feel as they are falling asleep? I am just expecting what are other obvious questions that patient will ask me?
Dr Wade Stedman
We had an experienced practitioner in Western Australia describe the process of dying from voluntary assisted dying medication as an accelerated normal process. So her description was one of being very peaceful. Very consistent theme across all of practitioners from every state as they say they have not had to use any adjunctive palliative care medications, you know, for other symptom management. So even if there's a half an hour or an hour or two hours between swallowing the substance to actually dying, people have said how comfortable and how peaceful the death is. So, you know, they haven't had to add in other adjunctive PRN medication. So, it is certainly getting described as a very peaceful death and not taking away from obviously it's always grief for family, like you can't take away from that that grief and bereavement, and as Kerry said before, we can't go into detail about the substance because of the Commonwealth Criminal Code.
Serena Chu
In general, how long does the process shorten in life for a patient who chooses VAD rather than pursue other care, and is a psychiatrist assessment required in patients with depression or mental illness?
Dr Ramanan Chandrabalan
So in regards to the first half of that question, I guess to meet the eligibility criteria, a patient needs to have a terminal diagnosis with a prognosis of six months or 12 months for a degenerative neurological condition. I am not sure if that was what the first half of that question was referring to, and in regards to the second part of the conversation, again, as Kerry and Wade have mentioned, really in the context of a previous history of depression or mental illness, it really comes back to the patient's decision making capacity and if a patient has a decision making capacity, to make decisions around their health care, then they would not need a psychiatric assessment. But of course, if you had concerns regarding their decision-making capacity, then you might want to consider a referral for a psychiatrist. But it is important to ensure that I guess as GP’s when we are making decision making assessments or assessments regarding a patient's decision-making capacity all the time, and the act also does specify that the patient is presumed decision making capacity, and so I guess if you had any concerns about the patient's decision-making capacity, that's where you might refer for an opinion.
Serena Chu
Can you expand on the first request form, please? Is this around any discussion on VAD?
Dr Wade Stedman
It is a bit more specific. So, a first request for voluntary assisted dying is described as a clear and unambiguous request for voluntary assisted dying. I am sure a lot of you, probably all of you as GP’s, has had patients come into your practice and say, ‘look, you know, I've had enough, and I wish it would all end’ or some other general statement about distress and concern about their own health or health in general. That is not a clear and unambiguous request for voluntary assisted dying. That is just a call for help. So, Yes, people can ask for information about voluntary assisted dying. You can discuss it with them in the context that we mentioned around other end of life care, but that doesn't mean it is a first request because you are having those conversations and just because somebody said look, you know, I want to end it all. If you're unsure, then you should do things that you are probably much more skilled at, in perhaps addressing their concerns, listening to them and maybe exploring a bit more detail about what it is that is actually troubling them and maybe address that. If it turns out that they genuinely want voluntary assisted dying, well then yes, it may end up being a first request. So hopefully that helps clarify.
Serena Chu
Thank you. Is there a template for medical legally assessing capacity?
Dr Wade Stedman
There is not a formal template. As Ram said, it's presumed capacity. So, people having a difficult life, threatening procedures like cardiac surgery, bone marrow transplant, chemotherapy, all of those things that we would normally assess capacity for in very serious situations, we are capable of doing that and we should continue to do what we would normally do. Assess that they can understand the information, retain it and know what it means if they follow through with it. So no formal list, but there are many criteria within the first assessment and within the consulting assessment that the authorised practitioners need to ensure the patient understands and I am told by the practitioners in other states and when I have witnessed consultations by travelling to other states, it becomes very clear when you are speaking to someone for an hour and a half whether they have got capacity or not, and it really hasn't proved to be a big problem for practitioners and only about 1% of total assessments require a formal referral for decision making capacity.
Serena Chu
Will the Care Navigator and Assist Service include health professionals to whom we can refer to assess competence? Geriatrician and neurologist are in short supply and private neuropsychologists track assessment and cost upwards of $1,000. Do you have any advice?
Dr Kerry Chant
So probably just to indicate that a lot of the patients, because they are going to have an oncology diagnosis and that constitutes about 70% of them, will be under both the public or private system connected. In the public system in our local health districts, there are ways in which we would assess capacity because those oncology patients are undergoing other treatment choices. Choices such as what chemotherapy, what surgery. So capacity and assessing capacity would be done in the same way. So, where someone's ability to consent, as Wade said, is assumed, but where that is called into question, then generally our liaison psychiatrists or other resources within our hospitals would provide support to the oncology team. So we do acknowledge that the Care Navigator Service, if you are in that situation and you are a coordinating consulting practitioner, the Care Navigation Service will assist, but it is really important that to remember that this is assumed capacity and as GP's you will really have a great insight into your patients and probably be one of the key people in determining your patient's ability to make informed consent and have assumed capacity.
Serena Chu
Does the patient have a choice of location where VAD can happen?
Dr Kerry Chant
They do have a choice, but obviously we will have to say that there will be options discussed with the person, because clearly if they have got the option of self-administration that means, they have got a lot more control over the timing. But if they wanted to choose administration by a health practitioner, if they wanted to be admitted to hospital for that episode, then obviously that requires some additional logistics, and whilst we do everything we can to meet people's needs and timeframes, we still have to prioritise the care needs of everyone and so we will do our best, but that will need to be factored into people's decision making as well.
Serena Chu
How do you manage relatives who do not want their loved ones to use VAD?
Dr Kerry Chant
The patient themselves don’t need to actually have to tell their relatives that they're going down the voluntary assisted dying pathway. That is something that I think as health professionals we would try and enlist discussion in the family, given that it is best to approach this in a family centered way. It is probably important to remember that there is often conflicts within families about options around pursuing treatment, to ceasing treatment and so we deal with these complexities within families all the time. Obviously, voluntary assisted dying is going to be a new complexity. But Wade, did you want to sort of comment on any perhaps experiences from interstate?
Dr Wade Stedman
Kerry touched on it's so complex and I think the best thing practitioners can do is try and enlist the family, as Kerry said. There will be circumstances where, as been described to me from other states, where a partner did not want to tell their partner that they were having voluntary assisted dying, because they knew that they would try and talk them out of it, and in many circumstances, the practitioners have been able to work with the patient and eventually get everyone on board and involve the family in the process, which is obviously, I think, probably the most beneficial for most cases, but there are circumstances where the individual just does not want to tell their family, and there are circumstances where people have completed the process without a husband or wife knowing. So, it is difficult, but it is a person's right to have their health care privacy and our job I suppose is to really make sure that we explore the reasons for that and do our best to try and get the whole family involved in their care. but ultimately it will be up to the patient.
Serena Chu
Just a final question for tonight. So just to clarify, usual who GP who knows the patient well can complete first request form without being a registered VAD practitioner or being involved in coordinating or administrating VAD. I have a patient with a mystic prostate CA who has already asked me about VAD and I would like to support him, but don't want to register as a practitioner myself at this stage.
Dr Ramanan Chandrabalan
So guess if your patient is making, as Wade mentioned before, a clear and unambiguous request to access voluntary assisted dying, then any practitioner who is an authorised practitioner or not an authorised practitioner should complete a first request form, which is freely available on the front page of the Voluntary Assisted Dying Portal website, so that that form can be completed and that form in theory should be completed by all practitioners who receive a first request from a patient, in the context of that who is willing to support the patient but does not want to become an authorised practitioner or doesn't have the time to become an authorised practitioner, then they could then refer that patient on or link that patient in with their known treating team within the public health system, or alternatively, they could ring the Care Navigator Service to be provided with support and be linked in to an authorised practitioner for that patient.
Serena Chu
I am just now going to hand over to Kerry who would like to speak a few final words.
Dr Kerry Chant
I just wanted to thank everyone for giving up their precious time on a Monday evening. Thank you for your interest in this important topic. We are happy to also get feedback from you after this on how we can better support general practice and do understand the important role you play in supporting patients at this most difficult time in their end of life. So please, thank you very much for engaging so actively and thank you for those excellent questions.
Serena Chu
Thank you. I would like to extend my thanks to Kerry, Wade and Ramanan for presenting this evening, and also everyone who joined us online. We do hope you enjoyed the session and you also enjoy the rest of your evening. That brings us to the end of the session. Thank you and good night everyone.