Dec 19, 2017

Voluntary Assisted Dying: A Poignant and Clinical Dilemma

During the Ministerial Advisory Panel’s consultation process, many representations from nurses were evident, in written responses community meetings, and a meeting organised for nurses by the ANMF.

Unsurprisingly, opinions heard on voluntary assisted dying were many and varied, mirroring those views the community.

Concerns from palliative care nurses are quite specific; that dying people are at a vulnerable time of life and may be demoralised or depressed, making them susceptible to suggestions for a ‘quick way out’; that palliative care expertise can always find a way to relieve suffering; and that the end of life is as valuable a time of life as any other.

Life itself is precious, and palliative care clinicians encapsulate this by the emphasis on assisting people to live until they die.

Some of this stance can be understood through a historical lens, when palliative care grew in response to the perception that dying was not done well across healthcare systems.

Thus developed an expertise which in Australia at least, is world class. Most importantly, has been the need to educate health professionals about the multidisciplinary skills required for a good death.

Over the last 30 years or so, palliative care services have had a huge influence on how people in Australia die.

Receiving care from a palliative care service will most likely provide relief from aspects of suffering for most people.

Palliative care provides expert end-of-life care physical emotional, spiritual and social using medical and non-medical interventions and impeccable assessment (WHO 2003), to meet the needs of each individual facing the end of their life.

However, those who work with the dying are not unfamiliar with requests for assistance to end life; they are part of everyday conversations.

Assisting a person to navigate necessary decisions at this stage of life requires significant skill, but it is a core skill of palliative care clinicians.

People’s wishes about all aspects of their care including the manner and timing of their death, are often a starting point for conversations about ca they require sensitive acknowledgment and interpretation and, a request for assisted death should always be respected.

In Europe, where a few countries have legalised forms of assisted dying, there has been a strong argument that where euthanasia is legalised, there should be no devaluation of palliative care practice. Indeed evidence shows that where assisted dying has been legalised, requests for palliative care increase.

Arguments about palliative care and euthanasia are predominantly seen as oppositional. This gives see to positions which highlight differences, instead of seeking commonalities like the shared intention of aiming to relieve suffering.

Perhaps in working through what this current proposed legislation means, there is an opportunity to find some clinical common ground, for the sake of those who need care.

Palliative Care Australia holds a position of ‘studied neutrality’ Johnstone 2012), in relation to assisted death, with the goal of not excluding anyone, regardless of the choices they make about the end of their life.

I believe this statement attempts to hold the complexities of these decisions, sitting in the “grey’, rather than holding firm to black or white, for or against, positions.

I argue that it is possible for a clinician to work with a person, as they work through their decisions, regardless of one’s own position on assisted death; and to be a conscientious objector without abdicating one’s duty of care for a person until the time they choose to die.

Palliative care clinicians are best placed to use their well-developed skills in expert symptoms management, intense communication and multidisciplinary teamwork offering holistic psychosocial and spiritual care.

An individual’s decision to seek voluntary assisted death is complex, involving not only the person themselves, but those who support them, family members or others.

Reasons for requesting death vary. from seeking relief of suffering an aversion to loss of dignity and independence, to honouring a long held belief in autonomous control over one’s life.

While there is no formal role in the proposed legislation for nurses to be involved in actions around voluntary assisted dying, it is still essential that nurses not shy away from the hard questions that will inevitably be asked of them.

If the legislation passes the care of people who may wish to access voluntary assisted dying, needs to continue. The care will be as expert as it always is; but is all the more poignant because (under the legislation), people requesting voluntary assisted dying need to be experiencing un-relievable suffering and at the end of their life.

So the end point of these people’s journey may be different, but meeting day to day care needs to assist the person to live until their death, remains as always, at the forefront of nursing work.

Obviously, there is much work to be done in developing c Cal guidelines to assist clinicians as they discern their own response to legislation. And because people die in all settings, all healthcare and aged care systems too, will need to develop organisational responses to requests for voluntary assisted dying, with guidance and support for staff at.

Nursing care has always been provided to any person when they are in need, regardless of what we may think of them.

We provide care to criminals, to people who have a lifestyle different to our own, to people who resist common-sense treatments.

We cannot abdicate the care of people seeking access to voluntary assisted dying, because we disagree with it; it is not our decision it is a decision for each individual.

This content was originally published in ANMJ Volune 25, No. 5, November 2017. 


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