1. Euthanasia- our concern?
Dr Simon Allan
Presented at St Albans PC,
25/2/18

2. Psalm 22

3. Last week- summarised He gave a Christian approach
Scripture guidance is not direct on this matter
Steve does not want Society to take the choice of medical assisted dying
Steve would rather see a caring response from Society

4. John 62 years Story of John 1996/97
Northern Territories Act briefly in action before shut down by Federal authority – 7 deaths in Darwin

5. Palliative Care context
Often seen as an issue for Palliative Care
Arohanui Hospice has up to 240 patients on the books per week (10 bed IPU)
A serious request for euthanasia comes up c. once per year.
Arohanui Hospice involved in c. 700 deaths/year
Problem of the observer (..”wouldn’t let a dog suffer like this”)more than the sufferer- need to care for the carer too.
So this is a small issue in Palliative Care

6. Polarising, contentious topic
We are affected by our and society’s backgrounds; we make decisions based on:
Morals
Culture
Beliefs
Ethics
Profession
Perspective

7. Euthanasia is not! Withdrawal of medical treatment
Refusal to have medical treatment
In other words: Acceptance of a “natural death” is not euthanasia
Refusing life sustaining treatment
Providing appropriate sedation to assist symptom control

8. Medical Assistance in dying
Prescription or supply of a lethal drug which a competent adult patient self-administers (Physician assisted suicide, voluntary assisted dying)
Administration of a lethal drug to a competent adult patient requesting to die (previously euthanasia in many formulations)

9. End of life definition Includes people with:
Advanced progressive incurable conditions general frailty and co-existing conditions and expected to die within 12 months
Life threatening acute conditions caused by an irreversible sudden catastrophic event.

10. Palliative Care Seeks to:
Optimise a patient’s QOL until death by addressing their physical, psychological, spiritual and cultural needs
Support the family, whanau and other caregivers throughout the illness and after death

11. Double effect
There is a morally defensible difference between actions with consequences that are both foreseen and intended, and actions that are foreseen but not intended. This gives a legally justifiable position to provide treatment intended to relieve symptoms but that could foreseeably hasten death.
E.g. palliative sedation

12. Historical Claims in favour
Individual autonomy- “to know I have a choice; it is my life!”
Avoidance of suffering
Harm minimization
The ethical continuum of EOL decision making

13. Claims in opposition
The value of human life and community interest in NOT taking life, is paramount
The meaning of autonomy is more elusive than you might think (regret, free will, involvement of others)
Risk to doctor's healer role, erosion of trust
Slippery slope- risk to vulnerable individuals
Moral loss that comes with avoidance of suffering and method of death

14. Other jurisdictions
Benelux countries and Switzerland: Physicians generally accept the practice Belgium has extended limits to include children and those “tired with life”, now seeking extension to psychiatric diagnosis and cognitive impairment Occurs at home by GP (50% of Dutch GP’s have done this, 30% more would) Swiss only allow self administered medication 5% of all deaths in Netherlands Increasing reports of difficulty in dying/failure to die

15. Oregon and Washington State
Doctor prescribes lethal dose, patient choose whether to take it
0.37% of all deaths in Oregon (close to 60% who get it prescribed take it)
Most die at home
Majority are white, well educated with cancer and autonomy/loss of dignity the most frequently cited reason
6/1127 patients woke up after ingestion
102 physicians wrote 204 prescriptions, no doctor referrals to the tribunal board
5% of Oregon patients received a psychiatric opinion

16. Others Vermont Montana California Colorado
Canada- attempts to force Palliative Care involvement
Victoria (confirmed- will be active c. July Within 6 months of dying, MND 12 months)
NSW (November- Bill failed by 1 vote in lower house)

17. Common ground for physicians
Everyone is entitled to high quality palliative care
Physicians should not abandon patients
Good EOL care and aged care should be available to all
People should be able to make autonomous decisions on their care- with caveats
Physicians have regard for the well being of themselves and colleagues

18. Common ground Care centered on patient, family and whanau
Communication skills
Social engagement and responsibility- health promotion around death and dying
Legislation of MAD must not devalue the need for palliative care or geriatric care
Legitimate concerns remain for vulnerable populations
Conscientious objection permitted
Coercion of individual or organization protected against

19. Political and popular
I fear we have moved beyond “for or against” on this matter
There is a need to contribute to the formation of better legislation (if it does become law)
The law is a blunt tool in human relations
Justice select committee- why?
Referendum- possible but the way the question is formulated to the Public is key

20. Studied neutrality?
Several professional groups are producing positions of neutrality
It is the prerogative of Society to decide law change and accept medical assistance in dying and there are diverse views within every part of society
However many medical practitioners see a central role for Palliative Care doctors and General Practice in assuming a key role in this process
This strikes at the very core of what these professionals do, how we do it and what our Public expects from us- eg Hospice, GP

21. Tom 64 year old Motor Neurone Disease Has the means to end his life
Has family approval
Discusses openly
Engages with Hospice
2-3 good discussions on the topic
Accepts our care and on his second admission, having done very well at home with some support he dies quietly in AH

22. And for me?
I know there are situations which I imagine would make me want to end my life
I do not believe it is safe to have a law allowing medically assisted dying
I do want to have care as I have experienced through team Hospice
I believe that most scenarios around death and dying are manageable with existing knowledge and intervention
I know that knowledge and application of care has improved enormously- although has a long way to go

23. Questions Should palliative care be involved at all in offering MAD?
Do you support individual choice in this matter?
Why should doctors be the key involved profession?
Do you think we will have pro-euthanasia legislation within the next few years? How will this change society, Hospice?
“Do you want to be a burden to your family”?
Is there a clear Christian position on euthanasia?

24. Psalm 23