Abstract
In November 2021, New Zealand joined the Australian states of Victoria and Western Australia in making voluntary assisted dying (VAD) legally available. Three other Australian states, Tasmania, Queensland and South Australia, also passed VAD legislation in 2021 (Table 1). VAD legislation in each jurisdiction provides a medico-legal framework, including assessment by two independent medical practitioners, to enable people experiencing unbearable suffering from a terminal illness to access medical assistance to end their lives. VAD marks a significant societal change as it becomes an option in end-of-life care, resulting in legal, ethical and clinical ripples and transforming the landscape of medical and psychosocial care of terminally ill patients.
Legalisation of voluntary assisted dying (VAD) in Australia and New Zealand.
VAD: voluntary assisted dying.
The End of Life Choice Act was passed in the New Zealand Parliament in November 2019, confirmed by a nationwide binding referendum in October 2020.
Role of psychiatrists in VAD legislation in Australia and New Zealand
The RANZCP’s current position statement on VAD states, ‘the role of psychiatrists in end-of-life care is to assess and treat mental health conditions that are contributing to suffering, and to treat those conditions in the first instance’ and ‘capacity assessment is a minimum safeguard for any voluntary or physician assisted dying process’. This position statement, last updated in September 2020, pre-dates the passing of VAD legislation in Tasmania, Queensland and South Australia. This RANZCP position statement needs to be updated to reflect the role of psychiatrists as outlined explicitly in the VAD legislation in various jurisdictions (see Table 1). For example, the End of Life Choice Act 2019 in New Zealand states that a psychiatrist must provide a third opinion if competence to make an informed decision about VAD is not established to the satisfaction of one or both medical assessors. Similarly, the Voluntary Assisted Dying Act 2017 in Victoria states that if the co-ordinating (or consulting) medical practitioner is unable to determine whether the person has decision-making capacity in relation to voluntary assisted dying as required by the eligibility criteria, for example, due to a past or current mental illness of the person, the co-ordinating (or consulting) medical practitioner must refer the person to a registered health practitioner who has appropriate skills and training, such as a psychiatrist in the case of mental illness.
Although the Voluntary Assisted Dying Act 2019 in Western Australia does not explicitly mention the role of psychiatrists, referral to a psychiatrist is included in their guidelines.
Existing Australian and New Zealand VAD legislation uniformly indicates that a person is not eligible for VAD based only on their suffering from mental disorder or mental illness. However, terminally ill people with mental illness may be eligible for VAD if they fulfil the core VAD eligibility criteria. Since patients with mental illness often have difficulty in accessing physical health services, psychiatrists may wish to advocate for their terminally ill patients to access high-quality palliative care and/or VAD services if appropriate. And indeed, psychiatrists in Tasmania are required to assist the VAD eligibility assessment process; the End-of-Life Choices (Voluntary Assisted Dying) Act 2021 states that the assessing medical practitioner may request information (including any medical records) from a psychiatrist, psychologist or registered health practitioner to determine VAD eligibility.
Existing Australian and New Zealand VAD legislation typically includes a review board, committee or commission whose functions include monitoring and reviewing implementation of VAD in these jurisdictions. In Tasmania, the commission can approve a VAD training course if it has consulted with a body which represents medical practitioners; a body which represents a person nominated by the Public Guardian within the meaning of the Guardianship and Administration Act 1995; a person nominated by the Chief Civil Psychiatrist within the meaning of the Mental Health Act 2013; and a psychiatrist or a psychologist. Psychiatrists may contribute to the education of other medical practitioners providing VAD services, e.g. in capacity assessment or in treating mental illness at the end of life. Psychiatrists may also facilitate education for psychiatric trainees and consider its inclusion in the RANZCP curriculum and formal education courses.
Psychological effects of VAD on health practitioners
Involvement in VAD can take an emotional toll on health practitioners, resulting in stress, feelings of isolation and concerns that they are being pressured or intimidated (Winters et al., 2021). A Dutch study found that emotional burdens and contradictory emotions were commonly reported by physicians involved in VAD (Evenblij et al., 2019). Many physicians involved with VAD in the Netherlands mentioned they would be reluctant to provide the services again (Stevens and Kenneth, 2006). Unresolved psychological issues among health practitioners involved in VAD can thus jeopardise the workforce available to provide VAD.
Psychiatrists may be interested in supporting the psychological well-being of health practitioners involved in VAD. In 2017, the World Medical Association amended the Hippocratic Oath to acknowledge the importance of medical doctors attending to their own health and well-being in order to be able to provide best care for their patients. Despite the documented psychological impacts of VAD on health practitioners, the existing literature does not adequately address requisite self-care practices. Self-care can prevent burnout and enhance resilience and overall well-being (Butler et al., 2019). It is particularly relevant for those health practitioners engaged in highly emotional or stressful clinical encounters (Butler et al., 2019). Indeed, the VAD guidelines in Western Australia include a section on practitioner self-care, which outlines the essential resources that can be accessed to support the mental health and well-being of medical practitioners, nurse practitioners and other professionals involved in the VAD process.
VAD: Indigenous populations and families
Although there is an international body of research on VAD, evidence about the involvement of Indigenous populations and families is limited. For example, a recent review found that only 14 out of 66 studies in the Netherlands included family members as study participants (Roest et al., 2019). Given that most research in VAD has been conducted in Western Europe, in-depth inquiry into the experiences of Indigenous, First Nations people in VAD decision-making in the Australian and New Zealand context is necessary. In particular, it will be important to explore the worldviews of Aboriginal, Torres Strait Islander and Māori peoples regarding VAD, including the role of family. How can Indigenous practices around death and dying inform VAD? How can psychiatrists support families as well as patients? What interventions, educational or service based, are needed to ensure equitable service delivery?
VAD research opportunities in New Zealand
With the implementation of the End of Life Choice Act 2019 in New Zealand, we are embarking on four research projects in 2022. The first project (J.Y.) explores the longitudinal experiences of people with life-limiting cancer who are applying for VAD, their families who are supporting them and their attending medical practitioner. This project aims to document and evaluate how the VAD system is working for those directly involved in VAD. The second project (G.C., R.F., N.H., M.C., A.V., D.B.M.) explores the experiences of health practitioners involved in VAD and the perspectives of family of people requesting VAD. This project aims to uncover knowledge and service gaps in the provision of VAD, along with understanding the psychological and other impacts of VAD on health practitioners and families. A knowledge translation plan will follow, aiming to expand knowledge and capacities among key stakeholders and to recommend changes in practice informed by the research findings. The third project (J.Y., G.C.) develops a research network in New Zealand focusing on VAD, thereby providing the foundation for identifying and addressing our imminent and ongoing research needs in this area. Three activities are planned for the third project:
Establishment of a network of researchers to build research capacity in VAD;
Development of a research agenda with input from various stakeholders (patients, health practitioners, government, wider society) with a focus on equity, access and safety;
Development of research applications to deliver that research agenda. The second project has the potential to lead to further health delivery research supporting the safe, equitable and effective provision of VAD services for patients, including support for families and health practitioners in New Zealand.
Novel treatments for end-of-life emotional distress
Providing effective, tolerable and rapid treatments for anxiety and depression at the end of life has been a challenge for both palliative care and psychiatry. Conventional analgesics, antidepressants and hypnosedatives may assist symptom control, often at the cost of significant side effects, and any beneficial effects of antidepressants are often delayed. Psychological interventions for the individual and family can be helpful to some degree, but benefits vary and accessing these resources can be difficult. There has been renewed interest in psychedelic medicines among researchers, psychiatrists and the public. When combined with psychotherapy, psilocybin and ketamine have both shown promise in clinical trials in rapidly relieving end-of-life depression. A comparable study (N.H., D.B.M.) using methylenedioxymethamphetame (MDMA) is set to launch in New Zealand this year. With appropriate provisioning, offering individuals access to psychedelic-assisted psychotherapy could be a useful alternative or supplement to VAD services (Menkes, 2021).
Conclusion
VAD presents complex challenges to patients, families and health professionals. Psychiatrists have the right to choose whether to participate in the VAD debate and practice. As VAD becomes legally available in many parts of Australia and New Zealand, it is essential to review and update the role of psychiatrists in VAD. The psychiatrist role has expanded from expert assessment and management of mental illness at the end of life to providing expert opinion on competency in relation to the VAD decision-making process under new legislation in Australia and New Zealand. There are numerous opportunities for psychiatrists working within the emerging VAD legal framework. Opportunities include educating and training other health practitioners who provide VAD services; advocating for people with a mental illness to have an equitable to access VAD services; supporting self-care and researching the psychological impacts among health practitioners who provide VAD services; and taking a clinical leadership in delivering high-quality VAD psychiatric assessments. Establishing a new RANZCP network on VAD could provide a means to examine these new roles and responsibilities critically, promote best practice VAD psychiatric assessment and engage with the public and health sectors in Australia and New Zealand.
Footnotes
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: G.C. and J.Y. are appointed members of Support and Consultation for End of Life Choice in New Zealand (SCENZ) Group, New Zealand’s Ministry of Health. G.C. and J.Y. were members of the Ministry of Health’s End of Life Choice Advisory network. J.Y. was a member of the 2020 End of Life Choice Act Referendum Society/Yes for Compassion.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Research team members and Funding Sources: First project (Navigating Assisted Dying: the experiences of New Zealanders with terminal cancer seeking an assisted dying, their support people and their attending medical practitioners): J.Y., Professor Antonia Lyons, Dr Richard Egan and Professor Kevin Dew. Funded by Cancer Society New Zealand. Second project (Experiences of the End of Life Choice 2019 Act amongst health practitioners, whānau and bereaved families): G.C., R.F., M.C., N.H., A.V., D.B.M., Associate Professor Frederick Sundram, Associate Professor Sarah Cullum, Associate Professor Susan Bull, Dr Adam Sims, Dr Jackie Robinson, Dr Deborah Balmer and Dr Helen Cassidy. Funded by Auckland Medical Research Foundation. Third project (A new research agenda to support safe and accessible assisted dying in Aotearoa): J.Y., G.C., Dr Jeanne Snelling, Ms Leanne Manson, Dr Richard Egan, Dr Janine Winters, Professor Ben White, Professor Lindy Willmott, Dr Jackie Robinson and Dr Te Hurinui Karaka-Clarke. Funded by New Zealand Health Research Council. Fourth project (Effect of MDMA-assisted therapy on anxiety and depression in advanced-stage cancer): N.H., D.B.M., Professor Paul Glue, Dr Will Evans, Dr Geoff Layton, Dr Thivya Jeyaranjan, Dr Chris King, Dr Shamsul Shah, Dr Ingo Lambrecht, Dr Lisa Reynolds, Dr Rhys Ponton, Associate Professor Bruce Russell, Associate Professor Frederick Sundram and Jessica Mills. Sponsored by the Universities of Auckland and Otago.
