Voluntary Assisted Dying (VAD) can have a profound influence on the individual care choices of people. Especially those facing increasing and major losses of capacity through progressive illness or disease, or anyone facing a life-limiting or terminal diagnosis.
How does Voluntary Assisted Dying work with end-of-life planning?
Voluntary Assisted Dying weaves into a few aspects of care choices and care planning. The most notable areas where VAD would influence your care options are:
- If you have an advance care plan
- If you enter palliative care
- End-of-life treatment options generally
- If you are losing capacity over time due to disability, illness or disease (note: having a degenerative disease, dementia or disability is not sufficient cause to access VAD. You also need to meet the criteria related to incurable suffering within six months of the requests made and other criteria).
Voluntary Assisted Dying is a process
There is some mythology and outright falsehood that encircles Voluntary Assisted Dying. There is a lot of conversation about people manipulating VAD to prematurely end the lives of family, especially in the disability community. There are also concerns that a person may opt for VAD in the first instance due to a level pain experienced in a moment of time that clears only to find they are locked into the Voluntary Assisted Dying.
Nothing could be further from the truth on all counts.
A number of safeguards exist with Voluntary Assisted Dying to ensure no one faces a premature death that is not in keeping with a person’s choices and/or the severity of their circumstances.
VAD Safeguards include:
- Voluntary Assisted Dying is only available to people who have the intellectual capacity to make the decision. Therefore, it cannot be made by someone who can’t understand what they are agreeing to. This includes but is not limited to anyone affected by dementia, mental illness, intellectual disability and any cognitive process that may otherwise impair a person’s ability to decide
- A person requesting access to Voluntary Assisted Dying is in their last six months of life for all states other than Queensland with an incurable and irreversible condition that is well-advanced and will cause death. For Queenslanders, the requests can begin to be recorded at 12 months. In short, a person cannot decide to make use of VAD without experiencing their descent into end-of-life and the accompanying impacts in a fulsome way
- The request for access to Voluntary Assisted Dying must be made three times. That way, there is unequivocal proof that on at least three separate occasions, a person has found the quality of their life is reduced to such a level that continuing that life is no longer preferable
- The person requesting access to VAD finds their suffering intolerable and inescapable. This includes physical suffering as well as psychological and/or existential. This suffering has to be demonstrated and/or articulated to a reasonable degree. And it cannot be influenced by any pre-existing mental illness.
As we’ve spoken about at length on the ExSitu blog before, Australia is changing the way we create care plans. The aim is to provide individualised and personalised care plans for the ageing population. These granular documents are values-based. The use of values is the way forward for all aged care service providers and end-of-life planning situations.
Why Australia is shifting to values-based care plans is quite simple
From an individual’s perspective:
No matter our background, wealth, status, connection to family, belief system, gender, sexuality or race, our values are what defines us. It is our values that help us connect with the community and determine our character. By articulating a person’s values, you can understand how a person would react and respond. You can articulate the person better and therefore provide support and treatment that better suits that person’s needs, wishes and wants.
From a provider’s perspective:
Values-based care plans allow care providers to provide tailored care at lower cost with higher client satisfaction rates and with reduced risk to the provider. By having a blueprint that outlines the individuals values, a provider can make better educated decisions, protect a person’s dignity in relation to risk-based scenarios and reduce the number of unnecessary and invasive treatments are required. And this doesn’t only span medical decisions or the physical aspects of care provision. It encompasses intellectual, psychological, spiritual and emotional aspects of care as well.
How care choices influence Voluntary Assisted Dying
Beyond the legal, medical and technical considerations involved in Voluntary Assisted Dying, articulating where your values lie in an end-of-life scenario can make all the difference.
Take dignity versus risk. In a situation where a care provider is assessing where they are legally vulnerable for any aspect of care they deliver prior to delivering that care, making a document that discusses where the individual believes dignity and risk intersect is paramount. Especially considering how dignity influences what further treatments a person may or may not seek as the next fork in the road occurs.
In a practical sense, values-based care plans help with the following areas:
Values as a guide to decision making
You cannot make a decision tree that can cover someone’s complete journey from wellness to ageing, disability, illness, disease or end-of-life. You can however get a sense of what choices a person would make as various scenarios arise that can help guide the decision-making process. This includes where dignity may lead to a cessation of treatment. Or defining how much suffering is unendurable for the individual.
Articulating decisions prior to a loss of capacity
To enact Voluntary Assisted Dying, the individual has to be making their choice of their own free will. This means that legally and medically, the individual has the capacity to make that decision to voluntarily end their life should their quality of life meet legal, medical and their individual’s personal criteria in tandem.
This has impacts for several reasons:
VAD can only be administered to the person making the request
Any decision to access Voluntary Assisted Dying needs to be made by the person accessing it. That means the request needs to be recorded in such a way that is irrefutably the person putting in the request. However, not all people can ask for VAD due to their illness, disease, injury or disability removing that option.
The request for VAD needs to be made three times
The reduction of quality of life and the request to access VAD must be articulated and made three times prior activation. As such, if the ability to write and/or speak will be lost as a result of progressive or degenerative illness, a person must be able to communicate the desire to access VAD in an agreed way. That is, the wish to activate VAD is recorded in a way that can be recognised by the law and the medical service providers. And the subsequent requests via other means (e.g., sign language or behaviour etc) must be similarly recorded and free from confusion.
The request cannot be ambiguous
To access Voluntary Assisted Dying, a person needs to prove they know what they are asking for. This includes meeting the criteria for disability as well as the effects of ageing, illness and disease. It also means that if a person has mental illness as a feature or as something they have encountered previously as a major life impact, there has to be proof that the decision to access VAD was made six months or more prior to evidence of the illness being present.
In New South Wales, it also means people with dementia may be ineligible for Voluntary Assisted Dying as the nature of the illness and the requirement a person requests access three times within the six months prior to their death means a person is unlikely to meet the criteria.
You cannot legally ask for VAD in an advance care plan or directive
As it stands within Australian legislation in all states, a person cannot request Voluntary Assisted Dying in an advance care directive. This is to protect a person’s decision-making ability and ensure all decisions related to VAD are fully informed, consistent, consensual and enacted by the person receiving the VAD service.
However, this does not mean you cannot outline the desire to access VAD to help inform decision-making processes. An alternative may exist within an individual’s care plan where a person’s own words demonstrated their VAD and/or refusal of treatment choices align with their values, and that the person is capable of providing insight and reasoning into their choices.
We must stress this does not mean any mention of VAD in a care plan will impair, influence or dictate life-preserving measures as a means of bypassing the inability to access VAD. It simply means that the individual’s values are recorded in such a way as to advocate for maintaining dignity. This is helpful as over-treatment is a feature within end-of-life through a failure to articulate where dignity and risk meet.
To find out more about Voluntary Assisted Dying, please contact your attending physician and check out the information on end-of-life directions within aged care.