Voluntary Assisted Dying has been legal in WA since 2021. But in light of reviews of the practice, how successful has it been – and is there room for improvement?
By Suzanne Harrison
True to form, Gabrielle, an 84-year-old former social worker, had the last laugh when she chose to end her life with VAD.
“You’re blocking the view”, she said to a nephew, as a large group of loved ones stood with arms linked around her bed. Gabrielle wanted one last look at the beautiful trees outside her French doors – and her friends and family were standing in the way.
“Everyone in the house roared with laughter, including the doctor,” says her son, Brendan, one of four children Gabrielle brought up largely on her own.
Brendan says he is comforted that one of the last things his mother heard is the sound of laughter, in her own home, surrounded by those most important to her.
“On her final day, she was at peace and happy,” says Brendan. “I felt we had no right to question her decision. If that’s what she wanted, she had the right to access it.”
After a transient ischaemic attack in her 70s, the active, headstrong Gabrielle noticed things were not right, particularly with coordination, which was unusual for the avid table tennis player.
Over time, her symptoms were diagnosed as the degenerative effects of motor neurone disease (MND), among a ‘grab-bag’ of other health issues.
She had lost the power of speech and one day knew that choking on her food was inevitable, Brendan explains.
Gabrielle’s own father had suffered a stroke and spent five years in a vegetative state, something Brendan says his mother – in one of her last written notes – said “I’m not going there”.
RELATED: Doctors sign up for assisted dying but more needed
Gabrielle is one of hundreds of people who have chosen to die by VAD in Western Australia since the Voluntary Assisted Dying Act 2019 came into law in 2021.
As of June 2024, all States and the Australian Capital Territory have passed legislation creating an assisted suicide and euthanasia scheme for eligible individuals.
According to the only national voluntary assisted dying charity, Go Gentle, 190 West Australians ended their life through VAD within the first year of the law coming into effect, a greater-than-expected number.
The numbers have continued to grow, with recent figures from the WA Department of Health showing 738 patients have died following administration of a VAD substance since July 2021. The vast majority were cancer-related and in palliative care, with an age range from 32 to 100.
As it stands now, an adult must meet the following criteria to be eligible for VAD:
- Make three separate requests
- Be assessed by two doctors
- Have a medical condition that is expected to cause death within 6-12 months
- Undergoing suffering that cannot be relieved in a tolerable manner
- Have the mental capacity to make the decision
- Be an Australian citizen or permanent resident who has been a resident in Western Australia for at least 12 months.
A person can withdraw their request for VAD at any time, even after they have had an assessment or made a request in writing, and as per the current ‘no carriage laws’, Go Gentle says people must raise the topic of VAD with their GP themselves.
Yet the number of practitioners who have completed the WA-approved training has grown at a more conservative rate.
The WA Voluntary Assisted Dying Board confirmed a total of 114 medical and nurse practitioners have completed the WA approved training – 103 medical practitioners and 11 nurse practitioners – since the Act came into play.
The figure stands at just over double the number of practitioners who had completed the WA approved training in March 2022, seven months after right-to-die laws came into effect.
In 2023-24, 13 medical practitioners and four nurse practitioners completed the training.
RELATED: Voluntary assisted dying: Is your practice ready?
Late last year the WA Department of Health released a statutory review of the Act, finding that awareness of VAD was “not consistently high across the State”.
While the Act itself does not require amendment, the review suggests that improving policy and operational processes, as well as education, training and information materials, will increase both compliance with the Act and levels of access and support for eligible people and VAD-assisted dying providers.
“Processes provided under the Act are generally operating well in supporting all those involved in providing and accessing voluntary assisted dying,” the department said in a statement.
“The panel has, however, made 10 recommendations centred on increasing compliance with the Act and improving access and support for eligible people and voluntary assisted dying providers.”
These include the development of a targeted strategy to improve community and health practitioners’ knowledge of assisted dying.
Dr Linda Swan, chief executive of Go Gentle, says that while there has been sufficient time to show that there is demand, positive family and patient interactions, and a satisfactory legal framework, the processes and medical involvement in VAD are a work in progress.
What can be done better?
“There are obstacles,” says Dr Swan. “Despite the laws in all states and the ACT, there is still a need to update and improve.
“We do have a focus on trying to highlight where there are unintentional regulations – the most concerning one is the gag laws.”
By this, Dr Swan means that doctors are not permitted to raise the concept of VAD to potential patients, it can only be discussed if the patient asks them first.
However, this rule does not exist in WA. As it stands at the time of print, this is only enforced in Victoria and South Australia.
“The second one – and this affects WA – is a federal law prohibiting the use of a carriage service [telephone, email, videoconference] to discuss, counsel, promote or instruct on VAD. This is crazy and outdated, especially for those living in regional areas,” Dr Swan said.
But the most common concern from those working in VAD is the general lack of awareness, both from inside and outside the medical community.
“When we get down to what could be done better, there’s a lack of awareness among clinicians, among the general public, that this is a viable end of life option.” She added that there had been cases where there was “what I would describe as institutional obstruction by clinicians”.
“If you have a personal objection, that’s fine, but it’s not fine to deny that person access by dismissing it or not referring them to someone who can help them,” she said. “It’s not about the practitioner it’s about the person (patient).”
RELATED: Voluntary Assisted Dying – what are the choices?
People like Dr Swan are well versed in the positives of voluntary assisted dying. Families have told her that watching a loved one choose that option is “a bizarre thing, but beautiful”. Among some of the Go Gentle testimonies are “we left nothing unsaid” and “he wanted his suffering to end”.
For VAD practitioner Dr Bhawani O’Brien, easing the suffering of those with terminal illness is something she sees as a privilege.
“When a patient’s life is so limited and their suffering is undeniable and all that palliative care can do is ease that suffering, they say to me: ‘I don’t want to be gaga in my last five days’.”
The Mt Lawley GP says the recent review was well thought out, but “there’s always room for improvement”. And she believes that a couple of those improvements could be enacted sooner rather than later.
“I hope people in the medical community and the Voluntary Assisted Dying Board pay notice to the recommendations. Every patient I go to, the family says, ‘I didn’t know this existed’.”
Dr Bhawani is keen to raise awareness and generate discussion on VAD, recalling that the last time she visited a medical school to talk on the subject she had tremendous interest from junior doctors.
“We’re not doing enough publicly and that’s a big priority,” she said. “I’ve had patients nearly miss out on a VAD option, yet they’d spoken to their oncologist eight or nine times.
“Patients get delays. They ask their specialist, and their first request has been ignored. There are many conscientious objectors in the medical community, but they still have an obligation to refer these people.”
In its 2023-24 annual report, the WA Voluntary Assisted Dying Board stated it was “disappointed by feedback received this year that requests for voluntary assisted dying have been brushed aside or ignored when made to a medical practitioner in a consultation”.
“We are aware that some people have experienced a delay in access, and some have been prevented from accessing their lawful choice for voluntary assisted dying under the Act as a result.
“Improving the information about voluntary assisted dying available to the community and to health professionals is an ongoing focus of the Board. Practical steps are being pursued to achieve this goal.”
Dr Bhawani was the practitioner at Gabrielle’s death, and Brendan describes her as a “rock star”.
“Bu (as she is known) is the authority on this,” says Brendan. “The process was thorough. She said: ‘this is how it will go’. And the process does get repeated throughout.”
Brendan says that once Gabrielle made the decision and got sign off, she had health tests every three months. At the last one, she was told her deterioration meant she had less than 12 months left.
“There was a huge grin and a double thumbs up,” he says. “So, you couldn’t question that.”
Brendan now realises that in the final months of his mother’s life living with the illness, she was mostly “cantankerous”, but as soon as she was granted access to VAD, her mood changed.
“She was happy,” he says. “And on the day, we got to give her a hug, and most people don’t get that.”
Dr Swan said this has also been her experience.
“The interesting thing is, when we hear from people who are dying and are potentially facing death, they get enormous relief from knowing voluntary assisted dying is approved,” she says.
At present, a person’s mental capacity to choose assisted dying is at the heart of this law, meaning dementia patients without viable decision-making abilities and no other illness are not eligible.
Dr Swan says there may be a possible pathway to this changing, “but it would take years and a lot more research to be done”.
Currently, the most common diseases that have resulted in people seeking assisted dying are cancers, motor neurone, and heart disease.
“It’s here and it’s working well. It’s rewarding for those involved and there is support for those who want to get involved,” Dr Swan adds.
Want more news, clinicals, features and guest columns delivered straight to you? Subscribe for free to WA’s only independent magazine for medical practitioners.
Want to submit an article? Email editor@mforum.com.au