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Voluntary Assisted Dying Bill - A GP's perspective

Photo: Voluntary Assisted Dying Bill - A GP's perspective
I am rarely a fence sitter, and yet I’ve found myself firmly placed in no man’s land. Before you judge me though, may I explain myself…I’m talking about euthanasia and the Voluntary Assisted Dying Bill being proposed in Victoria.

First, some background on my relationship with death; it’s been rocky to be honest. As an intern I struggled with death and dying; it wasn’t unusual for my husband to find me sobbing in bed after a patient had died at work. I would dwell on the patient’s final moments (what were they thinking? were they content? had they seen it coming?). I would agonise over how their family would be feeling that night after losing their mother/brother/wife/child. I would become anxious about my own mortality – when would I die?  Would it be unpleasant like the one I had witnessed today?
If anyone could counsel me on setting boundaries and dealing with this part of my job it was my husband, he was doing his internship too and signing just as many death certificates. By nature, I am an over thinker who wears my heart firmly on my sleeve, and death was certainly a topic I ruminated on heavily in my early years as a doctor.

As a resident I dealt with death countless times. I had instances where I saw death approach slowly from a distance (we all, patient included, knew it was coming and we prepared for it as best we could). I saw death jump rapidly from left field; no warning, no announcement. And I saw death creep towards us, so surreptitiously that none of us, including the doctors, knew it was on the horizon.

I’ve seen people die “well” – comfortably and with dignity, and I’ve seen them die distressingly; their families permanently scarred by the suffering their loved one experienced. I’ve left hospital with a tight feeling in my chest devastated that we, the medical profession, hadn’t given the patient and their family more dignity, support, warmth, comfort. I have seen us as a profession deal with death and dying beautifully, with care, but I have also seen it done very, very, poorly.

As a GP I have patients diagnosed with terminal illnesses; my role is to provide support and be their advocate as they navigate the complicated world of specialists and hospitals where occasionally they get drowned out by the Professors who manage their treatment.

Sometimes the medical profession forgets it is in fact the patient who makes the final decisions about their treatment. Death, and dealing with it, is part of being a doctor. And despite what many people in the community think, we do not know exactly when death is coming.

Many times, patients have asked “how long do you think we have Preeya? The oncologist said 6-8 weeks, what’s your opinion?” Honestly, I don’t know is what I have to tell them (and I secretly wonder why I don’t have this crystal ball my colleagues do).

I have always struggled with the notion that we as doctors give patient’s an estimated time frame for their life – I know it can be helpful to plan but please don’t take our “mmm maybe 6 weeks” as a definite. I have seen patients survive years after their 6-week life expectancy and by the same token one patient die within days of being told he likely had months to live.

As doctors, we take all the medical details into account (our knowledge of the illness, of the patient and our past experiences with similar patients) – we make a measured guess on how long we think one might survive; it’s an educated guess but it is a guess nonetheless.

The Assisted Dying Bill currently being debated has many criteria that must be fulfilled for one to be considered a candidate. The process is extensive with 3 requests that need to be made before one is deemed suitable.

One of the criteria listed is that “the person’s illness is expected to cause death within weeks or months, not exceeding 12 months.” I truly believe that is a clause that needs to be inserted but, how do we know 12 months out whether or not someone is going to die? I would not feel confident making that call because I know that things can change quickly in medicine.

Occasionally patients see doctors as Gods, and unfortunately some of us perpetuate this belief. We most certainly are not. We have an abundance of intricate knowledge that our patients do not but that is where our super powers end.

Another condition of the Bill that provokes anxiety is that “the person must be diagnosed with a disease, illness, or medical condition that is incurable, is advanced, progressive and will cause death” It is the “will cause death” that I am at odds with. We don’t always know with 100% certainty if your diagnosis will kill you – that’s me being honest and perhaps my colleagues will petition to have duct tape over my mouth after this.

In medicine there is a lot of uncertainty; in predicting life expectancies there is even more. In a condition like multiple sclerosis when does the doctor decide that it has moved from a disabling chronic condition to a terminal advanced condition that will cause death?

Despite the uneasiness I have with some of the criteria, I have to say they are strict enough to prevent misuse of this Bill but also lenient enough to ensure that patients who require this service can still access it. See what I mean about fence sitting?

I have seen the process of dying go very poorly; the patient and their family robbed of the peaceful comfortable death they had envisioned. This can have damaging consequences for the people left behind. I like to think, if this Bill existed and if the patient was deemed suitable – perhaps we can provide a patient and their loved ones with a great sense of comfort, control and relief after an already tumultuous journey.

There is one patient, whose name and face I will always remember (I often think about her children to this day); she held my hand and asked if we could help her end it all so that her children didn’t have to watch her slow deterioration – in that moment I knew I desperately wanted to help her. She had been through the ringer – we had worked for weeks trying to make the diagnosis and struggled to treat her when we did – she was dying and it was happening slowly and painfully despite all the medications we were giving her. It is one of the only moments I have felt an overwhelming desire to help my patient stop the suffering for herself and her children. We had no idea how long it would take for her to die, how long her pain would last, how long her children would have to wait for the final moment.

In hindsight, she was the person who would have benefitted from this Bill – she was the perfect patient (and honestly, I don’t think there would be many). She was ready, her children were ready – we just didn’t have the means at the time to help her in the way that she wanted. She died in the middle of the night alone; her children were not present. But they could have been. They could have held her hand in her final moments and had more closure themselves if this Bill had been in place, if we had some control over her passing. Her children could have known with more certainty when their universe was going to implode, and whilst it still is not ideal I think in this case everyone would have done better; the patient, her children and the medical team.

I know there are many of my colleagues who are opposing this Bill very strongly. Many who debate that we took the Hippocratic Oath when we graduated and we promised to do no harm. You may say but “they are just words” but that oath is burned into our soul; they are words but they are read by doctors all over the world upon attaining their degree – it binds us in a deeper way than just “colleagues”.

A fellow GP recently made the argument that we as a society are perhaps becoming too controlling– we cannot control death. Having said that though, they would have said that about birth and labour years ago and now look - women go into labour with a 100-point list of their “dos and don’ts” – no epidural or episiotomy, but yes to gas and morphine.

I do agree with my colleague that perhaps we are trying to control too much but maybe when it comes to death, particularly after a prolonged distressing illness, this is what some people need- control. There are many points in this debate, and we as a medical profession are somewhat at odds, I think, with our duty of care to prolong life, prevent harm and the notion of helping someone end their life even if it is at the patient’s request and in their best interests. I feel that conflict very strongly within myself too.

If this Bill is passed I don’t think it will work for every patient who has a terminal illness nor do I think it will work for every doctor. I don’t think there will suddenly be large numbers of people approved for euthanasia. But there might be a handful of instances where we can help a fellow human being have a dignified, peaceful, comfortable death and end their suffering on their terms. And that’s worth something isn’t it?

As I sit on the fence, and watch wide eyed as the debate over the Voluntary Assisted Dying Bill plays out in Parliament, I am facing a different debate within myself between Preeya the GP and Preeya the mum/daughter/wife/friend. The doctor in me wants this process, if it passes, to be safe, with strict criteria to prevent abuse and to protect patients but with enough accessibility that those who need this intervention can have it.

The doctor in me is slightly fearful; I am not sure if I would register to be one of the doctors who implements the medications to end a life; I just don’t think I am built for it. The mother, daughter, wife in me wants this option open, however, if I ever need to call on it one day. So, you see, whilst there is a debate going on in parliament, the medical profession and many of the individuals within it, are having our own internal debate. If someone could bring me another cushion for this fence that would be great.

Written by Dr.Preeya Alexander, A.K.A "The Wholesome Doctor" who is a working GP in Melbourne.

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