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Javanparast S, Phelan C, Allcroft P. Interface between voluntary assisted dying and palliative care in Australia: what evidence do we need to inform policy and practice? Intern Med J 2024; 54:192-193. [PMID: 38267380 DOI: 10.1111/imj.16310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Sara Javanparast
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Caroline Phelan
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Peter Allcroft
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
- Southern Adelaide Palliative Services, Adelaide, South Australia, Australia
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Peisah C, Sheppard A, Leung KC. Objections to assisted dying within institutions: systemic solutions for rapprochement. BMC Med Ethics 2023; 24:100. [PMID: 37974178 PMCID: PMC10655327 DOI: 10.1186/s12910-023-00981-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023] Open
Abstract
In this Matters Arising article, we outline how the recent article "The impact on patients of objections by institutions to assisted dying: a qualitative study of family caregivers' perceptions" (White et al., 2023 Mar 13;24(1):22) informed Voluntary Assisted Dying (VAD) implementation in our large Australian public health setting, where objections do not emanate from, but within, the institution. In reporting the harms to patients and caregivers created by institutional objection, White et al. provide an evidenced-based road map for potential potholes or risks associated with VAD implementation. We discuss the complexities emerging from the diverse views of health professionals and the ethical tensions arising from such, especially within certain specialties, and how we developed systemic strategies that support patients, caregivers and staff alike. We highlighted the need to shift from "Do you support VAD?" to "How can we support you as healthcare professionals to integrate VAD into your practice, in a way that complies with the legislation, meets the needs of patients and caregivers, and feels safe and does not compromise your moral stance?"
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Affiliation(s)
- Carmelle Peisah
- Discipline of Psychiatry and Mental Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
- Capacity Australia, Sydney, Australia.
| | - Adrianna Sheppard
- Research and Education Network, Westmead Hospital, Sydney, NSW, 2145, Australia
| | - Kelvin Cy Leung
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Close E, Willmott L, Keogh L, White BP. Institutional Objection to Voluntary Assisted Dying in Victoria, Australia: An Analysis of Publicly Available Policies. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:467-484. [PMID: 37428353 PMCID: PMC10624699 DOI: 10.1007/s11673-023-10271-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/21/2022] [Indexed: 07/11/2023]
Abstract
BACKGROUND Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider OBJECTIVE: To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria. METHODS Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically analysed using the framework method. RESULTS The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice. CONCLUSION This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions' public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4001, Australia.
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4001, Australia
| | - Louise Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4001, Australia
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White BP, Jeanneret R, Close E, Willmott L. The impact on patients of objections by institutions to assisted dying: a qualitative study of family caregivers' perceptions. BMC Med Ethics 2023; 24:22. [PMID: 36915087 PMCID: PMC10009962 DOI: 10.1186/s12910-023-00902-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Voluntary assisted dying became lawful in Victoria, the first Australian state to permit this practice, in 2019 via the Voluntary Assisted Dying Act 2017 (Vic). While conscientious objection by individual health professionals is protected by the Victorian legislation, objections by institutions are governed by policy. No research has been conducted in Victoria, and very little research conducted internationally, on how institutional objection is experienced by patients seeking assisted dying. METHODS 28 semi-structured interviews were conducted with 32 family caregivers and one patient about the experience of 28 patients who sought assisted dying. Participants were interviewed during August-November 2021. Data from the 17 interviews (all with family caregivers) which reported institutional objection were analysed thematically. RESULTS Participants reported institutional objection affecting eligibility assessments, medication access, and taking the medication or having it administered. Institutional objection occurred across health settings and was sometimes communicated obliquely. These objections resulted in delays, transfers, and choices between progressing an assisted dying application and receiving palliative or other care. Participants also reported objections causing adverse emotional experiences and distrust of objecting institutions. Six mediating influences on institutional objections were identified: staff views within objecting institutions; support of external medical practitioners and pharmacists providing assisted dying services; nature of a patient's illness; progression or state of a patient's illness; patient's geographical location; and the capability and assertiveness of a patient and/or caregiver. CONCLUSIONS Institutional objection to assisted dying is much-debated yet empirically understudied. This research found that in Victoria, objections were regularly reported by participants and adversely affected access to assisted dying and the wider end-of-life experience for patients and caregivers. This barrier arises in an assisted dying system that is already procedurally challenging, particularly given the limited window patients have to apply. Better regulation may be needed as Victoria's existing policy approach appears to preference institutional positions over patient's choice given existing power dynamics.
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Affiliation(s)
- Ben P White
- Faculty of Business and Law, Australian Centre for Health Law Research, Queensland University of Technology, PO Box 2434, Brisbane, QLD, 4000, Australia.
| | - Ruthie Jeanneret
- Faculty of Business and Law, Australian Centre for Health Law Research, Queensland University of Technology, PO Box 2434, Brisbane, QLD, 4000, Australia
| | - Eliana Close
- Faculty of Business and Law, Australian Centre for Health Law Research, Queensland University of Technology, PO Box 2434, Brisbane, QLD, 4000, Australia
| | - Lindy Willmott
- Faculty of Business and Law, Australian Centre for Health Law Research, Queensland University of Technology, PO Box 2434, Brisbane, QLD, 4000, Australia
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McDougall R, Pratt B, Sellars M. Ethical Diversity and Practical Uncertainty: A Qualitative Interview Study of Clinicians' Experiences in the Implementation Period Prior to Voluntary Assisted Dying Becoming Available in their Hospital in Victoria, Australia. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:71-88. [PMID: 36800132 PMCID: PMC10126061 DOI: 10.1007/s11673-022-10224-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/01/2022] [Indexed: 05/04/2023]
Abstract
In the Australian state of Victoria, legislation allowing voluntary assisted dying (VAD) passed through parliament in November 2017. There was then an eighteen-month period before the start date for patient access to VAD, referred to as the "implementation period." The implementation period was intended to allow time for the relevant government department and affected organizations to develop processes before the Act came into effect in June 2019. This qualitative interview study investigates the perspectives of a multidisciplinary sample of twelve clinicians from a single metropolitan hospital during this implementation period. Maximum variation sampling was utilized to ensure breadth across discipline (medical, nursing, allied health), speciality, and stated level of support for the VAD legislation. Four key themes were identified from the interview data: preparing for the unknown, ethical diversity within the organization, building a respectful culture, and concerns about the inability of the legislated approach to capture clinical nuances. Overall, these clinicians' workplace experiences during the implementation period were shaped by the ethical diversity within their organization and a sense of uncertainty about how the VAD legislation would integrate with the practical realities of their clinical setting. The concept of "ethical diversity" could be a useful one for supporting staff in an organization during a VAD implementation period.
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Affiliation(s)
- Rosalind McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria 3010 Australia
| | - Bridget Pratt
- Queensland Bioethics Centre, Australian Catholic University, Brisbane, Queensland 4000 Australia
| | - Marcus Sellars
- Department of Health Services Research & Policy, Research School of Population Health, College of Health & Medicine, The Australian National University, Australia, Canberra, Australian Capital Territory 2600 Australia
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Downs J, Ayton A, Collins L, Baker S, Missen H, Ibrahim A. Untreatable or unable to treat? Creating more effective and accessible treatment for long-standing and severe eating disorders. Lancet Psychiatry 2023; 10:146-154. [PMID: 36697122 DOI: 10.1016/s2215-0366(22)00400-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 01/25/2023]
Abstract
The evidence base for the treatment of severe eating disorders is limited. In addition to improving access to early intervention, there is a need to develop more effective treatments for complex presentations of eating disorders. For patients with long-standing and severe illnesses, particular difficulties might exist with their engagement with treatment and achieving treatment outcomes. Alarmingly, there is an emerging international discourse about a concept labelled as terminal anorexia and about the withdrawal of treatment for people with severe eating disorders, resulting in the death of patients, as a legitimate option. This concept has arisen in the context of vastly overstretched specialist services and insufficient research and funding for new treatments. This Personal View combines multiple perspectives from carers, patients, and mental health professionals based in the UK, highlighting how the risks of current service provision are best alleviated by increasing resources, capacity, and training, and not by a narrowing of the criteria according to which patients with eating disorders are offered the care and support they need.
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Affiliation(s)
- James Downs
- Royal College of Psychiatrists, London, UK; Faculty of Wellbeing, Education, and Language Studies, Open University, Milton Keynes, UK.
| | - Agnes Ayton
- Department of Psychiatry, Oxford University, Oxford, UK
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Auret K, Pikora TJ, Gersbach K, Donovan RJ. “Respecting our patients’ choices”: making the organizational decision to participate in voluntary assisted dying provision: findings from semi-structured interviews with a rural community hospice board of management. Palliat Care 2022; 21:161. [PMID: 36114542 PMCID: PMC9482306 DOI: 10.1186/s12904-022-01051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There is limited literature around how palliative care organizations determine the degree to which they will interface with voluntary assisted dying in jurisdictions where it is legal. The aim of this research was to describe the experience of the board of management of an Australian community-based hospice during their decision-making process around whether to support voluntary assisted dying in the facility, prior to the legislation coming into operation.
Methods
The Board considered this decision over ten meetings in 2020, during which time they received information on the legislation, relevant literature, feedback from workshops which included the community, comment from hospice founders, staff survey results and presentations by clinicians able to discuss the impact of voluntary assisted dying on palliative care services. Members were encouraged to make notes of their own experiences during this time. Following this, semi-structured interviews were conducted with seven of the nine board members. Interviews were audio-recorded and transcribed verbatim and analysed using conventional qualitative content analysis method.
Results
The board members experienced a sense of journey in reaching an overall decision, which was to allow full participation in voluntary assisted dying provision for inpatients. Themes based on the journey motif included: starting from a personal view; moving to a hospice perspective; exploring if voluntary assisted dying can be part of end-of-life care; awareness and assessment of risks to the Hospice; arriving at a common platform to vote on; factors facilitating a safe decision-making journey; and personal impact of the journey.
Conclusions
The group highlighted several facilitators of a successful outcome including having adequate time, the availability of useful resources, sound board processes and a trusting culture. The study may provide support to other healthcare organisations as they face similar decisions triggered by legislative change.
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Ho A, Norman JS, Joolaee S, Serota K, Twells L, William L. How does Medical Assistance in Dying affect end-of-life care planning discussions? Experiences of Canadian multidisciplinary palliative care providers. Palliat Care Soc Pract 2021; 15:26323524211045996. [PMID: 34568826 PMCID: PMC8458666 DOI: 10.1177/26323524211045996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background More than a dozen countries have now legalized some form of assisted dying, and additional jurisdictions are considering similar legislations or expanding eligibility criteria. Despite the persistent controversies about the relationship between medicine, palliative care, and assisted dying, many people are interested in assisted dying. Understanding how end-of-life care discussions between patients and specialist palliative care providers may be affected by such legislation can inform end-of-life care delivery in the evolving socio-cultural and legal environment. Aim To explore how the Canadian Medical Assistance in Dying legislation affects end-of-life care discussions between patients and multidisciplinary specialist palliative care providers. Design Qualitative thematic analysis of semi-structured interviews. Participants Forty-eight specialist palliative care providers from Vancouver (n = 26) and Toronto (n = 22) were interviewed in person or by phone. Participants included physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health professionals (n = 4). Results Qualitative thematic analysis identified five notable considerations associated with Medical Assistance in Dying affecting end-of-life care discussions: (1) concerns over having proactive conversations about the desire to hasten death, (2) uncertainties regarding wish-to-die statements, (3) conversation complexities around procedural matters, (4) shifting discussions about suffering and quality of life, and (5) the need and challenges of promoting open-ended discussions. Conclusion Medical Assistance in Dying challenges end-of-life care discussions and requires education and support for all concerned to enable compassionate health professional communication. It remains essential to address psychosocial and existential suffering in medicine, but also to provide timely palliative care to ensure suffering is addressed before it is deemed irremediable. Hence, clarification is required regarding assisted dying as an intervention of last resort. Furthermore, professional and institutional guidance needs to better support palliative care providers in maintaining their holistic standard of care.
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Affiliation(s)
- Anita Ho
- Centre for Applied Ethics, The University of British Columbia, 227 - 6356 Agricultural Road, Vancouver, BC V6T 1Z2, Canada
| | - Joshua S Norman
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Soodabeh Joolaee
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada; Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kristie Serota
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Louise Twells
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Leeroy William
- Supportive & Palliative Care Unit, Eastern Health, Melbourne, VIC, Australia
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Booth S, Eleftheriou P, Moody C. Implementing voluntary assisted dying in a major public health service. Med J Aust 2021; 214:343-346.e1. [PMID: 33715191 DOI: 10.5694/mja2.50982] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/20/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022]
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Recent Literature. J Palliat Med 2021. [DOI: 10.1089/jpm.2020.0682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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