December 6, 2023 • 25 mins
Access to a dignified death, free from pain and suffering, should be available to all.
In this episode of Law Matters, Catherine Henry is joined by Hunter senior geriatrician, founding Chair of Hunter Ageing Alliance, and 2024 NSW Senior Australian of the Year, Dr. John Ward to explore the profound implications of the recently introduced Voluntary Assisted Dying (VAD) laws in NSW.
In this episode you’ll learn:
- Why NSW may be at an advantage by being the last state to implement these laws
- A better understanding of the nuanced decisions and challenges faced by terminally ill individuals and their care providers
- The practical aspects of the VAD legislation, including eligibility criteria, safeguards, and the role of medical practitioners in facilitating compassionate end-of-life care
- The potential impact of VAD laws on people living in rural and remote areas.
Disclaimer
While this podcast is aimed to be informative, it is not intended to be a substitute for legal advice. You should see a solicitor for complete advice that relates directly to your situation.
For more information please visit:
Q&A on Voluntary Assisted Dying.
Find out more about VAD from NSW Health.
If you have a legal issue and live in NSW you can find out more at Catherine Henry Lawyers, or call the team on 1800 874 949.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Catherine Henry (00:00):
Before we start in this episode, we make mention
of suicide in the context ofassisted dying. If this raises
issues for you, please contactlifeline on 13 11 14. On the
28th of November 2023, newvoluntary assisted dying laws
came into place in New SouthWales. We are the last state to
(00:24):
have introduced voluntaryassisted dying legislation,
which is commonly referred to asVAD. So what do these laws mean
for those who are terminallyill, their families and their
doctors? We're going to explorethis a little bit more in this
episode. Hi, I'm CatherineHenry, and I'm so glad you can
(00:45):
join me on the law matters withCatherine Henry lawyers Podcast.
Today we're talking aboutvoluntary assisted dying. These
laws came into place on Tuesday,the 28th of November 2023. We're
talking here about helping toend somebody's life. And even
though the person may be in thefinal stages of a terminal
illness, the process is stillfraught with emotion. And these
(01:07):
conversations are not easy ones.So let's look at how this
legislation will work withsomeone who has been following
this closely and who also workswith many people who are towards
the end stage of life. Hunterbased senior geriatrician Dr.
John Ward. Dr. Ward is afounding member of the Hunter
Ageing Alliance, as am I and hehas very recently just been
(01:31):
named New South Wales SeniorAustralian of the Year 2024.
John Ward, welcome and bigcongratulations.
Dr John Ward (01:38):
Thank you, Catherine.
Catherine Henry (01:40):
So John, you've been involved in aged care and
geriatric medicine since the1980s. Can you tell us how
important this new VADlegislation will be regarding
providing the best care forterminally ill people?
Dr John Ward (01:53):
Well, I think it's going to be important for a
small group of people, I don'tthink it's so huge number. But
those people who are at the endstages of an unpleasant disease,
many of whom course will beyoung with cancer or
neurodegenerative disease, butsome of them will be older. And
(02:16):
they will want to finish theirlife at a stage when they feel
they're losing dignity, whenthey can no longer communicate,
when they're incontinent whenthey're having to be moved
entirely by other people. Andthey feel this is not the way
(02:37):
they wanted to end their life.The other group for whom it will
be important, or those men whoat the moment committing
suicide. Now one of the thingswhich is not really known in our
community, is the higher highestincidence of suicide. Now, if I
can just explain the differencebetween incidence and
(03:00):
prevalence, if you're looking atthe total numbers in the
community, the highestprevalence of suicide is younger
men. But the highest incidenceof suicide, that's the number
per 1000 population is actuallyolder men. And they're killing
themselves because their qualityof life has become so poor. It's
(03:20):
because their spouse has died,they've got no friends, they're
losing their vision they'rehearing, they're becoming
incontinent and losing theirmobility,
Catherine Henry (03:28):
They don't wish to go into residential aged
care,
Dr John Ward (03:30):
And they certainly don't wish to go into
residential aged care. Now, manyof those will have a terminal
illness are several terminalillnesses that you could argue
will bring their life to an endwithin 12 months, or six months.
And so they will be anothergroup who want to access this,
whether they'll use it or not,is another matter. And that's
(03:52):
the way I think a large numberof people will use this
legislation is not necessarilyto carry through it. But just to
have it there as a an insurancepolicy as a comforting sort of
strategy as the life movesforward.
Catherine Henry (04:08):
Yeah. And up until this moment, up until the
28th of November. A criminalsanctions apply to the situation
of assisted dying. And I'm justwondering, there's a legal side
and a medical side and how doyou feel that your colleagues
who's in the medical professionfeel about voluntary assisted
(04:29):
dying?
Dr John Ward (04:31):
Well, I think most doctors have been helping people
to die in a secondary way.
Catherine Henry (04:38):
Can you explain that
Dr John Ward (04:39):
Well, people who've got an intractable
illness and have symptoms thataren't able to be controlled
with palliative care. Now, Idon't know what proportion of
people that is that palliativecare physicians would say that
most people, their problems aresolved by palliative care, but
in my experience there's a smallnumber for whom that's not
(04:59):
possible like pancreatic canceror prostate cancer with bony
secondaries, and so on.
Catherine Henry (05:05):
And palliative care can can be quite patchy in
terms of access.
Dr John Ward (05:09):
So I think all doctors have been using
analgesics, opiate analgesics tohelp the quality of life for
these people. And as thesecondary intention know that
they've been facilitating oraccelerating their deaths. And
that's been really legallyaccepted, I think. So as long as
(05:30):
your intention is not to killsomebody prematurely, but if
you're helping them medically,and the secondary intention of
that is to say life will beshortened. That's, I don't think
has ever been a legaldifficulty. But this has
certainly been contentious inthe medical profession. And I
know myself, I had a long timecoming around to this. I always
(05:52):
thought it was something thatought to be there. But I didn't
think that it was something thatdoctors should be part of,
because I thought then thatchanged the way that patients
related to us. But now I've comearound to think that no, that's
that's a cop out really.
Catherine Henry (06:12):
That provision in the Hippocratic Oath? Yeah,
the doctors like to refer towhen conversations about these
issues come up,
Dr John Ward (06:19):
But to be pushing that on to somebody else,
knowing that you're going to beusing it, I don't think is a
courageous thing to do. So I'vecome around to the belief now
that this is an issue, asignificant part of our medical
armamentarium. And we should useit as appropriate.
Catherine Henry (06:38):
Right. And we are in the Hunter. And we have
been preparing for thislegislation for some time,
because it was actually passedby the New South Wales
Parliament 18 months ago, thereis, there have been things going
on in the Hunter establishmentof a new unit, I understand
you've done some training toprovide the assistance to those
(07:01):
who need it. Can you tell uswhat's involved in the training?
Dr John Ward (07:06):
We had to do online training to start with,
do the online training and readthe manual. And then having done
that and satisfied thatrequirement, you could either do
a further online course, whichwas many hours, or do a face to
face training day, which was afull day followed by an
(07:27):
assessment. And I did both ofthose. But in the end, I decided
not to proceed to become one ofthese doctors. Because Hunter
New England health has set up,which seems to be an excellent
unit to deal with it headed by acancer surgeon and ethicist and
(07:49):
lawyer.
Catherine Henry (07:49):
Yes, quite well known in all of those fields, in
the hunter.
Dr John Ward (07:53):
Dr Charles Douglas, and supported by a lot
of people who have a veryexperienced in end of life care.
And my own life is busy enoughwithout wanting to add something
unnecessary, because I've reallyonly doing it thinking that the
number of domains will be enoughof you there wouldn't be enough.
(08:13):
But it does seem to be enough.If it turns out not to be
enough. Maybe I'll change yourmind. Yes, but
Catherine Henry (08:18):
you have done what is required in order to be
one of those doctors, if that'sturns out to be necessary here.
So could you tell us about thecriteria for accessing the VAD
laws? How does somebody showthat they had somebody get in
and be able to use the this newlegislation?
Dr John Ward (08:39):
All right, you you've have to have a close
affiliation with New South Waleseither be an Australian resident
who lives in New South Wales, orsomebody who's lived here for a
year or who has some closemedical connection. That means
you are accepted as someone whohas a claim on New South Wales,
you need to be over 18 and youneed to have an illness that
(09:01):
will likely and new your lifewithin six months, or if it's a
neurodegenerative illness within12 months, you need to have the
capacity to make a decision towant to proceed with voluntary
assisted dying. And followingyour assessments. If you're
accepted, you need to have thecapacity at the end to make a
(09:24):
final decision that you willproceed to accept the
medications. And you need tohave done all this without any
duress, the assessors need to behappy that this has been a free
decision that you've madewithout any duress.
Catherine Henry (09:40):
And that the issue of duress is one that I
would imagine a lot of people inthe lead up to this the passing
of this legislation and since itwas passed, continue to grapple
with. So in your view, how doyou deal with issues around
duress? Do you have any thoughtsaround this?
Dr John Ward (10:01):
Well, I think that most there are three sorts of
doctors involved in this.There's the coordinating doctor
who actually initiates theprocess that the person goes to
who I assume in most cases willbe their GP or a GP, a GP
closely attached to thepatient's own GP, then you have
(10:23):
to go before two consultingdoctors who make an assessment,
see what's suitable. And thenfinally, there's an
administering doctor, whichagain, might your GP, or you can
administer the medicationyourself, which is a difference
from other jurisdictions. Soyou've got those two choices. So
I would think that most GPswould know whether there was an
(10:45):
issue of duress. And ifnecessary, they would know who
to call upon to tease out thatquestion. So as a geriatrician,
that might be the sort of thingthat I might be called upon to
look at. A I might be calledupon to test a person's
capacity. But I think most GPscould do that very well
themselves, or I might be calledupon to assess duress, which is
(11:11):
what I frequently do already.
Catherine Henry (11:14):
In what context, do you deal with
duress?
Dr John Ward (11:16):
Around other legal issues like wills, Power of
Attorney
Catherine Henry (11:20):
potential elder abuse?
Okay, and if you feel that thereare issues around this, there's
an assisted dying, voluntaryassisted dying board? How do you
see the role of that boardoperating?
Dr John Ward (11:34):
There are five members on the board, it's
headed by a lawyer that chairsthe board, to the other members,
the lawyers, only one of them isa doctor and once a dentist. So
that's what makes up the board.The role of the board is to
oversee the act to make sure theact is adhered to. But they also
have the final decision as towhether accept someone from the
(11:56):
assessments of the consultingphysicians to accept them for
voluntary assisted dying, andthen to make the decision that
the pharmaceutical branch atNorth Shore should administer
the medications to the doctor orto the directly to the patient.
Catherine Henry (12:15):
And can we learn anything from the
Legislative schemes that havebeen implemented around the
country about the way in whichthe voluntary assisted boards
will operate? Because, as Iunderstand it, it has been one
of the reasons that there was apush to have this prolonged
introduction period was becausethey wanted to see how it was
(12:36):
operating in, for example,Victoria, do you think that we
will be able to benefit forbeing the last people to
introduce the legislation andsee how it works?
Dr John Ward (12:45):
I look, I'm sure we will be. And I think there's
a lot of people feel that thisNew South Wales legislation is
the best in the country that hassigned out a few of the
loopholes that exist in theother states, I must say, I'm
not familiar with thelegislation in in the other
states, but I think overall,most states have been fairly
(13:05):
happy with the way it's gone.The uptake has been reasonable,
but not enormous. They haven'tbeen swamped. So I think most
people feel that has been, youknow, a useful thing in medical
care.
Catherine Henry (13:20):
Yeah, I know, in Victoria, there are 68 I
think legislative safeguardsthat have to be that are in the
legislation, and we don't havethat restrictive approach. And
it as you say, and I'minterested to hear you describe
our legislation as the best inthe country, were criticised in
many ways for being the last kidon the block to introduce
(13:42):
important social legislation.And there are other examples.
But, you know, we can also learnfrom what's happened. So
families, doctors, patients, howdo you see this playing out? And
how do you feel that thoseinvolved in the care of a person
(14:05):
who is on all the on the face ofit eligible to access the
legislation? Operating what whatsort of potential issues do you
see within families who may notnecessarily agree with the
decision that has been made byperson wanting to access the
legislation and the VAD?
Dr John Ward (14:25):
I think it's not that much different from all
other decisions that we make,whether it's some advanced care
plans or whether it's legalissues like wills, Power of
Attorney, enduring guardian,whether someone should go into
an aged care facility or remainat home. Good medical practice
(14:47):
means that you've got to have afamily conference. And that
family conference needs toinvolve everybody. And there are
a lot of dysfunctional familiesas we know and there will be a
lot of people who will come outof the woodwork at the last
minute. And unfortunately,that's just good medical
practice. And if you're involvedin people at the end of life,
(15:10):
you have to have a great deal ofpatience. And you have to be
prepared to have multiple familyconferences. Even if you feel
you solved the issue, someonewill come from Queensland and
say, you know, I've never beenconsulted about this. And you
have to have sit down, do itagain. Because one of the things
I feel strongly about dying, isa good death is not necessarily
(15:33):
the one that the patient wanted.It's the one that leaves behind
a united family. So a gooddeaths adhering to the patient's
wishes, that leaves behind adivided family where half never
speak to each other. Again, Idon't see that as a good death.
And it's, it's avoidable. It'savoidable by good by family
(15:55):
conferencing, and buy goodmedical, social practice.
Catherine Henry (15:58):
I imagine you've been involved in a lot of
conversations around this nowabout the end of life. You've
been a geriatrician since, youknow, for some decades, and this
isn't new to you, and, andyou've seemed to have a very
calm approach to what we seebeing introduced in New South
Wales. So it's not a hugequantum shift as far as, as far
(16:22):
as you're concerned. It'ssomething that you've been
involved in these conversations,difficult conversations,
emotional conversations withfamily members about how best to
construct a good death.
Dr John Ward (16:36):
No, I think it is a quantum shift. I mean, we've
never had this sort ofconversation before of a patient
deciding to prematurelyterminate their life. So it's
something that's quite new. ButI think the principles are
probably fairly similar tothings that we practiced before.
(16:58):
The big gap in it, at all, ofcourse, is dementia.
Catherine Henry (17:02):
Yes, I'm pleased that we're going to get
into that because that is thebig bus isn't as in VAD that the
big chunk of people at the endof their life who won't be able
to access because they've lostcapacity.
Dr John Ward (17:15):
That's right. And it's the, probably the main
cause of the loss of dignity andfamily discomfort in older age,
and it's, so I understand whyit's included early on in the
(17:35):
legislation. But I do have myown ideas about how it could be
later on, it's probablypremature to think about it now.
Catherine Henry (17:45):
You don't want to tell us a little bit about
what you have in mind?
Dr John Ward (17:47):
We all know, people whose parents died of
dementia, who are terrified ofgetting dementia themselves,
and, and then siblings of themget dementia, and they're even
more frightened. And they have astrong concept of the dignity of
their life, and a strong wishnot to proceed to a stage which
(18:10):
is undignified. As far asthey're concerned. The reason
it's not included is that youneed within 12 months of
terminal neurodegenerativedisease to make the decision. Of
course, if you're within 12months of the end of your
dementia, you've lost capacity.And then you need to have the
(18:31):
capacity right at the end toconfirm it. And of course,
obviously, that's not the case.But it doesn't seem impossible
to me that someone couldn't setvery objective criteria at the
start when they knew they're inthe early phases dimension. We
know that that can go on forsome years where you're still
driving, you're still managingyour money. You're still living
(18:53):
a normal life, but you know thatyou've got an early dementia and
it's going to progress. And Idon't see it's beyond the bounds
of possibility that you couldset objective criteria, and then
say, well, when those criteriacut in - very objective, not
subjective, not something thatthe family could manipulate,
(19:15):
very objective criteria thatmedical people could measure
that that would be the time atwhich you would like your life
to end.
Catherine Henry (19:24):
So there's the early stage of the dementia
process. But what about do youforesee that somebody could
build it into an advanced caredirective prior to developing
any symptoms or signs ofdementia?
Dr John Ward (19:39):
Yes, that's quite a contentious issue. I'm not a
huge supporter of advanced caredirectives for people whose
health is reasonable. I mean,you know,
Catherine Henry (19:53):
So you're not in favour of a lot of lawyers. I
know that it is a bit bit of anarea that certain lawyers who
work in the estate planningarea, say that not only should
you have a will, and an enduringguardian and an enduring power
of attorney, but you should havean advanced care directive. And
I know that only something like10% of Australians, if that
(20:15):
would have an advanced caredirective or living wills,
sometimes they're, they're cool,but you're not in favour.
Dr John Ward (20:21):
No, I don't think they're useful. You can make
some general comments about thethings that you value in your
life and put that into youradvanced care directive. But I
don't think that gives itterribly much meaning I don't
see them being useful until thetrajectory of your illness is
clear. So once you've gone intoa nursing home, you know why
(20:43):
you're there. what's likely tohappen, you got a pretty good
idea of the prognosis and howthings are going to pan out.
That's when you do an advancedcare directive. I don't see it
as someone who is cognitivelywell and healthy, but fears
dementia, because I don't thinkthey know really, what that
(21:04):
trajectory of illness is goingto look like.
Catherine Henry (21:07):
Okay, well, I'd be interested in seeing how that
plays out. I imagine that itcould be something that could be
thought about in the context ofadvanced care directives. But
let's wait and see. Can we movejust to how things are in
regional, rural and remote areasof New South Wales? We've heard
a lot over the last two yearsabout how people living outside
(21:30):
the metropolitan areas don'thave the health care options
that those in the cities have,and even those outside Sydney.
So how do you feel that the VADwill impact on those who live
outside of the cities of NewSouth Wales, Sydney, Newcastle,
we've got a big VAD centre, asyou've told us, what about
(21:51):
people out in Central West andand very remote areas of the of
the state?
Dr John Ward (21:58):
Well I don't think there'll be doctors on the
ground? In every area, that'sfor sure.
Catherine Henry (22:04):
Telehealth is that is that going to be part of
this new scheme?
Dr John Ward (22:07):
You can discuss some parts of it by telehealth
but there are other parts of itto chew legally can't say for
example, you can't discuss thedrugs or medications or the
means of dying over the phone orby telehealth. So there are some
parts that can be done bytelehealth, but other parts are
going to have to be done by faceto face assessment. Now, whether
(22:31):
that means that the person hasto be brought down to the
doctor, or the doctors got to goto the person. Now I know that
New South Wales Health havegiven this a lot of thought. And
I assume that the unit at JohnHunter hospital is also given a
lot of thought because of coursewe look after right up to the
Catherine Henry (22:48):
very big catchment area,
Dr John Ward (22:49):
the Queensland border. And so there's going to
be a few doctors doing a lot oftravelling at considerable cost
one would think,
Catherine Henry (22:57):
Yeah, John, what about those who have always
expressed the very strong wishabout dying at home? A lot of
people express that that's veryimportant to them. How do you
see that working with voluntaryassisted dying is that something
that can be incorporated withinthe scheme that's being
(23:18):
introduced?
Dr John Ward (23:19):
I think easily and you can die and use this method,
anywhere you wish. So you canuse it in a nursing home, you
can use it in a hospital, youcan use it at home, a lot of
people I think will choose touse it at home because they will
want their family to be aroundthem.
Catherine Henry (23:36):
This concept of the good death.
Dr John Ward (23:37):
Yes, and have a little party and say goodbye to
everybody. And the other choicethey have is to have it
administered by someone like adoctor or nurse or to administer
themselves. Now you can eitheradminister it orally or
intravenously, and someone elsecan assist you with this. But
(24:05):
there are criteria that you haveto do a certain amount yourself
so that it's very clear thatthis is your decision. But you
know, it will be very attractiveto a lot of people to do this at
home.
Catherine Henry (24:17):
Yeah, well, thank you for explaining that. I
think that it does make a lot ofsense for people wanting to go
down this path and with thesupport of their the health
professionals that they consultwith and their families to be in
a in that home environment. Sothat that does make sense. I'll
be very interested in being awitness to how this new
(24:41):
legislation works in practiceand where we have in the hunter
a quite a large unit it wouldseem thank you so much, Dr. John
Ward for giving your time today.I know it's very precious.
You're very busy. And andcongratulations again on your
very significant recognition.recently.
Dr John Ward (25:01):
Thank you Catherine
Catherine Henry (25:10):
I hope you got a lot out of this episode of law
matters. I'm Catherine Henry andCatherine Henry Lawyers we work
on end of life legal issues,whether that's from thinking
about advanced care directivesto voluntary assisted dying. On
another note, this is the finalepisode for 2023. We'll be back
(25:31):
in 2024 with more interestingand insightful topics. I hope
you and your family have a safeand happy holiday period and
wish you all the best. Thispodcast was produced by Pod and
Pen Productions
Before we start in this episode, we make mention
of suicide in the context ofassisted dying. If this raises
issues for you, please contactlifeline on 13 11 14. On the
28th of November 2023, newvoluntary assisted dying laws
came into place in New SouthWales. We are the last state to
(00:24):
have introduced voluntaryassisted dying legislation,
which is commonly referred to asVAD. So what do these laws mean
for those who are terminallyill, their families and their
doctors? We're going to explorethis a little bit more in this
episode. Hi, I'm CatherineHenry, and I'm so glad you can
(00:45):
join me on the law matters withCatherine Henry lawyers Podcast.
Today we're talking aboutvoluntary assisted dying. These
laws came into place on Tuesday,the 28th of November 2023. We're
talking here about helping toend somebody's life. And even
though the person may be in thefinal stages of a terminal
illness, the process is stillfraught with emotion. And these
(01:07):
conversations are not easy ones.So let's look at how this
legislation will work withsomeone who has been following
this closely and who also workswith many people who are towards
the end stage of life. Hunterbased senior geriatrician Dr.
John Ward. Dr. Ward is afounding member of the Hunter
Ageing Alliance, as am I and hehas very recently just been
(01:31):
named New South Wales SeniorAustralian of the Year 2024.
John Ward, welcome and bigcongratulations.
Dr John Ward (01:38):
Thank you, Catherine.
Catherine Henry (01:40):
So John, you've been involved in aged care and
geriatric medicine since the1980s. Can you tell us how
important this new VADlegislation will be regarding
providing the best care forterminally ill people?
Dr John Ward (01:53):
Well, I think it's going to be important for a
small group of people, I don'tthink it's so huge number. But
those people who are at the endstages of an unpleasant disease,
many of whom course will beyoung with cancer or
neurodegenerative disease, butsome of them will be older. And
(02:16):
they will want to finish theirlife at a stage when they feel
they're losing dignity, whenthey can no longer communicate,
when they're incontinent whenthey're having to be moved
entirely by other people. Andthey feel this is not the way
(02:37):
they wanted to end their life.The other group for whom it will
be important, or those men whoat the moment committing
suicide. Now one of the thingswhich is not really known in our
community, is the higher highestincidence of suicide. Now, if I
can just explain the differencebetween incidence and
(03:00):
prevalence, if you're looking atthe total numbers in the
community, the highestprevalence of suicide is younger
men. But the highest incidenceof suicide, that's the number
per 1000 population is actuallyolder men. And they're killing
themselves because their qualityof life has become so poor. It's
(03:20):
because their spouse has died,they've got no friends, they're
losing their vision they'rehearing, they're becoming
incontinent and losing theirmobility,
Catherine Henry (03:28):
They don't wish to go into residential aged
care,
Dr John Ward (03:30):
And they certainly don't wish to go into
residential aged care. Now, manyof those will have a terminal
illness are several terminalillnesses that you could argue
will bring their life to an endwithin 12 months, or six months.
And so they will be anothergroup who want to access this,
whether they'll use it or not,is another matter. And that's
(03:52):
the way I think a large numberof people will use this
legislation is not necessarilyto carry through it. But just to
have it there as a an insurancepolicy as a comforting sort of
strategy as the life movesforward.
Catherine Henry (04:08):
Yeah. And up until this moment, up until the
28th of November. A criminalsanctions apply to the situation
of assisted dying. And I'm justwondering, there's a legal side
and a medical side and how doyou feel that your colleagues
who's in the medical professionfeel about voluntary assisted
(04:29):
dying?
Dr John Ward (04:31):
Well, I think most doctors have been helping people
to die in a secondary way.
Catherine Henry (04:38):
Can you explain that
Dr John Ward (04:39):
Well, people who've got an intractable
illness and have symptoms thataren't able to be controlled
with palliative care. Now, Idon't know what proportion of
people that is that palliativecare physicians would say that
most people, their problems aresolved by palliative care, but
in my experience there's a smallnumber for whom that's not
(04:59):
possible like pancreatic canceror prostate cancer with bony
secondaries, and so on.
Catherine Henry (05:05):
And palliative care can can be quite patchy in
terms of access.
Dr John Ward (05:09):
So I think all doctors have been using
analgesics, opiate analgesics tohelp the quality of life for
these people. And as thesecondary intention know that
they've been facilitating oraccelerating their deaths. And
that's been really legallyaccepted, I think. So as long as
(05:30):
your intention is not to killsomebody prematurely, but if
you're helping them medically,and the secondary intention of
that is to say life will beshortened. That's, I don't think
has ever been a legaldifficulty. But this has
certainly been contentious inthe medical profession. And I
know myself, I had a long timecoming around to this. I always
(05:52):
thought it was something thatought to be there. But I didn't
think that it was something thatdoctors should be part of,
because I thought then thatchanged the way that patients
related to us. But now I've comearound to think that no, that's
that's a cop out really.
Catherine Henry (06:12):
That provision in the Hippocratic Oath? Yeah,
the doctors like to refer towhen conversations about these
issues come up,
Dr John Ward (06:19):
But to be pushing that on to somebody else,
knowing that you're going to beusing it, I don't think is a
courageous thing to do. So I'vecome around to the belief now
that this is an issue, asignificant part of our medical
armamentarium. And we should useit as appropriate.
Catherine Henry (06:38):
Right. And we are in the Hunter. And we have
been preparing for thislegislation for some time,
because it was actually passedby the New South Wales
Parliament 18 months ago, thereis, there have been things going
on in the Hunter establishmentof a new unit, I understand
you've done some training toprovide the assistance to those
(07:01):
who need it. Can you tell uswhat's involved in the training?
Dr John Ward (07:06):
We had to do online training to start with,
do the online training and readthe manual. And then having done
that and satisfied thatrequirement, you could either do
a further online course, whichwas many hours, or do a face to
face training day, which was afull day followed by an
(07:27):
assessment. And I did both ofthose. But in the end, I decided
not to proceed to become one ofthese doctors. Because Hunter
New England health has set up,which seems to be an excellent
unit to deal with it headed by acancer surgeon and ethicist and
(07:49):
lawyer.
Catherine Henry (07:49):
Yes, quite well known in all of those fields, in
the hunter.
Dr John Ward (07:53):
Dr Charles Douglas, and supported by a lot
of people who have a veryexperienced in end of life care.
And my own life is busy enoughwithout wanting to add something
unnecessary, because I've reallyonly doing it thinking that the
number of domains will be enoughof you there wouldn't be enough.
(08:13):
But it does seem to be enough.If it turns out not to be
enough. Maybe I'll change yourmind. Yes, but
Catherine Henry (08:18):
you have done what is required in order to be
one of those doctors, if that'sturns out to be necessary here.
So could you tell us about thecriteria for accessing the VAD
laws? How does somebody showthat they had somebody get in
and be able to use the this newlegislation?
Dr John Ward (08:39):
All right, you you've have to have a close
affiliation with New South Waleseither be an Australian resident
who lives in New South Wales, orsomebody who's lived here for a
year or who has some closemedical connection. That means
you are accepted as someone whohas a claim on New South Wales,
you need to be over 18 and youneed to have an illness that
(09:01):
will likely and new your lifewithin six months, or if it's a
neurodegenerative illness within12 months, you need to have the
capacity to make a decision towant to proceed with voluntary
assisted dying. And followingyour assessments. If you're
accepted, you need to have thecapacity at the end to make a
(09:24):
final decision that you willproceed to accept the
medications. And you need tohave done all this without any
duress, the assessors need to behappy that this has been a free
decision that you've madewithout any duress.
Catherine Henry (09:40):
And that the issue of duress is one that I
would imagine a lot of people inthe lead up to this the passing
of this legislation and since itwas passed, continue to grapple
with. So in your view, how doyou deal with issues around
duress? Do you have any thoughtsaround this?
Dr John Ward (10:01):
Well, I think that most there are three sorts of
doctors involved in this.There's the coordinating doctor
who actually initiates theprocess that the person goes to
who I assume in most cases willbe their GP or a GP, a GP
closely attached to thepatient's own GP, then you have
(10:23):
to go before two consultingdoctors who make an assessment,
see what's suitable. And thenfinally, there's an
administering doctor, whichagain, might your GP, or you can
administer the medicationyourself, which is a difference
from other jurisdictions. Soyou've got those two choices. So
I would think that most GPswould know whether there was an
(10:45):
issue of duress. And ifnecessary, they would know who
to call upon to tease out thatquestion. So as a geriatrician,
that might be the sort of thingthat I might be called upon to
look at. A I might be calledupon to test a person's
capacity. But I think most GPscould do that very well
themselves, or I might be calledupon to assess duress, which is
(11:11):
what I frequently do already.
Catherine Henry (11:14):
In what context, do you deal with
duress?
Dr John Ward (11:16):
Around other legal issues like wills, Power of
Attorney
Catherine Henry (11:20):
potential elder abuse?
Okay, and if you feel that thereare issues around this, there's
an assisted dying, voluntaryassisted dying board? How do you
see the role of that boardoperating?
Dr John Ward (11:34):
There are five members on the board, it's
headed by a lawyer that chairsthe board, to the other members,
the lawyers, only one of them isa doctor and once a dentist. So
that's what makes up the board.The role of the board is to
oversee the act to make sure theact is adhered to. But they also
have the final decision as towhether accept someone from the
(11:56):
assessments of the consultingphysicians to accept them for
voluntary assisted dying, andthen to make the decision that
the pharmaceutical branch atNorth Shore should administer
the medications to the doctor orto the directly to the patient.
Catherine Henry (12:15):
And can we learn anything from the
Legislative schemes that havebeen implemented around the
country about the way in whichthe voluntary assisted boards
will operate? Because, as Iunderstand it, it has been one
of the reasons that there was apush to have this prolonged
introduction period was becausethey wanted to see how it was
(12:36):
operating in, for example,Victoria, do you think that we
will be able to benefit forbeing the last people to
introduce the legislation andsee how it works?
Dr John Ward (12:45):
I look, I'm sure we will be. And I think there's
a lot of people feel that thisNew South Wales legislation is
the best in the country that hassigned out a few of the
loopholes that exist in theother states, I must say, I'm
not familiar with thelegislation in in the other
states, but I think overall,most states have been fairly
(13:05):
happy with the way it's gone.The uptake has been reasonable,
but not enormous. They haven'tbeen swamped. So I think most
people feel that has been, youknow, a useful thing in medical
care.
Catherine Henry (13:20):
Yeah, I know, in Victoria, there are 68 I
think legislative safeguardsthat have to be that are in the
legislation, and we don't havethat restrictive approach. And
it as you say, and I'minterested to hear you describe
our legislation as the best inthe country, were criticised in
many ways for being the last kidon the block to introduce
(13:42):
important social legislation.And there are other examples.
But, you know, we can also learnfrom what's happened. So
families, doctors, patients, howdo you see this playing out? And
how do you feel that thoseinvolved in the care of a person
(14:05):
who is on all the on the face ofit eligible to access the
legislation? Operating what whatsort of potential issues do you
see within families who may notnecessarily agree with the
decision that has been made byperson wanting to access the
legislation and the VAD?
Dr John Ward (14:25):
I think it's not that much different from all
other decisions that we make,whether it's some advanced care
plans or whether it's legalissues like wills, Power of
Attorney, enduring guardian,whether someone should go into
an aged care facility or remainat home. Good medical practice
(14:47):
means that you've got to have afamily conference. And that
family conference needs toinvolve everybody. And there are
a lot of dysfunctional familiesas we know and there will be a
lot of people who will come outof the woodwork at the last
minute. And unfortunately,that's just good medical
practice. And if you're involvedin people at the end of life,
(15:10):
you have to have a great deal ofpatience. And you have to be
prepared to have multiple familyconferences. Even if you feel
you solved the issue, someonewill come from Queensland and
say, you know, I've never beenconsulted about this. And you
have to have sit down, do itagain. Because one of the things
I feel strongly about dying, isa good death is not necessarily
(15:33):
the one that the patient wanted.It's the one that leaves behind
a united family. So a gooddeaths adhering to the patient's
wishes, that leaves behind adivided family where half never
speak to each other. Again, Idon't see that as a good death.
And it's, it's avoidable. It'savoidable by good by family
(15:55):
conferencing, and buy goodmedical, social practice.
Catherine Henry (15:58):
I imagine you've been involved in a lot of
conversations around this nowabout the end of life. You've
been a geriatrician since, youknow, for some decades, and this
isn't new to you, and, andyou've seemed to have a very
calm approach to what we seebeing introduced in New South
Wales. So it's not a hugequantum shift as far as, as far
(16:22):
as you're concerned. It'ssomething that you've been
involved in these conversations,difficult conversations,
emotional conversations withfamily members about how best to
construct a good death.
Dr John Ward (16:36):
No, I think it is a quantum shift. I mean, we've
never had this sort ofconversation before of a patient
deciding to prematurelyterminate their life. So it's
something that's quite new. ButI think the principles are
probably fairly similar tothings that we practiced before.
(16:58):
The big gap in it, at all, ofcourse, is dementia.
Catherine Henry (17:02):
Yes, I'm pleased that we're going to get
into that because that is thebig bus isn't as in VAD that the
big chunk of people at the endof their life who won't be able
to access because they've lostcapacity.
Dr John Ward (17:15):
That's right. And it's the, probably the main
cause of the loss of dignity andfamily discomfort in older age,
and it's, so I understand whyit's included early on in the
(17:35):
legislation. But I do have myown ideas about how it could be
later on, it's probablypremature to think about it now.
Catherine Henry (17:45):
You don't want to tell us a little bit about
what you have in mind?
Dr John Ward (17:47):
We all know, people whose parents died of
dementia, who are terrified ofgetting dementia themselves,
and, and then siblings of themget dementia, and they're even
more frightened. And they have astrong concept of the dignity of
their life, and a strong wishnot to proceed to a stage which
(18:10):
is undignified. As far asthey're concerned. The reason
it's not included is that youneed within 12 months of
terminal neurodegenerativedisease to make the decision. Of
course, if you're within 12months of the end of your
dementia, you've lost capacity.And then you need to have the
(18:31):
capacity right at the end toconfirm it. And of course,
obviously, that's not the case.But it doesn't seem impossible
to me that someone couldn't setvery objective criteria at the
start when they knew they're inthe early phases dimension. We
know that that can go on forsome years where you're still
driving, you're still managingyour money. You're still living
(18:53):
a normal life, but you know thatyou've got an early dementia and
it's going to progress. And Idon't see it's beyond the bounds
of possibility that you couldset objective criteria, and then
say, well, when those criteriacut in - very objective, not
subjective, not something thatthe family could manipulate,
(19:15):
very objective criteria thatmedical people could measure
that that would be the time atwhich you would like your life
to end.
Catherine Henry (19:24):
So there's the early stage of the dementia
process. But what about do youforesee that somebody could
build it into an advanced caredirective prior to developing
any symptoms or signs ofdementia?
Dr John Ward (19:39):
Yes, that's quite a contentious issue. I'm not a
huge supporter of advanced caredirectives for people whose
health is reasonable. I mean,you know,
Catherine Henry (19:53):
So you're not in favour of a lot of lawyers. I
know that it is a bit bit of anarea that certain lawyers who
work in the estate planningarea, say that not only should
you have a will, and an enduringguardian and an enduring power
of attorney, but you should havean advanced care directive. And
I know that only something like10% of Australians, if that
(20:15):
would have an advanced caredirective or living wills,
sometimes they're, they're cool,but you're not in favour.
Dr John Ward (20:21):
No, I don't think they're useful. You can make
some general comments about thethings that you value in your
life and put that into youradvanced care directive. But I
don't think that gives itterribly much meaning I don't
see them being useful until thetrajectory of your illness is
clear. So once you've gone intoa nursing home, you know why
(20:43):
you're there. what's likely tohappen, you got a pretty good
idea of the prognosis and howthings are going to pan out.
That's when you do an advancedcare directive. I don't see it
as someone who is cognitivelywell and healthy, but fears
dementia, because I don't thinkthey know really, what that
(21:04):
trajectory of illness is goingto look like.
Catherine Henry (21:07):
Okay, well, I'd be interested in seeing how that
plays out. I imagine that itcould be something that could be
thought about in the context ofadvanced care directives. But
let's wait and see. Can we movejust to how things are in
regional, rural and remote areasof New South Wales? We've heard
a lot over the last two yearsabout how people living outside
(21:30):
the metropolitan areas don'thave the health care options
that those in the cities have,and even those outside Sydney.
So how do you feel that the VADwill impact on those who live
outside of the cities of NewSouth Wales, Sydney, Newcastle,
we've got a big VAD centre, asyou've told us, what about
(21:51):
people out in Central West andand very remote areas of the of
the state?
Dr John Ward (21:58):
Well I don't think there'll be doctors on the
ground? In every area, that'sfor sure.
Catherine Henry (22:04):
Telehealth is that is that going to be part of
this new scheme?
Dr John Ward (22:07):
You can discuss some parts of it by telehealth
but there are other parts of itto chew legally can't say for
example, you can't discuss thedrugs or medications or the
means of dying over the phone orby telehealth. So there are some
parts that can be done bytelehealth, but other parts are
going to have to be done by faceto face assessment. Now, whether
(22:31):
that means that the person hasto be brought down to the
doctor, or the doctors got to goto the person. Now I know that
New South Wales Health havegiven this a lot of thought. And
I assume that the unit at JohnHunter hospital is also given a
lot of thought because of coursewe look after right up to the
Catherine Henry (22:48):
very big catchment area,
Dr John Ward (22:49):
the Queensland border. And so there's going to
be a few doctors doing a lot oftravelling at considerable cost
one would think,
Catherine Henry (22:57):
Yeah, John, what about those who have always
expressed the very strong wishabout dying at home? A lot of
people express that that's veryimportant to them. How do you
see that working with voluntaryassisted dying is that something
that can be incorporated withinthe scheme that's being
(23:18):
introduced?
Dr John Ward (23:19):
I think easily and you can die and use this method,
anywhere you wish. So you canuse it in a nursing home, you
can use it in a hospital, youcan use it at home, a lot of
people I think will choose touse it at home because they will
want their family to be aroundthem.
Catherine Henry (23:36):
This concept of the good death.
Dr John Ward (23:37):
Yes, and have a little party and say goodbye to
everybody. And the other choicethey have is to have it
administered by someone like adoctor or nurse or to administer
themselves. Now you can eitheradminister it orally or
intravenously, and someone elsecan assist you with this. But
(24:05):
there are criteria that you haveto do a certain amount yourself
so that it's very clear thatthis is your decision. But you
know, it will be very attractiveto a lot of people to do this at
home.
Catherine Henry (24:17):
Yeah, well, thank you for explaining that. I
think that it does make a lot ofsense for people wanting to go
down this path and with thesupport of their the health
professionals that they consultwith and their families to be in
a in that home environment. Sothat that does make sense. I'll
be very interested in being awitness to how this new
(24:41):
legislation works in practiceand where we have in the hunter
a quite a large unit it wouldseem thank you so much, Dr. John
Ward for giving your time today.I know it's very precious.
You're very busy. And andcongratulations again on your
very significant recognition.recently.
Dr John Ward (25:01):
Thank you Catherine
Catherine Henry (25:10):
I hope you got a lot out of this episode of law
matters. I'm Catherine Henry andCatherine Henry Lawyers we work
on end of life legal issues,whether that's from thinking
about advanced care directivesto voluntary assisted dying. On
another note, this is the finalepisode for 2023. We'll be back
(25:31):
in 2024 with more interestingand insightful topics. I hope
you and your family have a safeand happy holiday period and
wish you all the best. Thispodcast was produced by Pod and
Pen Productions
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!