Dr Danielle Ferraro, Dr Frank Brennan and Nicky Stitt: The many nuances of VAD and palliative care

There is one certainty when it comes the issue of voluntary assisted dying (VAD) and palliative care – it is a complex topic that raises professional, legal and personal challenges.

It was a topic raised at the 2023 Oceanic Palliative Care Conference (23OPCC) in great detail across the program, the need for these conversations was evident by the overflowing rooms where anything related to VAD was being discussed and shared.

A panel discussion featuring those delivering and facilitating VAD was a key learning opportunity for the 1400 delegates.

Palliative care professionals need to discuss VAD issues

Patients in palliative care are the same patients who may be eligible for VAD, so it’s a vital issue for palliative care professionals to analyse – despite the challenges.

“A lot of palliative care clinicians worry about this altering our practice, changing what we do, or doing something wrong,” says Dr Frank Brennan, Palliative Care Physician at Calvary Health Care.

“The most important thing is for us to hold to our north star – who we are as palliative care health professionals?, why we are doing palliative care. We’re bringing comfort to those are are suffering from life-limiting illnesses, bringing all our professionalism and compassion to that,” he says.

“We need to continue working with our patients, including those who are requesting VAD.”

Dr Brennan adds, “We also need to be conscious of all of our colleagues – people who participate, those who are unsure, and the conscientious objectors – because we need to have respect for each other.”

The reasons for VAD requests are varied and sometimes surprising

Dr Danielle Ferraro, Medical Oncologist at Eastern Health Melbourne, says a number of elements around VAD have surprised her.

“One of those things is the reason that people are looking for VAD – it’s largely people who don’t want to be unconscious with their family sitting around them while they’re incontinent or needing to be bathed or toileted,” she says.

Nicky Stitt, VAD Care Navigator – Nurse Consultant at Peter MacCallum Cancer Centre, adds that previous experiences and perceptions also play a role in VAD requests. “We hear experiences of death within their family … and they don’t want that for themselves. It’s about choice.”

For a patient who’s nearing the end of their life, choice is important

Stitt has witnessed many patients needing a sense of choice and control over their own death.

“In my experience as a navigator, overwhelmingly people who contact us don’t want to die; they want to live. They are living with a life-limiting, terminal illness that is going to cause their death within the next days, weeks or months, and they have fear … of dying in a way that they do not consider a good death,” she says.

The patient has been told by a health professional that death is coming, and to get their affairs in order. “Part of getting those affairs in order is control – it’s about when, where and how,” Stitt says.

“There are choices for them, they’re in control for the first time in possibly a very long time.”

Sometimes VAD is an unused comfort

Stitt says that many patients who request VAD don’t use it. “A third of people in Victoria don’t use the medication,” she says.

However, knowing the option is there can be reassuring for a patient. “It’s about knowing there’s a safeguard there – I’ve heard it described as another tool in the palliative toolbox. Knowing there’s something there that can relieve their suffering is almost palliative in itself, because it reduces their anxiety,” says Stitt.

The personal toll of VAD on healthcare workers

Having done VAD assessments for some time now, Dr Ferraro says she can see the effect it’s having on her.

“It takes a personal toll – this is really hard work. It’s not something you do lightly,” she says.

“Particularly practitioner administered VAD is incredibly traumatic as a doctor, and certainly not something I do because I want to do it, but if this is the patient’s ultimate request – if their ultimate goal is the comfort that I can give them – then I can facilitate that, even if it makes me personally uncomfortable.”

To deal with this, Dr Ferraro believes it’s important to set up support networks.

“I think I underestimated how much support you need as a practitioner doing this,” she says. “It can be really rewarding and patients are incredibly grateful, but it absolutely takes a toll.”

Palliative care is vital, whether a patient requests VAD or not

Dr Ferraro says that palliative care is vital at this time. “The overwhelming majority of patients I’ve seen have had palliative care involved. They’re aware that excellent palliative care can manage a lot of symptoms but that is not what they want for themselves or their family.”

In Melbourne, Stitt has seen over a few years how palliative care professionals and VAD can co-exist. “We’ve seen and witnessed the relationships between VAD and palliative care grow stronger and stronger, regardless of people’s personal views or organisational views – people are seeing through that and are looking at patient-focused care,” she says.

“VAD provides a peaceful death, and palliative care wants to provide a peaceful death, so the outcome is very similar.”

Video recordings of 23OPCC sessions involving discussion of VAD are now available to watch on demand via the 23OPCC Education Hub. Recordings are available free of charge to delegates as part registration. Subscriptions can also be purchased for between $200 and $400. More info and access – HERE.