November 2021

1News 7 Nov 2021
Palliative care professor Rod MacLeod said despite the Act being called “End of Life Choice”, there would be some people who didn’t have a choice because they couldn’t opt to access palliative care. He said it was a lottery because hospice services rely heavily on charity.  “It depends on where you live, it depends on the disease that you might be experiencing, it depends on your ethnicity sometimes,” he said. “So, I think at the moment, although we have good palliative care services in the country, it’s not evenly distributed in any way.” MacLeod said the Government should boost its funding of the services.
https://www.1news.co.nz/2021/11/07/more-palliative-care-funding-wanted-as-assisted-dying-becomes-legal/

Stuff
Based on overseas experiences, the Ministry of Health estimates up to 950 people could apply for assisted dying each year, with up to 350 being assisted to die. But there is uncertainty about what the actual demand will be.

In Victoria, Oregon, and Canada, assisted dying accounts for between 0.3 and 2 per cent of all deaths; with 124 confirmed assisted deaths in the first 12 months Victoria offered the service.

As of October 27, 96 doctors across the country have expressed interest in being included on the Support and Consultation for End of Life in New Zealand (SCENZ) group list to act as an attending medical practitioner in the assisted dying process. Eight nurse practitioners have put their hand up to be on the list; 13 psychiatrists have expressed their interest to perform assessments if requested; and 93 have expressed interest in independent practitioner second assessments.

The ministry expects assisted dying services will be provided mainly by general practitioners, in a person’s home or other community settings. What impact this will have on an already stretched health workforce is unknown. More than 6000 health professionals have completed the training module available to health workers, and 129 medical and nurse practitioners have accessed training. Sixty-four per cent of practicers happy to be involved are in the North Island, and 36 per cent in the South Island.

In the lead-up to the referendum, close to 1600 doctors signed an open letter opposing assisted dying; arguing proper palliative care makes euthanasia unnecessary. The move to fully fund assisted dying but not palliative care has also come under recent criticism.
https://www.stuff.co.nz/national/health/euthanasia-debate/300443715/assisted-dying-now-legal-in-new-zealand-end-of-life-choice-act-a-huge-relief-for-some?cid=app-iPhone

Radio NZ
A palliative care doctor who opposes euthanasia says robust information must be collected about why terminally ill people choose to end their lives under the new law. Care Alliance deputy chair Sinead Donnelly said health officials should be asking people who meet the act’s criteria whether they’re choosing euthanasia because of pain, a lack of palliative care options or other reasons. It needs to be asked “if people are choosing euthanasia because, for example, there’s lack of access to palliative care for specific groups in specific regions,” she said. “We’re very concerned about equity at the moment, and Māori and Pasifika, for example, are they choosing euthanasia? … We need to identify if it is due to a lack of access to services.” Donnelly said failing to collect meaningful information could make it harder to recognise issues of access to healthcare.

Last month the government announced the appointment of three experts to monitor assisted dying. They are: medical ethicist Dr Dana Wensley, nursing executive Brenda Close and palliative care consultant Dr Jane Grenville.
https://www.rnz.co.nz/news/national/455120/end-of-life-choice-act-takes-effect-in-new-zealand

Palliative Medicine Doesn’t Include Euthanasia – ANZSPM

The peak body for palliative medicine in New Zealand and Australia has released an updated Position Statement entitled The Practice of Euthanasia and Physician-Assisted Suicide just days before euthanasia and assisted suicide becomes legal in New Zealand.

The Statement by ANZSPM (Australian and New Zealand Society of Palliative Medicine) says that “In accordance with best practice guidelines internationally, the discipline of Palliative Medicine does not include the practices of euthanasia and physician-assisted suicide.”

It also unequivocally states that “ANZSPM does not support the legalisation of euthanasia and physician-assisted suicide” and “endorses international guidelines reaffirming that these practices are not part of palliative care.”

ANZSPM members are medical practitioners who provide care for people with a life-threatening illness.

It also says that

• “Patients have the right to refuse life-sustaining treatments including the provision of medically assisted nutrition and/or hydration. Refusing such treatment does not constitute euthanasia or physician-assisted suicide.”
• “Withholding or withdrawing treatments that are not benefitting the patient, is not euthanasia or physician-assisted suicide.”
• “Treatment that is appropriately titrated to relieve symptoms and has a secondary and unintended consequence of hastening death, is not euthanasia or physician-assisted suicide.”
• “Palliative sedation for the management of refractory symptoms is not euthanasia.”

Most people simply want to ensure that the administration of pain relief and the withdrawal of burdensome treatment are not treated as illegal. That is already the case.

The Position Statement also warns that attention should be given to “symptoms that research has highlighted may commonly be associated with a serious and sustained “desire for death” (e.g. depressive disorders and poorly controlled pain).”

“Nothing in this new law guarantees the protection required for vulnerable people, including the elderly, depressed or anxious, and those who feel themselves to be a burden or who are under financial pressure. It is also impossible to fully measure levels of coercion on a patient,” says Bob McCoskrie, National Director of Family First NZ.

“It is reassuring for patients and families to know that most Hospices and most palliative care specialists and other medical professionals want nothing to do with euthanasia or assisted suicide.”

OPEN LETTER

To: Totara Hospice re End of Life Choice Act

We are writing to express our concern that you will be one of the only hospices in New Zealand offering euthanasia and assisted suicide under the new law to come into force on Sunday 7 November. As a loved and trusted service which has served the South Auckland community for 40 years, we respectfully ask that you reconsider your decision in light of the following key points.

We already have “choice”.

A person may already refuse medical treatment.

• turning off life support
• ‘do not resuscitate’ (no CPR) requests
• stopping of treatment or food

 Those things are legal. And they’re not euthanasia.

Most people simply want to ensure that the administration of pain relief and the withdrawal of burdensome treatment are not treated as illegal. Allowing the natural process to take place with appropriate palliative care including pain management is completely different to intentionally bringing about the patient’s death.

Mistakes could be made

Some people will request assisted suicide or euthanasia on account of a diagnosis/prognosis. But as you are aware, there can be no absolute certainty around that. The new law relies on a diagnosis that a person suffers from a terminal illness which is “likely” to end his or her life within six months.

How will you measure “likely”? And can you guarantee that you will be right each and every time. Patients will be relying on that assurance.

Coercion is a significant issue.

Many will request assisted suicide because of coercion either internally or from relatives, or concerns around costs of treatment. Others will be struggling and possibly even be depressed.

The new law is seriously deficient in so far that it only requires doctors to “do their best” to ensure that the person is free from pressure – an extremely low legal threshold. Moreover, it fails to outline any process for ensuring patients are free from coercion. Can you guarantee that every patient who is euthanised will be completely free of coercion.

As the NZ Medical Association told the Select Committee considering the new law: “The provisions in the Bill will not ensure that a decision to seek assisted dying will always be made freely and without subtle coercion.”

In Oregon, Washington state and Canada which already allow euthanasia, the statistics show that the feeling of being a burden is one of the key reasons that terminal patients requested euthanasia.

Also of concern is that elder abuse is already a significant problem in New Zealand. About 80% of it remains hidden and unreported. We cannot ignore the possibility that dependent elderly people may be coerced into assisted suicide in their final weeks and months. That feeling of being a burden on loved ones, and the knowledge of that expensive rest home and geriatric care and medical bills, are all subtle forms of coercion pushing an already vulnerable person towards a quick cheap solution.

Cost may drive decisions

The new law only provides a ‘right’ to one choice – premature death. There is no corresponding right to palliative care. But as you are well aware, good palliative care and hospice services are resource intensive & can be expensive; euthanasia would be cheaper. This law change could introduce a new element of ‘financial calculation’ into decisions about end-of-life care for families and for vulnerable patients.

Our specific law is a flawed and dangerous one

Even a cautious approach from Totara Hospice will not offer complete reassurance to vulnerable patients. These are the specific concerns in the operation of the law:

• unlike other jurisdictions, no independent witnesses are required at any stage of the process, including at the death
• the person’s mental competence doesn’t have to be assessed at the time the lethal dose is administered. Can you guarantee that you will know their intention at the time that they are at their most vulnerable?
• There is no mandatory cooling-off period or ‘thinking time’ – unlike overseas where there are specific cooling off periods of 9 days and up to 15 days.
• There is no requirement for an existing doctor / patient relationship. As we now know, there are very few medical professionals who want to be part of this process. Patients will ‘shop around’ for the doctor that gives you the answer a patient wants – but who doesn’t know their background – or more importantly, the family dynamics and whether there is obvious coercion going on – which a family doctor will have knowledge of.
• Once of the worst provisions is that the patient can block family members from being aware of their decision to have euthanasia. There is no requirement that the person discuss their request for assisted suicide with any other person. This is a serious flaw in the Act. But family members may be fully aware of why the request is being made – and may have alternative solutions that don’t involve killing the patient. Are you concerned that you may euthanise patients without any family involvement or support?

How many mistakes?

One of the arguments used for not having the death penalty in NZ was – what if we get one wrong. It was that fear of a mistake that was a good justification for not having the death penalty in law.

How many euthanasia mistakes are we willing to accept? How many euthanasia mistakes are you willing to accept?

Why not?

The most concerning aspect is that “legalised” means normalised.

Euthanasia is no longer illegal and ‘off the table’. It is an actual legal and approved option.

Patients may come to feel euthanasia would be ‘the right thing to do’. They’ve ‘had a good innings’ and do not want to be a ‘burden’ to their nearest and dearest. They don’t want to be a drain on their family’s resources and time.

This law now means that vulnerable people facing a terminal illness will be asking themselves – why should I not be accessing euthanasia / assisted suicide?

And this underlying obligation will be felt even greater when they utilise the services of Totara Hospice.

It’s now a clear option on the table at Totara Hospice – sadly.

We believe patients facing death have a fundamental human right – a right to receive the very best palliative care, love and support that we can give to alleviate what they may be naturally scared of, surrounded and supported by loved ones,

Hospice NZ defines Palliative Care as “active total care… [F]or people whose illness is no longer curable, the goal is around providing quality of life, managing pain and symptoms to enable people to live every moment in whatever way is important to them.”

We ask the Totara Hospice to take euthanasia / assisted suicide off the table.

Assisting suicide at a hospice is never an appropriate solution.