VAD: the pharmacy role in practice

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As Victoria’s voluntary assisted dying laws are set to come into effect, the AMA’s WA branch is warning that VAD could facilitate murder

From Wednesday 19 June 2019, Victorians with a terminal illness will be able to make an initial request to access VAD.

A pharmacy service based out of Melbourne’s Alfred Hospital will become the sole service for dispensing VAD medications across the state, which according to the Andrews Government will ensure patients are provided with clear information regarding administration, and that unused medicines are returned and destroyed.

For people who are too ill to travel, the pharmacy service will deliver the medication and provide information on administration, and then collect any unused medication.

The Voluntary Assisted Dying Review Board, chaired by former Supreme Court Judge Betty King QC, will review every instance of voluntary assisted dying being accessed.

The voluntary assisted dying model is the most conservative in the world. The safeguards include:

  • Only adults with decision-making capacity, who are suffering and have an incurable, advanced and progressive disease, illness or medical condition that is likely to cause death within six months (or 12 months for people with neurodegenerative conditions) can access the scheme.
  • A person may only access voluntary assisted dying if they meet all of the strict eligibility criteria, make three clear requests and have two independent medical assessments that determine they are eligible.
  • The request must always be initiated by the person themselves, with health practitioners who are treating the person and raise the issue subject to unprofessional conduct investigations.

The Victorian Government has also provided $72 million in this year’s Budget for palliative care.

“A person’s quality of death is part of their quality of life – and everyone deserves a genuine, compassionate choice,” said Premier Daniel Andrews.

“This is the most conservative model of its kind in the world. We know that only a small number of people will choose to access voluntary assisted dying, but it will make a world of difference for those who do.”

Michael Dooley, pharmacy director of The Alfred Hospital, told the ABC how the pharmacists’ role will work.

“After a doctor has got a permit for the patient, the doctor will then send us a prescription,” he said.

“The patient will then contact the statewide pharmacy service requesting the medications.

“At that point, we’ll go and visit the patient wherever they are and sit down with them and whoever else they want to be there and we’ll go through the medications with them.

“We’ll provide the medications in a locked box in a kit. The kit contains patient information, it contains a locked box with the medication in it, as well as some other pre-medications they take earlier.”

He said that the pharmacists will explain the process to the patient, leave the medications with the patient and answer any questions they may have.

“It’s up to the patient to decide if and when they choose to take that medication.

“The role of the statewide pharmacy service is to educate them, do that in a compassionate manner and make sure the medications are provided in a safe manner for them.”

Jarrod McMaugh, representing the Pharmaceutical Society of Australia on Victoria’s VAD Taskforce, told the AJP that there are several issues pharmacists need to consider.

He said that the primary issue is that conversations with people about VAD need to be driven by those people, not the pharmacist, due to the heavy penalties involved.

“Any pharmacist who is not working in the statewide pharmacy service who is presented with a prescription that they feel is for VAD is an invalid script,” he said.

“Any pharmacist in any setting who feels they have been presented with a prescription that is inappropriate should contact the prescriber in all instances (regardless of the purpose), and implement their clinical judgement in order to never supply a dangerous prescription.”


Murder for financial gain

Meanwhile, the Australian Medical Association’s WA branch has made a submission to that state’s ministerial expert panel on the issue, outlining a number of concerns.

Western Australia is currently considering implementing VAD legislation.

Among the issues concerning the AMA WA is what it identifies as the risk to public and patient safety in allowing self-administration of lethal medicines in the home.

This includes the potential for unlawful deaths “if patients had decided not to proceed with voluntary assisted dying but retained access to the medication”.

“It is easy to foresee circumstances where the medication is then used on a patient who no longer had capacity to consent to administration of the medication or to commit murder for financial gain,” it says.

It also warns that VAD should not be treated as an alternative to good palliative care.

“The AMA WA says that it believes this sentiment and the perceived desire to legalise voluntary assisted dying has arisen as a result of the current shortfalls in provision of palliative care in WA and a low level of understanding of the realities of end of life decision-making,” the AMA WA submits.

“Consequently, the correction of deficiencies in palliative care and end of life decision-making must be a prerequisite to the introduction of voluntary assisted dying legislation for community and parliamentary debate.

“For the vast majority of individuals, good quality palliative care will improve their end-of-life experience without consideration of voluntary assisted dying.

“The introduction of any system which bypasses the need to provide palliative care, threatens the provision of that service and those who depend on it.”

Mr McMaugh told the AJP that the AMA WA branch’s comments were “clearly emotive, which is unfortunate, as there is clearly defined structures within the Victorian VAD legislation and regulation that puts a patient at the centre of the VAD process”.

“A practitioner would meet with extremely severe penalties for trying to coerce a person into using VAD (five years in prison) or for administering without a permit (life in prison). I am confident the WA bill would contain similar safeguards.

“The capacity to obtain a permit requires two independent medical practitioners to be involved in the evaluation of a patient’s enduring intent to utilise VAD, eligibility, and decision making capacity.

“It would be inconceivable that a medical practitioner could utilise these systems to commit murder. In addition, the provisions for conscientious objection for all health practitioners’ means that no one could be forced to participate against their will.

“AMA WA should have more faith in their members and colleagues.”

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