Wednesday, 1 August 2018

Medical Treatment Planning and Decision Making

The Medical Treatment Planning and Decision Act 2016 came into force in March 2016. This legislation governs a persons right to access or to refuse medical treatment and helps them to do so even if they subsequently become unable to communicate their wishes.
If a person has decision making capacity and is over the age of 18 years they can make an " advanced care directive" in consultation with their health practitioner. This is a written document which can set out both instructional directives which must be followed and can also set out values directives which are non binding but indicative as to preferences only.
The directive is only referred to once a person loses decision making capacity for their own health care.
Obviously it is critical to be clear and accurate regarding any instructional directives you might wish to include in such a document. For this reason, instructional directives are better prepared in direct consultation with your medical practitioner who will help to ensure that your instructions are clear and easily understood.
An instructional directive might specify that you " ...consent to heart bypass surgery in specified circumstances." or " ..refuses cardiopulmonary resuscitation.
A values directive might specify that you don't want your life prolonged if you can't recognise or communicate with your family or friends.
An advanced care directive:-
1.Must be in English.
2. Must include your full name, date of birth and address.
3. must be signed by the person making it and;
4. Must be witnessed by a registered health practitioner and another adult person who is not the Medical decision maker.
If a child is making a health care directive at least one witness must b a health practitioner with prescribed training and experience.
Those witnessing need to certify that:-
The person signing the directive appeared to have decision making capacity;
The person appeared to sign freely and voluntarily.
The person signed in front of the two witnesses.
The witness is not also the appointed medical decision maker.
The person appeared to understand the nature and effect of the document they were signing.
Obviously such a document is only of value if brought to the attention of those treating the person making such a directive.
To be appointed as a medical treatment decision maker a person must
the be at least 18 years old. Appointments may be limited or very general. No health practitioner is required but one of the witnesses must be a person authorised to take affidavits. The decision maker must sign an acceptance.
Whilst it is possible to appoint more than one medical treatment decision maker, it is only possible to have one person at  a time so second and subsequent decision makers would only come into play if the first or earlier decision makers died or became incapable.
Again, the document will only be of value if it is available to all concerned.

Thursday, 12 July 2018


The Voluntary assisted dying Bill 2017 was introduced to facilitate a process whereby Victorians might be permitted to make informed decisions regarding their own end of life choices.
It is scheduled to come into force in 2019.
Assisted dying means "the administration of a voluntary assisted dying substance and includes steps reasonably related to such administration."
To be eligible to end their own life a person must be a Victorian resident over18 years of age who has decision making capacity. They must have been diagnosed with a disease, illness or medical condition which is incurable, advanced, progressive and will cause death in less than 6 months. Finally they must be experiencing suffering that cannot be relieved in a manner that the person considers tolerable.
If a person wishes to end their life pursuant to this legislation they must first make a personal request to a registered medical practitioner. It must be a clear and unambiguous request but can be relayed by gestures or other means of communication available to the person concerned.
Health practitioners are specifically precluded from initiating discussions about or from suggesting voluntary assisted dying to a patient.
The medical practitioner receiving the unsolicited request has seven days to inform the person whether they will accept or refuse the request. Medical practitioners cannot be compelled to participate in the process.
Once a medical practitioner accepts he or she will become the coordinating medical practitioner who will assess eligibility and refer the person for a second opinion from another medical practitioner.
If eligible, the person must be provided with full disclosure of all other treatment available to them.
After eligibility is determined the person may execute a written declaration to act as a record of the voluntary and enduring nature of the request. If they make such a declaration they may make a final request to access voluntary assisted dying no sooner than 9 days after the first request was made. There is an exception to the time limit where both medical practitioners are of the view that the persons death is likely to occur in less than the 9 day period.
The person accessing VADB must appoint a contact person to monitor the assisted dying substance.
The health practitioner may, after completion of all required formalities, apply to the Secretary of the Department of Health for a permit for EITHER  a self administration permit OR  a practitioner administration permit.
The penalty for administering the substance other than in accordance with the permit is Life Imprisonment.
Offences under the proposed legislation include:-
Inducing another to request voluntary assisted dying.
Inducing another to self administer a voluntary assisted dying substance.
Falsifying forms or records.
Making false statements or reports.
Failure to return any unused VAD substance.

The following article is reproduced with the kind permission of Spectator Magazine:-

Did Granny jump, or was she pushed?

Euthanasia is a threshold too far

Dr Henry Marsh, British neurosurgeon, was displeased when the UK Parliament rejected euthanasia three years ago. The good doctor said, ‘Even if a few grannies get bullied into [suicide], isn’t that the price worth paying for all the people who could die with dignity?’
As euthanasia returns to the federal arena, courtesy of an equine exchange between Prime Minister Turnbull and Senator David Leyonhjelm, we should give some thought to those grannies.
Our head of state certainly did back in 1995 when euthanasia was last a federal issue. Governor-General at the time, Bill Hayden, explained to doctors on the Gold Coast why he supported euthanasia, not only as a right but also as a positive duty to society.
‘There is a point’, he said, ‘when the succeeding generations deserve to be disencumbered of some unproductive burdens.’
In Holland, where euthanasia is legal, doctors have unlawfully put to death several hundred patients each year without their consent

This firm message to society’s unproductive burdens was supported the next day by a former state governor, Sir Mark Oliphant. He told ABC radio about an aged colleague in Canberra who ‘should be dead’ and was cluttering up the world when he shouldn’t be.
Governor-General Hayden had enlightened his audience about past cultures where the grannies and grandads would take poison or wander off into the forests when their usefulness to society was done. The elderly Japanese, defined as such by loss of all teeth, would jump from the rim of a volcano for the greater good. But this is the point: did the toothless Japanese granny jump, or was she pushed?
More subtly, did she indeed jump, but only because of an irresistible cultural push?
That is the insidious new oppression that we do not need to have.
The lonely old people I see in nursing homes have a keen sense of being a burden. They would perceive euthanasia less as a ‘right to die’ and more as a ‘duty to die’. They would get the message that they are no longer welcome, and they would do the right thing by society.
Consider an elderly (now deceased) patient of mine, a woman with depression and minimal self-confidence, who received a vicious letter from a close relative effectively telling her she should be dead, and demanding certain arrangements in her will. She then developed cancer. What would the ‘right to die’ mean to such a patient, so isolated and intimidated?
For sophisticated types like Hayden and Marsh, death on demand would enlarge their autonomy. But given the psychological vulnerability of the average old person, the sense they already have of being ‘unproductive burdens’ and the power of insensitive family or medical staff to reinforce this sense, such a decision will be made from a position of humiliation and weakness.
Former Prime Minister Paul Keating concurred last year, writing, ‘It is fatuous to assert that patients will not feel under pressure once this bill becomes law to nominate themselves for termination’.  And the Australian Medical Association President last year, Dr Michael Gannon, cautioned that ‘the sick, the elderly, the disabled, the chronically ill and the dying must never be made to feel they are a burden.’
Hence the AMA’s formal reaffirmation, as recently as 2016, that ‘doctors should not be involved in interventions that have as their primary intention the ending of a person’s life’.
That word ‘intention’ is key to clearing up a lot of confusion on euthanasia. Some people think it is euthanasia if I give granny adequate morphine to stop her pain, but it is not, because my intention is only to ease her symptoms, never to end her life.
Or if her medical team turns off life support because there is no longer any chance of recovery, that is not euthanasia but merely acceptance of dying.
Power corrupts, and the doctor-patient relationship will be corrupted by the power to take life. In Holland, where euthanasia is legal, doctors have unlawfully put to death several hundred patients each year without their consent. In neighbouring Belgium, the circle of criteria for euthanasia has steadily expanded from adults to children; from the terminally ill to those simply ‘tired of life’; from cases of depression and chronic fatigue to those distressed by anorexia; even a 41 year old man who so regretted his sex change operation that he wanted to die.   And the Belgian doctors obliged.
Keating sees this slipperiest of slopes as entirely predictable: ‘Once termination of life is authorised the threshold is crossed. From that point it is much easier to liberalise the conditions governing the law. And liberalised they will be.’
Indeed they will be, for if we enshrine in law the curious claim of a ‘right to die’ (as incoherent as the ‘right’ to pay taxes) then who are you to restrict that right?
Plan B is to retain the prohibition on intentional killing as the cornerstone of law, while striving to improve palliative care – a powerful field of medicine that offers, for the first time in history, the prospect of a tolerable death for all in this lucky country.
Importantly, rejection of euthanasia is not dependent on perfecting palliative care for all patients. Nor is its rejection a religious issue. Its rejection stands on the rock-solid ground of social justice, as the Hon. Kevin Andrews explained on presenting his Euthanasia Laws Bill 1996: ‘The people who are most at risk are the most vulnerable, and a law which fails to protect vulnerable people will always be a bad law’.
The Andrews Bill, which vetoed the power of glorified town councils in Darwin and the ACT to determine the great matter of euthanasia, is what the libertarian Senator Leyonhjelm seeks so recklessly to overturn.
For if we open the door to euthanasia, society would not, contra Andrew Denton, go gentle into that good night; it would go brutal as a culture which chooses to make people dead rather than care for them in dying; whose unproductive burdens will freely jump to their death, but only because of an insidious cultural push.
David van Gend is a Queensland GP and university lecturer in palliative medicine