Study of Victoria’s assisted dying prospective approval process in practice

Victoria is the first Australian state to enact assisted dying laws and one of only two places in the world where a government department must issue a permit before the patient can receive assisted dying.

  • Study is first internationally to look at how Victoria’s pre-approval process for VAD operates from doctors’ perspective
  • 32 doctors involved in lawful voluntary assisted dying in VAD’s first year of operation interviewed
  • Not only the law but also the technology behind the process needs careful consideration to avoid barriers to VAD for eligible patients, study found.

The first empirical study internationally to analyse how a pre-approval and oversight model for assisted dying operates in practice has identified some concerns.

The study, published in the British Medical Journal Supportive and Palliative Care, was conducted in Victoria by Professors Ben White and Lindy Willmott, from QUT’s Australian Centre for Health Law Research, whose extensive end-of-life law research informed the Victorian Voluntary Assisted Dying legislation, the first to be enacted by an Australian state.

The qualitative study interviewed 32 doctors from diverse specialities who had been involved in providing lawful assisted dying (AD) during the first year of Victoria’s prospective approval system.

Professor Willmott said the study participants’ responses suggested that not only the law but also the technology design was crucial for the system to work properly and avoid barriers to eligible patients’ access to assisted dying.

“The participants also cited time-consuming paperwork, ‘pedantic’ requests for correction to patient information, and delays through each stage of the process as procedural problems,” Professor Willmott said.

“Briefly, the process begins only after a patient has requested AD from the doctor.

“What follows are two aspects of external prospective oversight and approval. The first is by an administrative Secretariat which supports the oversight body, the Voluntary Assisted Dying Review Board (VADRB).

“The Secretariat receives, through the online VAD Portal, the legislatively-mandated forms at three stages in the AD process including when patient eligibility is assessed by two doctors.

“Then, if two doctors assess the person as eligible, the coordinating doctor applies to a civil servant in Victoria’s Department of Health and Human Services (DHHS) for a government permit.

“The DHHS must approve or decline a permit within three business days and once granted, the doctor can prescribe the medication for the patient to self-administer or for doctor-administration if necessary.”

Professor White said key themes identified from the doctors’ perspectives included:

  • The pre-approval and oversight process was overly bureaucratic – doctors said: ‘byzantine bureaucratic process’, ‘highly legalistic’. Many reported ‘frustration’ at having forms returned by the Secretariat for typos or minor corrections. However, some participants said the Secretariat’s detailed scrutiny of forms as ‘reasonable’ and ‘necessary’, even if ‘annoying’.
  • The mandatory online Portal technology was a barrier – doctors described it as ‘clunky’ and ‘non-intuitive’.
  • Some doctors said the prospective oversight and approval process caused unnecessary delays: ‘…-the Board is working 9 to 5, Monday to Friday. And then we got to a weekend … and there’s nothing until the Monday … it was very shortly after that point that the patient effectively lost consciousness … So, we probably lost – I would say we lost three to four days of actual time because of the process.’ [participant]
  • The prospective process caused difficulties for very sick patients who did not have long to live. Some doctors perceived this process ‘unfairly’ excluded some patients from AD. The article states: ‘It took too long and was too demanding for patients. While some delays occurred after prospective approval (eg, delays getting medication), participants identified specific instances where patients missed out due to oversight and approval ‘bureaucracy’.
  • Despite these concerns, prospective oversight and approval process protected doctors and ensured safety: ‘Their function really is to protect us. If I do something wrong, then I’m quite vulnerable … Unless we’ve got a really good administrative Board that will not let anything through that is not within the legislation, then I would feel a little bit exposed.’ [participant]

“Assisted dying (AD) is increasingly becoming lawful internationally,” Professor White said.

“While all AD models have oversight mechanisms, Victoria, Australia is rare in requiring formal approval before AD is permitted. Colombia is the only other country currently with a pre-approval AD process.

“New Zealand and the UK are among countries considering, enacting or implementing prospective approval models yet virtually no research had been done about their operation until now.

“This study of the Victorian system suggests, at least in its first year of operation, that there may be costs to its approach. Careful evaluation of the strengths and weakness of prospective oversight and approval is needed, in relation to the legal framework and how the AD system is designed and implemented,” Professor White said.

“At the heart of designing pre-approval AD systems is striking the optimal balance between providing access to eligible patients and ensuring the system operates safely.

“Evidence shows that the Victorian system is safe, but for eligible patients – who by definition are terminally ill and suffering – challenges remain in gaining access to AD.”

Prospective oversight and approval of assisted dying cases in Victoria, Australia: a qualitative study of doctors’ perspectives was published in the British Medical Journal Supportive and Palliative Care.

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