June 2023 marks 4 years since the implementation of Voluntary Assisted Dying (VAD) in Victoria. It also marks the start of a Parliamentary review into Victoria’s VAD Act, providing an opportunity for reflection on the first 4 years of the Act. The Voluntary Assisted Dying Act 2017 (Vic) allows terminally ill patients, who meet a set of rigorous eligibility criteria, to seek assistance in ending their life. As a final year medical student who is preparing for a career in rural medicine, I am particularly interested in the effect of rurality on equity of access to such a vital service.
Since the law came into effect in June 2019, Safer Care Victoria have reported that more than 900 Victorians have used VAD to end their life. Median age was 73 years and most (> 80%) suffered from a primary malignancy. Most were also based in Melbourne, with only one third (36.5%) from regional Victoria. This suggests the VAD legislation is not working as well as it could for people located in regional and rural parts of the State.
The current legislation requires 2 doctors to assess a patient for eligibility, and stipulates that one of these doctors be a specialist in the patient’s medical condition. Of the 302 medical practitioners registered to provide VAD services in Victoria, only 35% practice in regional areas, with most of these doctors located in larger regional centres. Given the lack of participating doctors, and shortage of specialist medical practitioners in rural Victoria, many patients are forced to travel great distances in order to access VAD.
Contributing to this, the Commonwealth Criminal Code restricts discussions of suicide over telephone or internet, making it illegal for discussions about VAD to occur via telehealth. As a result, consultations must be face-to-face which places further travel burdens on already unwell patients. In addition, doctors are not obliged to refer patients on if they conscientiously object to VAD.
A wave of law reform has occurred in Australia following the Victorian Act, with other States introducing their own VAD legislation. Victoria may be able to learn from this newer legislation, particularly in Western Australia, where a range of initiatives have been introduced to facilitate access for rural and remote patients. These include less restrictive eligibility criteria for participating medical practitioners (for example, participating doctors are not required to hold a fellowship from a specialist medical college), permitting participation of international medical graduates, and an expanded role for Nurse Practitioners in the provision of VAD. In addition, WA legislation requires that conscientious objectors provide patients with standardised information, including contact details of the VAD Statewide Care Navigator service. Finally, the WA legislation includes specific guidelines regarding the appropriate use of telehealth, by differentiating VAD from suicide, in reference to the Commonwealth Criminal Code.
In order to improve equity of access for rural and remote patients, I recommend that those reviewing the Act consider removing the requirements that at least one of the medical practitioners involved be a specialist in the patient’s condition. In line with WA, VIC legislation should also be updated so that conscientious objectors are required to provide standardised information on and refer patients to the Statewide VAD Care Navigator Service, as well as ensuring that VAD is differentiated from suicide to encourage appropriate use of telehealth.
Imogen Pratt is a 4th year student at Warnambool Clinical School, Deakin University (2023). Imogen’s year 3 studies were as part of the Rural Community Clinical School.