GP at the gate to death by choice

03 May 2022 1:24 PM | EOLC Admin (Administrator)

by Fiona Cassie fcassie@nzdoctor.co.nz

GPs who have completed the online training programme may be prepared to offer assisted dying to their own patients, due to the long relationship they have built up.

GPs are finding it rewarding to work with patients who seek assistance in dying, Kristin Good tells reporter Fiona Cassie

Left: Specialist GP Kristin Good, registrar of the Assisted Dying Service [Image: NZD]

"If we didn’t wrap the support around the practitioners, this would be a very isolating sort of medicine."

A small but growing number of GPs is training to provide assisted-dying services solely for their own patients, says Kristin Good, registrar of the Assisted Dying Service at the Ministry of Health.

The fastest-growing group of doctors training to help people end their lives are GPs, often in response to their patients raising the topic of assisted dying, says Dr Good, a specialist GP based in Auckland.

“The GPs are saying, ‘I will provide an assisted death for my patient with whom I’ve had this long relationship’,” she says.

But GPs are also saying they are not prepared to offer the services to anybody but their own patients, and so are declining to be added to the Support and Consultation for End of Life in New Zealand (SCENZ) list. This list names the service’s 130 medical and nurse practitioners available to provide assisted dying.

More than half of the 81 self-identified GPs who have completed the ministry’s online training programme are not on the list. “Some of those GPs have now been involved in more than one death.”

Dr Good says the shift of some GPs from saying “I will never provide this service” to finding the work rewarding, has been a gratifying part of her new role, added last year to her existing portfolio as the ministry’s chief clinical advisor, health system improvement and innovation.

Implementing the service, created by passing of the End of Life Choice Act 2019, was not an expected path for her.

“This isn’t an act I voted for, I might add,” she says. “So, you can imagine this has been quite a journey for me.

“And I’d be lying if I said that the polarising nature of this topic has not made for some very challenging conversations.”

Dr Good, who works full time for the ministry from Auckland, says she is an advocate for patient choice.

Bending over backwards

It has been rewarding to hear of the gratitude of people accessing the service, and to get GPs’ feedback.

“What I see in the practitioners is this very person-focused approach where they bend over backwards to be obliging.

“The doctors who are providing this service describe it as a privilege to be involved and they also consistently describe it as hugely rewarding.”

High-calibre practitioners are providing assisted dying, she says, praising their “complete dedication” in continuing to deliver the service despite COVID-19 stretching the workforce.

While the “vast majority of whānau wish this wasn’t a decision their family member was making”, the GPs have respected their right to make that decision.

One surprise for her and the team has been the number of Māori applying to the service, 12 (5.8 per cent) to date, with a number having gone on to have an assisted death.

“We heard ahead of time that assisted dying was not consistent with tikanga Māori, but that hasn’t played out in what we’ve seen in reality.”

She says Māori applicants have been using the assisted-dying protocol of discussing what a good death looks like to them, to create a care plan that “really makes this death their own”.

“That has included starting with waiata and karakia and the shrouding of the person with a korowai, before they receive the medication, and other things that are meaningful for that individual.”

Based on international trends, particularly Australia, the ministry had been concerned the number of practitioners providing assisted dying, could fall sharply after they carried out their first assisted death.

“I was warned about that, so we have tried to wrap as much support around practitioners as we possibly [can].” Early on, Dr Good would personally phone every practitioner after they had assisted a death for the first time.

The two, soon to be three, ministry nurses who handle all patient and practitioner queries for the service have also developed a strong relationship with the practitioners, she says. The nurses run regular question and answer sessions; the service also provides quarterly peer support groups and an annual forum, and has helped establish local networks.

“If we didn’t wrap the support around the practitioners, this would be a very isolating sort of medicine.”

Who’s who in the service?

The SCENZ list started with 131 practitioners in November and, while a handful fell away due to COVID workloads, IT hitches or heading overseas, it now sits at 130; 120 medical practitioners and 10 NPs.

Specialist GPs make up 39 per cent of the SCENZ medical practitioners, but only 37 of those 47 GPs have completed training.

The other medical practitioners listed are oncologists, intensive care specialists, urgent care doctors, general medicine doctors and a small number of palliative care doctors.

Just over 90 of the medical practitioners listed on SCENZ are available as attending medical practitioners to provide initial assessments and attend at assisted deaths. Some are also on the list of 83 independent medical practitioners available to provide the required second assessment.

Eleven psychiatrists are available if the first or second assessing doctors are unable to determine the applicant’s competency to make a decision. This hasn’t been needed yet.

Dr Good says it’s important more NPs take part.

She says some NPs were understandably unhappy because the service allows them to help people plan a death, and to administer medication for assisted deaths, but only under the instruction of an attending medical practitioner. NPs cannot write prescriptions for assisted-dying medications – an issue being worked on by the Nursing Council.

“Nurse practitioners have been particularly willing to travel around the country, which has been absolutely fantastic,” Dr Good says.

A number of GPs and NPs are working together as teams, and the ministry wants to build on this, she adds.

High demand

Dr Good says assisted dying is not an acute service and the ministry had set an expectation that the service would take four to six weeks.

But demand was high in the early days, with 20 per cent of the call volume coming through in the first week alone.

That led one applicant to make a formal complaint about waiting too long for an initial referral to an attending medical practitioner.

It’s one of the three formal complaints received; one of these complaints has gone to the health and disability commissioner.

Dr Good says referrals in urban areas are now made within one to two days or sometimes on the day of the call. In rural and remote areas, it can take one to two weeks.

Demand remains high, with on average the service’s nurses receiving 46 enquiries a week about assisted dying. The service also has high numbers of calls from practitioners wanting to know about training or referrals.

One aspect of the service that needs improving is communication with the patient’s general practice when an assisted death has been approved and taken place, Dr Good says.

“I am aware that this isn’t happening as well as it should, and we are working on that.”

But, she says, consent is required. Some applicants don’t want their GP to be told, as they know or suspect their GP is a conscientious objector to assisted death.

Dr Good says one interesting development is the response of palliative care services to someone applying for assisted dying.

“We know, from overseas, that the quality of palliative care increases when assisted dying is introduced because, clearly, satisfactory or good palliative care is preferable to someone feeling they need to access assisted dying because their suffering is intolerable – when it can be relieved.”

The trend has shown up in New Zealand. Some people receiving palliative care have applied for assisted dying because of intolerable suffering and pain and have then experienced better pain relief, so they haven’t proceeded with assisted dying.

Dr Good says just one hospice has worked with the service, south Auckland’s Totara Hospice, which has sought to develop a strong partnership between palliative care and assisted-dying services.

First quarterly report: 66 assisted deaths to date

Assisted Dying Quarterly Report: 7 November 2021 to 31 March 2022

Download 290.18 KB

More than 200 people applied for and 66 people had an assisted death in the early months of the Assisted Dying Service.

The Ministry of Health has published its first quarterly report on the service, covering from 7 November last year, when the End of Life Choice Act 2019 came into force, to 31 March.

Of the initial 206 assisted-dying applications, 168 went on to have an initial assessment completed by an attending medical practitioner, and 126 to receive a second opinion from an independent medical practitioner.

Forty applicants were assessed as being ineligible for the service for a variety of reasons, and 59 of the applications are still in progress.

Of the 66 people who have had an assisted death to date, most (73 per cent) died at home, 17 per cent in aged-care facilities, 6 per cent in DHB facilities and 4 per cent in a hospice.

Eleven of the 206 applicants withdrew their application. Thirty of the applicants died while their application was in process.

Of the initial 206 applicants:

  • 79 per cent are NZ European/ Pākehā and 5.8 per cent Māori
  • 55 per cent are women
  • 74 per cent are aged 65 years or older and only 4 per cent are aged under 45
  • 65 per cent have a cancer diagnosis, followed by 10 per cent with a neurological condition
  • 80 per cent were receiving palliative care at the time of their application.

Comments

  • 03 May 2022 4:03 PM | Anonymous
    This is good news . . . . much as we expected it to be. Our Ministry of Health has done an effective job of implementing and supporting the service.
    Link  •  Reply

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