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By Anna Kelsey-Sugg for Saturday Extra
Intensive care specialist Ken Hillman believes it's become too hard to die.
When his grandfather died in 1959, it was in his own room at home, with little medical intervention.
"Most people's grandfathers died at home in those days, because the general practitioner was the last medical representative in that line. If he said 'there's nothing more to offer', then there was nothing more to offer," Professor Hillman says.
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Source: NZ Herald
After many years working in palliative care, Dr Libby Smales has seen the suffering that can be associated with dying and remains passionate about the value of good palliative care.
Source: Noted, NZ
Not wanting to be a burden is a valid reason for accessing assisted dying, writes Graham Adams, who is a cancer patient.
Source: Gisborne Herald, NZ
Religion doesn’t speak with one voice. This has recently been demonstrated with Judaism and Anglicanism in the matter of assisted dying. Traditionally, the hierarchy retains the moral absolutist position of black/white prohibitions according to the tenets of its ideology. That means an absolute “No” for assisted dying.
Attached is a Horizon Research report similar in form to the previous one done in June 2017.
This was commissioned by EOLC and includes 4 questions which have relevance to the debate on EOLC at the moment. It shows continued strong support for EOLC with very small numbers in opposition. A great piece of information to show to MPs or doubters as to the cause.Parts of it could also be used when you are giving an oral submission.
Paul Courvette and his wife Liana. "He was thrilled he could chose the time and place of his death," Liana said. Photo / supplied
Paul Couvrette awoke, like any other day. Except it wasn’t any other day – it was the day Couvrette had chosen to die.
He ate breakfast, like any other day. He walked his dogs on the beach, like any other day. Then, after a final dinner with family and a last glass of Scotch, the 72-year-old announced: “I’m ready now”.
He lay down on his bed with his wife, he thanked the doctor and the nurse who were about to administer his lethal injections, he told his wife once more how much he loved her. Then he died quietly and comfortably at home.
With aggressive cancer having spread from his lungs to his brain, and with no chance at recovery, Couvrette chose to die on his own terms – how and where he wanted.
In Canada, where Couvrette lived, he had that choice. In New Zealand, politicians are now preparing to vote on the same right for Kiwis.
“He was thrilled that he could choose the time and place of his death. He had no fear,” his wife of 11 years, Liana Brittain, told NOTED.co.nz. “He was totally at peace with his decision. He was very upbeat.”
In May last year, Couvrette became the first medically-assisted death on Prince Edward Island, Canada’s smallest province, near Nova Scotia on the Atlantic coast.
As New Zealand now tussles with the moral and legal arguments inherent in assisted dying, it’s worth examining how the practice has worked in other countries.
Around 2000 people died with medical assistance in Canada in the first 12 months following the June 2016 legalisation, according to a Canadian Government report released in October last year. In the first six months, from June-December 2016, Canada recorded 803 assisted deaths nationally. During the subsequent six months, however, the number jumped 47 per cent, with 1179 people choosing medical assistance for death. Even with the increase, the number of assisted deaths in Canada still represents less than 1 per cent of all deaths.
The most common medical condition that led people in Canada to opt for medically-assisted death was cancer, which accounted for about 63 per cent of cases.
The Canadian assisted death legislation is based on the “Oregon model”, named after the US state first to introduce legislation, which permits assisted death for mentally competent people with terminal illnesses who have a defined life expectancy. Seven US states (California, Colorado, Hawaii, Montana, Oregon, Vermont, and Washington), plus Washington DC, all follow the Oregon model, as does Victoria in Australia. New Zealand legislation, if passed, would likely also follow this model.
In other countries – such as the Netherlands, Belgium, and Switzerland – the law allows for medically assisted death for sufferers of depression, advanced requests for dementia patients, and for minors with terminal illnesses.
In Canada, advocacy and lobby group Dying With Dignity continues to fight for more relaxed assisted dying controls – including rights for people with mental illnesses, dementia, and for people under-18. Meanwhile, on the other side of the fence, Dying With Dignity chief executive Shanaaz Gokool said, opposition groups continue to fight in court for restrictions. It’s an ongoing battle.
“The opponents have not been quiet. Like us, they’re participating or trying to participate, in the legal cases challenging aspects of the federal assisted dying law. There are a number of anti-assisted dying petitions that are circulating, including in churches, schools and at universities. There are groups that are trying to keep patients from being allowed to access assisted dying in publicly funded facilities such as hospitals and long-term care facilities,” she said.
“As it happens, these groups are much, much better funded than we are, even though they represent the point of view of only a small fraction of the Canadian population.”
The procedure is obviously not to everyone’s religious or moral tastes. Many conservative opponents in Canada still – as in New Zealand – can’t stand the idea. But supporters believe strongly that it should be an option for an individual in pain.
“There are many, many ways you can choose consciously to celebrate the end of your life,” Brittain said. “You can also choose to have palliative care, palliative sedation, you can choose to die naturally, you can choose to voluntarily stop eating and drinking. [Assisted dying] is not for everyone … it’s a choice.”
Her husband chose “quality of life over quantity”, she said. He didn’t want to waste away, and he didn’t want to endure treatments that would restrict or ruin his final weeks or months, Brittain said.
His death – with or without medical assistance – was imminent and inevitable. So, instead of suffering for an extended period, he was able to go out how he wanted.
“A lot of thought went into it. But I can assure you – once Paul made that decision, it was like the weight of the world had been lifted off his shoulders.”
“We had this amazing celebratory 10 days prior to his procedure. [Paul’s death] was a blessing. It was so empowering for him to have that opportunity to not only die with dignity but to dictate all the terms of his passing,” Brittain said.
For Rob Rollins, the chance to opt out of his suffering and dictate the terms of his impending death, “brought him so much peace”.
Rollins, 56, of Ontario, had fought throat cancer for 18 months – but after 40 radiation treatments, chemotherapy, and throat surgery had left him unable to eat or drink, he decided he was ready. Like Couvrette, he chose to die at home, on a date and time that suited him.
“We talked about it and for him, it was something that was very important – he wanted to be able to die on his terms, no hospitals, no comas, none of that type of stuff,” said his husband John MacTavish.
And, like Couvrette, Rollins’s spirits lifted once he decided to set the date and time of his death. He set a date three days ahead: January 6, 2017.
“Once that decision was made, and things put into place, those three days were the best days that Rob had had in years,” MacTavish said. “He had total control, he was able to not need as many pain meds … We just had three of the most incredible days that just brought everything together, all of our 28 years together, and it brought him so much peace.”
Rollins scheduled his death for 11.30am. MacTavish bundled his husband up in their wedding quilt and hugged him as the doctor administered the series of fatal injections.
“Four minutes later, it was over. I have witnessed [many] deaths – friends, people I worked with, loved ones – and this was the most beautiful experience of my life, in a way, to see how it is and how it should be,” MacTavish said.
“I think [assisted dying] is the most humane thing we can do as human beings for each other. I think everybody deserves the right. In any country … it’s the right thing to do for individuals who suffer and who just say ‘enough’.”
by Graham Adams / Noted /19 March, 2018
Questions linger over the motivation for setting up a sham traffic stop to identify Exit members and exactly how often similar breaches of the law occur.
The IPCA report into a bogus alcohol checkpointthat police used to identify attendees at a pro-euthanasia meeting was finally delivered last Thursday, well overdue and seriously underweight.
Although a brief eight pages, it took nearly 18 months before it was ready for public release after complaints had been laid in 2016, and eight months after the IPCA said the report’s release was imminent.
It offers startling insights into police practice, none of them heartening. Of course, its major finding — that the October 2016 vehicle checkpoint in Lower Hutt was illegal — could not have come as a surprise to anyone acquainted with the law. It was such a flagrant abuse of police powers granted under the Land Transport Act — which restricts checkpoints to matters of land transport enforcement such as testing alcohol levels and checking car registration — that the police took the unusual step of handing themselves into the Independent Police Conduct Authority for what was widely expected to be a public flogging.
As it turned out, the report is quite gentle with the police — as, indeed, is often the way with the IPCA. Nevertheless, despite the indulgent, softly, softly approach, it is thoroughly alarming.
First, neither the Detective Senior Sergeant nor Detective Inspector who ordered the checkpoint to identify the elderly attendees at the Exit meeting stopped to consider whether it was legal. They rang their superiors, the Acting District Commander and the Area Commander, to get approval for the checkpoint shortly before it was implemented. But both failed to warn it would be illegal under the Land Transport Act (and would also not be covered by general powers to prevent suicide as permitted by section 41 of the Crimes Act). No legal opinion was sought and they allowed it to proceed.
As the report notes: “The Acting District Commander and the Area Commander should have recognised that the proposed actions were unlawful and should have advised the officers.”
Just as worrying was the admission by the Detective Senior Sergeant that “police have used similar checkpoints in the past for intelligence purposes”. And the five officers who conducted the bogus alcohol traffic stop also said they assumed it was fine because checkpoints had been used for gathering intelligence before.
It seems extraordinary that all the police involved — including very senior officers — either didn’t understand that the checkpoint was illegal, or didn’t bother to consider its legality, or accepted that it was de facto police policy to use checkpoints primarily for intelligence-gathering.
The authority skirts around this last possibility by noting it “is not aware of any other instances where checkpoints have been established for purposes other than land transport enforcement and have not gathered any evidence which supports this assertion. In addition, there is no police policy which supports the [Detective Senior Sergeant’s] view [that they are used for intelligence].”
This is a long way from saying it hasn’t happened before or even that it is uncommon. As Otago University law professor Andrew Geddis told Noted: “Absence of evidence is not evidence of absence.”
Assistant Commissioner Bill Searle, on behalf of the police, accepted the IPCA’s findings, admitting in a statement that “establishing a vehicle checkpoint to identify meeting attendees was unlawful”. But he excused the officers’ behaviour because “our staff acted in order to protect life and did not intentionally break the law”.
This indicates the police hierarchy accepts that all the officers involved did not understand they were breaking the law, because if, in fact, they did know the checkpoint was illegal they must have been intentionally breaking it.
For the rest of us, not knowing the law is no excuse, but apparently, it serves as one for the police, even though they swear an oath to uphold it.
And in what way could they be acting to protect life when they admitted they had no concerns that any of the attendees at the Exit meeting were in imminent danger of committing suicide? Turning up announced at the homes of some 15 of them, and asking whether they had a secret stash of Nembutal and about their association with Exit is hardly going to be reassuring if any one of them had, in fact, been suicidal. There seems to have been no consideration given to just how frightened and threatened many of these mostly elderly people might — and did — feel at police appearing on their doorstep.
The report’s account of the police officers’ alarm about the attendees’ well-being thoroughly stretches credulity. The Detective Inspector described covertly monitoring the Exit meeting: “It wasn’t until we heard [them] conveying all these possibilities to commit suicide… that we were of the view that the risk level had raised considerably… There was a real possibility that [someone could commit suicide] within five to seven days once they had that information.” (The report notes: “No explanation was given for how these timings had been arrived at.”)
Yet, the officers clearly knew beforehand that they were monitoring a meeting of an organisation whose sole purpose is to provide information on how to end one’s life peacefully. In fact, the Detective Senior Sergeant and Detective Inspector told the Authority that they asked for a surveillance warrant for the Exit meeting because they “suspected that some of the conversations at the meeting would be about supplying and using pentobarbitone”.
How could they be surprised and alarmed when Exit members discussed exactly that?
The checkpoint was triggered by the investigation into the death of Annemarie Treadwell, a 77-year-old Wellington woman who died in June 2016 after taking pentobarbitone, aka Nembutal.
It led to Wellington Exit co-ordinator Susan Austen being charged with three counts of importing pentobarbitone as well as a charge of aiding Treadwell’s suicide.
Austen pleaded not guilty to all the charges, which were a result of a police operation that collected her emails and bugged her phone and her house — including recording the Exit meeting immediately before the checkpoint was set up to identify attendees.
The police claim the reason the checkpoint was set up and names taken was concern for the welfare and safety of the Exit members who attended that meeting and had nothing to do with the investigation into Treadwell’s death.
The authority noted it would be concerned if the subsequent welfare visits to the homes of the meeting attendees “had been utilised as a tactic to progress the police investigation into the activities of Ms Z [the woman they believed had counselled Treadwell before her death]”.
Yet, a Lower Hutt Exit member, who wasn’t named, commented to Stuff about the police visit to her home after she had been stopped at the checkpoint: “[The police] said they were investigating the activities of the leader of the [Exit] group. They did not explain further what they meant by this.”
Also, another of those visited, “Mr W”, told the IPCA he found the welfare visit “odd”, and stated: “I think they were there for other reasons than just about my state.”
In February, Austen was found guilty on two of the charges of importing pentobarbitone but acquitted on the much more serious charge of aiding a suicide, which carries a maximum sentence of 14 years’ imprisonment.
The jury apparently accepted the defence’s contention that simply possessing a lethal drug, whether it is intended to be used or not, could have a “profound palliative effect to reduce suffering” that may even extend life by reducing anxiety from anticipating an unpleasant death.
Furthermore, Treadwell was not only a member of Exit but also an activist for the euthanasia cause and had submitted an impassioned plea for a law change to the Health select committee looking into assisted dying. She also had written a note found after her death asserting that no one had coerced her or influenced her in any way to take her own life.
Exit International’s head, Dr Philip Nitschke, described Austen’s trial as a “show trial with one objective — to ‘send a message’ and frighten any elderly New Zealander tempted to put in place a personal, practical end-of-life plan”.
For the police to visit Exit members who attended a lunch devoted to discussing a perfectly legal act such as suicide smacks of overreach, if not a campaign of harassment or intimidation, especially as it was conducted during a time of heightened political sensitivity over euthanasia. At the time the checkpoint was conducted in 2016, the parliamentary select committee inquiry into New Zealanders’ attitudes to assisted dying was still under way.
Nitschke viewed it as a direct attempt to intimidate Exit members. And many people will not be convinced that concern for the Exit members’ welfare was the real reason for the checkpoint or the home visits. At Susan Austen’s trial, when the police said they had obtained the names of the Exit members to make sure they were okay, her supporters laughed.
Maryan Street, the president of the End-of-Life-Choice Society, which is agitating for a law change but is not associated with Exit, said last week of the IPCA report: “The finding confirmed that those stopped at the bogus checkpoint were targeted for their beliefs and lawful activism, not because of any threat to law and order or public safety.”
She asked the police to provide “assurances that [the] campaign for a law change will not be targeted with unwarranted surveillance and intervention”.
Inevitably, questions were raised about why the checkpoint was authorised in the first place. Wellington human rights lawyer Michael Bott said, after the checkpoint hit the news in 2016: “It appears to be some kind of moral crusade driven from someone on top to stop people going to a public meeting to learn about Exit and their goals.”
Others at the time queried whether it had been politically motivated by those opposed to a liberalisation of the law. Act MP David Seymour asked: “There is then the question of motive. Who was pushing for this surveillance, what was their motivation, and why were the Police Minister and Solicitor-General not aware of such a politically sensitive operation?”
A spokeswoman for Judith Collins, the then Police Minister, told media the case was an operational matter for police, and directed all questions to them.
When Noted asked Michael Bott last week whether he believed the checkpoint and intrusions into the lives of Exit members were politically motivated, he replied: “I do not think a particular party was involved. But that certain senior officers are prepared to condone the unlawful detention of New Zealanders who had attended an Exit meeting does show perhaps the strength of their collective personal view about the subject matter of the [Exit] meeting.”
Professor Andrew Geddis, while concerned by the police’s illegal behaviour, identifies a wider problem. He told Noted: “There is the bigger picture of the police intruding into the homes of elderly people — many of whom will never have come to police attention before — simply because they want to consider end-of-life options. Because our law treats all decisions to end your life for any reason as being a ‘suicide’, it authorises anybody (including the police) to intervene to try to stop this from occurring.
“I think this is wrong — the law ought to distinguish between ‘suicides’ and ‘assisted dying’, which is what David Seymour’s End of Life Choice Bill before Parliament does.”
It is richly — and sadly — ironic that the IPCA report should be made public at the same time a debate is raging over the police’s pursuit policy, sparked once again by eminently avoidable deaths. A few days before the report appeared, two young people died in a crash fleeing police south of Nelson, which also killed a 53-year-old woman in another car.
Police chases saw 10 deaths in 2017, and 22 people die since 2014, yet the police stoutly defend them as essential to maintaining law and order. “Protecting life” doesn’t seem to feature. Those who die are presumably collateral damage in an overriding goal of never letting even a minor offender evade the law.
Nevertheless, we are asked to believe that the police were so concerned about protecting the lives of elderly people who were educating themselves about how to end their lives peacefully at a time of their choosing that they had a squad of police officers urgently set up an illegal checkpoint to harvest their details and visit them at home to quiz them about their association with Exit.
The Privacy Commissioner, John Edwards, investigated the collection of personal information at the checkpoint, separately to the IPCA inquiry. His report, which was also made public last Thursday, noted: “Some complainants said the visits from police made them feel uncertain about their ability to speak freely and anxious that more visits would follow.”
He concluded: “Police approached them after unlawfully collecting their information, and questioned them about a socially and politically sensitive subject. It is fair to say that the actions by the police officers caused those complainants harm.”
The matter may not end here. After the IPCA report was published, Andrew Geddis tweeted about what he would do if he had been subjected to an illegal checkpoint: “Well, if I were one of those stopped, I'd be getting my lawyer to ask the police how much they’re going to give me for breaching my [NZ Bill of Rights Act] rights ... and readying a class action if they aren't forthcoming.”
Disability Rights Commissioner Paula Tesoriero condemned the End of Life Choice Bill claiming that “Before the country legislated choice in death, it needed to work towards ensuring, to the greatest extent possible, all people had the same freedom of choice in life.”
That’s laudable in an ideal world, says EOLC's Ann David, and we should undoubtedly strive to improve the lives of people with a disability. But to insist on perfection for one group of disadvantaged people before we can begin to address the wrongs committed against another group of disadvantaged people is ridiculously unjust.
Many people with disabilities support assisted dying legislation. Also, the Bill has nothing to do with disability but everything to do with irreversible, escalating, extreme suffering that cannot be palliated by any means.
Instead of torpedoing the entire bill, Paula Tesoriero might have proposed useful amendments. For example: “Disability alone will not constitute eligibility for assisted dying”.
She might also have considered what tests currently apply for the presence of mental competence and the absence of coercion when a patient requests cessation of life support or when doctors offer terminal sedation. Answer: None official. By comparison, the End of Life Choice Bill is safer for people with disabilities.
Internationally recognised diversity consultant Philip Patston has questioned Disability Rights Commissioner Paula Tesoriero’s stance on the End of Life Choice Bill.
In an email to Tesoriero, Patston challenged her statement that, “We must first work towards ensuring, to the greatest extent possible, that all people have the same freedom of choice in life before we consider legislating choice in death.
“It’s my role to reflect the concerns of the disability community and what I am hearing is that there are significant concerns about this Bill.”
Patston, who worked for the Commission between 1994 and 1998, suggested that, as Disability Rights Commissioner, “your role as Commissioner is to ensure disabled people are not treated differently on the grounds of disability.
“Surely,” said Patston, “your role is to ensure disabled people have the same choices as other Tangata o Aotearoa/New Zealanders. This needs to include the right to choose dignity in dying.”
Named as a top 10 diversity consultant in the Global Diversity List in 2015, 2016 and 2017, Patston agreed that legislative safeguards need to be in place, to prevent coercion and to ensure informed consent and appropriate assessment.
“But this is important for the very wealthy, the very poor, and others, including people with terminal illness.
“There are many vulnerable groups, not just those who experience disability.”
Imagine, mused Patston, if we stopped all people driving cars because some people crash and kill themselves and/or others. “I'm sure there would be outrage about the infringement of rights to drive, even though it may be wrongfully lethal.”
As he said in my affidavit in support of Lecretia Seales’ case, Patston believes we land in dangerous territory when we try to protect one group by denying the rights of another. Both disabled people and those with terminal, incurable, illness deserve the right to choice and autonomy.
“My voice and those of many other disabled people who are not afraid of assisted dying and have trust in a fair, compassionate, good-willed society, need to be represented in this important, democratic conversation,” Patston said.
Managing DirectorDiversity New Zealand Ltd
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It is desirable that medical practitioners read the End of Life Choice Bill as it is quite likely that legalisation of voluntary assisted dying may have occurred before the end of 2018
This opinion piece has been submitted by 10 retired and working doctors - Jack Havill, Libby Smales, Dame Margaret Sparrow, Lannes Johnson, Angel Hancock, John Musgrove, James Davidson, Alison Glover, Stanley Koshy and Frank Kueppers. Further details of the authors are provided at the end of the article.
The End of Life Choice Bill (David Seymour) has now passed its first reading by a large majority (76 for, 44 against). The select committee is part of the justice select committee, all members of which voted yes to the first reading.
Repeated scientific polls of the public over the years have shown increasing numbers supporting voluntary assisted dying, now 75-80 per cent supportive (Horizon Poll May 2017), so even if a referendum is held, it is likely the vote will support legalisation of a law to enable voluntary assisted dying.
It is desirable that medical practitioners read the bill as it is quite likely that legalisation of voluntary assisted dying may have occurred before the end of 2018.
Some parts of the Bill and related issues are discussed below and interested doctors are invited to participate in a group who support End of Life Choice in principle.
The End of Life Choice Bill (EOLC Bill) defines a person eligible for voluntary assisted dying as someone who:
Two medical practitioners must agree that the criteria are met, and the second doctor must be independent of the first.
The director-general of health will establish a group of medical practitioners known as the Support and Consultation for End of Life In NZ (SCENZ) Group. This group will maintain a list of medical practitioners, specialists in mental health, and pharmacists willing to participate in voluntary assisted dying.
The group will be responsible for allocating the independent medical practitioner, offer advice, and replacement where the medical practitioner has a conscientious objection to providing this service. The group will write standards of care, provide advice on medical and legal procedures, and provide practical assistance where required.
Procedures for voluntary assisted dying will include ingestion of the prescribed drug in the presence of the doctor, or a direct injection of the drug if the patient wishes.
What do doctors and nurses think of voluntary assisted dying?
The limited evidence we have from surveys of New Zealand doctors is that 35-50 per cent support voluntary assisted dying. , , 
The NZ Nursing Organisation (70,000 members) has a position statement supporting voluntary assisted dying, as does the Australian Nursing Federation. Surveys have indicated that 65-70 per cent of nurses in New Zealand are supportive of voluntary assisted dying.
Formal evidence is only part of the picture, and anecdotal evidence suggests that many doctors are neutral or supportive, but fear admitting this openly in the current organisational climate.
Opponents of voluntary assisted dying suggest doctors are not at all supportive and should keep out of the area of assisted dying due to the moral problems – they are there to cure the patients! To many doctors the moral issues associated with not being able to relieve suffering in the way that the patient wants, constitute a greater moral burden (not to mention the sadness they feel), and some disobey the law and deliberately help patients die illegally. 
The Royal Australian College of General Practitioners now supports voluntary assisted dying as does the Australian Medical Students Association – the coming generation of doctors.
The Canadian Medical Association (2014) states that: "physicians are committed to providing high quality care at the end of life. They are also committed to maintaining their patients’ quality of life. There are rare occasions where patients have such a degree of suffering, even with access to palliative and end of life care, that they request medical aid in dying. In such a case, and within legal constraints, medical aid in dying may be appropriate. The CMA supports patients’ access to the full spectrum of end of life care that is legal in Canada. The CMA supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying …’.
Other associations across the world are becoming neutral, or supportive, and it is obvious that there is gathering support from doctors, and this increases as legalisation occurs and doctors realise that voluntary assisted dying can be part of excellent care to the patient.
Some argue that voluntary assisted dying will destroy the relationship between the patient and the doctor. All the evidence is against this.
Katherine Morris (Surgical Oncologist, New Mexico, USA, who also worked in Oregon) describes her views in her submission to the New Zealand health select committee (2015-16): "The argument that AID (Assistance in Dying) will fundamentally change the nature of the physician/patient relationship does not make sense to me. My experience was the opposite.
"In my view, the most fundamental aspect of the physician/patient relationship is the imperative to meet the individual patient's health care needs. In this respect, the medical community does the very best that it can.
"If the medical community is not able to offer a cure, or extend life with good quality (as defined by the patient), and the patient's goal is a modicum of control over their dying process, then AID seems to represent a natural continuum of the physician/patient relationship.
"In those circumstances, AID is the physician seeking to help the patient meet their health care goals to the best of their ability."
GPs often find themselves in the centre of difficult treatment programmes as the patient bounces between home, hospice, hospital and resthomes. Development of palliative care and hospices in most of New Zealand has been admirable, but still has a long way to go.
It is important to know that movements supporting voluntary assisted dying, such as the End-of-Life Choice Society NZ, wholeheartedly endorse these modes of treatment and would see most patients described in the intended Bill as being helped by these services. In Oregon, most patients who have assisted death have been treated in a hospice environment.
In the Netherlands and Belgium, palliative care doctors have been some of the leaders in the voluntary euthanasia movement.  However, for those who think palliative care is sufficient, there are a number of issues which should be considered including:
1) Relief of suffering from palliative care - It is clear that palliative care cannot always relieve physical suffering or "existential suffering" due to loss of autonomy and dignity, and there are a number of patients who ask for assisted medical death in spite of good palliative care. Palliative care health professionals argue their techniques are becoming increasingly refined, but some patients find the prospect of dying while under sedation repugnant. Figures released from an Australian study widely quoted in 2016 show that, 10-20 per cent of patients on hospice programmes experience unbearable pain/suffering as they die.  Over 1000 submissions to the health select committee on assisted dying wrote about bad deaths in their relatives and friends, and many of these were in hospice. Some of these submissions were from experienced palliative care nurses and doctors supporting voluntary assisted dying. 
2) Patients not under direct palliative or hospice care - Libby Smales, a NZ palliative care physician, an experienced hospice doctor points out in her submission to the health select inquiry into assisted dying (2015-16), that there is a major shortage of palliative care experts in New Zealand. She also says, that even with the best palliative care, patients can have suffering deaths.
Dr Smales points out that in legalised jurisdictions where voluntary assisted dying has been authorised, mandatory referral to palliative care doctors has often been enshrined in law, which is not the case in New Zealand. Examples of this are in Belgium and Canada.
Lannes Johnson, who has extensive palliative care and general practice experience in Auckland), in his submission to the health select committee 2015-2016, points out that most patients do not die in hospice-controlled situations, but in resthomes (about 4 times as many).
He describes cases where horrible deaths have occurred because of lack of experience and entrenched attitudes about not "giving too much sedation and pain relief, in case it causes death".
3) Integration of palliative care and voluntary assisted dying - Palliative care and physician-assisted death are not mutually exclusive; the former should be universally provided at a high level, and the latter should be available as an adjunct where requested. In Belgium particularly, voluntary assisted dying has been integrated with heavily funded palliative care, and as a result the speciality of palliative care has grown enormously.
The Canadian law mandates growth of palliative care integrated with voluntary assisted dying. The recent Victorian law mandates a major increase in palliative care funding.
There are many other issues which medical practitioners have to work though, including the sanctity of life, the difference between murder and voluntary assisted dying, autonomy of patients, shifting norms in society, the mischievous claims that the aged and disabled are vulnerable to abuse in association with voluntary assisted dying, the difficulty that doctors experience in expressing their opinions when voluntary assisted dying is illegal, and moral issues usually related to religious belief.
In conjunction with an Australian doctors group who support voluntary assisted dying, we in New Zealand have set up a group of doctors who support End of Life Choice in principle. Some are retired, some are GPs, some are hospital specialists, and all are still working through the issues.
We have responded to the Gillett article on euthanasia in the NZ Medical Journal (19 Jan 2018) and sent a suggested survey to the NZMA which they could use for their members. We consult about various issues and share information about voluntary assisted dying.
If any medical practitioners wish to join this group of the contact person is Dr Jack Havill firstname.lastname@example.org. We are careful if a person wants to remain anonymous to those outside the group, and the individual’s name will only be revealed with permission, for example, as signatures to a letter. We correspond by group emails.
1. Havill J. Physician Assisted Dying – a survey of Waikato general practitioners. NZ Med J 2015;128(1409):70-71, 20 Feb 20
2. Poll of Doctors on Assisted Dying. New Zealand Doctor July 2015
3. Oliver Pam, Wilson M, Malpas Phillipa. New Zealand doctor’s and nurses’ views on legalising assisted dying in NZ. NZ Med J 2017;130(1456): 2 June
4. Malpas Phillipa, Mitchell Kay, Koschwanez Heidi. End-of-life medical decision making in general practice in NZ – 13 years on. NZ Med J 2015;128(1418):27-39, 24 July
5. Bernheim J, Deschepper R, Diselmans W, Mullie A, Bilsen J, Deliens J. Development of palliative care and legalization of euthanasia: antagonism or synergy? 2008;336:864-67
6. Wollongong University Health Services Unit – see submission by Dr Libby Smales to Health Select Committee on Assisted Dying.)
7. Dying Badly – NZ Stories, Havill and Barber. Online – see ‘Yes to Dignity’ website
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