Voluntary Assisted Dying (VAD)

What is VAD?

  • VAD refers to the process whereby a health practitioner helps to end the life of a patient who is suffering from the late stages of an advanced disease.

Is VAD legal in Australia?

  • Yes, in most jurisdictions. Victoria became the first state in Australia to legalise VAD by passing the Voluntary Assisted Dying Act in 2017. Now, VAD is also legal in New South Wales, Queensland, South Australia, Tasmania and Western Australia. However, only in Victoria and Western Australia is VAD currently occurring whilst the other three states have yet to commence the program.
  • VAD will start in Tasmania in late 2022, in Queensland on 1 January 2023, and in South Australia in early 2023.

Am I eligible for VAD?

  • There is extremely strict criteria that a patient must meet in order to be eligible for VAD. There are some key differences between the states in terms of the specific criteria but there are some main similarities. In order to be eligible, the patient must:
    • Be at least 18 years old
    • Be an Australian citizen or permanent resident *see below for exceptions in certain states
    • Have been living in the state for at least 12 months at the time they make their first request for VAD *see below for exceptions in certain states
    • Have been diagnosed with an advanced disease with a predicted survival time of a maximum of six months (or maximum of 12 months for a neurodegenerative condition) *see below for exceptions in certain states
    • Feel as though their advanced disease is causing them unacceptable suffering
    • Be deemed capable of making a decision about voluntary assisted dying and be able to communicate these wishes to their doctor. *see below for more information on decision-making capacity
    • Be acting voluntarily without any evidence of coercion
    • Be able to make the request consistently (on at least three separated occasions) which indicates an enduring desire to go through with the process

What constitutes “decision-making capacity?”

  • Decision-making capacity is an essential component in all elements of healthcare. A patient must be able to prove they have the capacity to make a fully informed decision by being able to understand, remember, and evaluate all the information and advice provided to them about VAD. The patient must be able to communicate their fully informed wishes to their doctor either verbally, in writing, or with gestures.

How do the states differ in their eligibility criteria for VAD?

  • All states except for Tasmania require the disease being suffered by the patient to be progressive. This means the patient must be experiencing an active deterioration in their health because of the disease.
  • The disease must be incurable in Victoria and South Australia whilst Tasmania requires the disease to be irreversible.
  • *Queensland allows a patient to apply for VAD if their expected time of death is within 12 months due to any diseases, rather than within 12 months just for neurodegenerative diseases (all other states require death to be predicted within the next six months for non-neurodegenerative conditions).
  • *Queensland allows an exception to the requirement of being a resident of the state for at least 12 months at the time a patient makes their first request for VAD. Instead, a patient may fulfil the residency requirements if they have a substantial connection to Queensland or meet compassionate grounds.
  • *Tasmania only requires the patient to have been living in Australia for at least three years prior to the first request for VAD, rather than requiring the patient to be an Australian citizen or permanent resident. However, the patient must still have spent at least 12 months living in Tasmania prior to requesting access to the VAD program.

How does the VAD process actually work?

  • Talking to a health practitioner
    • If you are thinking about VAD, the first step is to speak to your trusted medical practitioner. This is a crucial part of the process as you must be fully informed to be able to make any future decisions. By law, only a medical practitioner (such as your GP or specialist doctor) or a nurse practitioner is allowed to have discussions with you about VAD. It is very important that you are also informed about all other end-of-life options, such as palliative care.
  • Making a first request
    • After speaking to your health practitioner, you can proceed to make a formal “first request” for VAD to your doctor. Following this request, two doctors will independently assess you and must agree that your condition is predicted to cause death within the next six months (or within the next 12 months for a neurodegenerative disease).
  • Making a written request
    • Following the assessment, you must then sign a written declaration that you are making a voluntary, informed and enduring decision to end your life. The written request must be witnessed by two individuals, with only one being allowed to be a family member. The witnesses must:
      • Have no vested interests in the process, such as financial or other material gain
      • Not be affiliated with operating the healthcare facility at which you are receiving treatment
      • Not be directly involved in your healthcare
  • Making a final verbal request
    • A verbal request for the lethal medication is the final step in the VAD process. This final request can only be made by you, at the earliest, 10 days since your first request. This is to ensure your decision has not been rushed. If it is predicted your condition will cause death before 10 days have passed, there may be exceptions.
  • Appointing a contact person
    • You must designate a person to return any unused medication to the pharmacy. This might occur because you pass away before taking the medication, or decide not to follow through with the process.
  • Receiving medication
    • Following the final request, the doctor applies for a permit to access the lethal medication. The medication is most often self-administered and in an oral form, meaning you swallow it. If you cannot swallow or, for some other reason, cannot physically take the medication, you are able to ask assistance from your doctor.

What are the positives elements of VAD?

  • Allows the patient a greater level of autonomy by allowing the patient to choose the time and circumstances in which they die
  • Reduces the unbearable pain and suffering of who patients living through the advanced stages of an incurable disease
  • Has the potential to reduce the number of suicides by providing the option to die rather than continuing to suffer
  • Reduces the amount of “under-the-counter” assisted dying that is suggested to have been happening in Australia in unlawful and unregulated ways
  • Increases the honesty and openness of the doctor-patient relationship by allowing more frank discussion about end-of-life options

What are the concerns with VAD?

  • Patients may feel coerced into VAD by family or friends who may benefit materialistically from their death
  • Creation of a ‘slippery slope’ that could lead to legalised murder
  • Places medical practitioners in a difficult ethical situation because assisting someone to die does not align with the fundamental healing role of doctors
  • Places too much power in the hands of doctors by allowing them to assist a patient to die
  • Less reliance on palliative care in Australia which is considered to have one of the best palliative care services in the world to assist people in their final stages of life

Are doctors required to participate in VAD?

  • The law does not require any doctor, nurse or other healthcare professional to participate in VAD. They cannot be forced to provide information to you about VAD, assess you for VAD, or administer lethal medication. If your doctor has a conscientious objective to VAD, they may be able to support you in finding another doctor who is willing to participate in the process. If not, you may need to take on the responsibility of finding a new doctor yourself who is more open to helping you with the VAD process.

Can elderly patients apply for VAD?

  • Yes

What is a neurodegenerative disease? Why is the VAD criteria different for these diseases?

  • Neurodegenerative diseases refer to conditions that are caused by the cells within the brain, called neurons, being damaged or dying. Neurons are essential for the proper functioning of the nervous system as they allow the brain to communicate with the rest of the body. Examples of common neurodegenerative conditions include Alzheimer’s disease (most common form of dementia), Parkinson’s disease, motor neuron disease, and Huntington’s disease. The symptoms of a neurodegenerative disease depends on which part of the brain is affected, but most often involve both cognitive and motor deficits.
  • Patients suffering from neurodegenerative conditions can access VAD if their condition is predicted to cause death within 12 months, rather than six months. This is because currently neurodegenerative disorders have no cure and their deterioration cannot be prevented. Although there are sometimes good ways to manage their symptoms, in the later stages most cases of neurodegenerative diseases become unbearable for patients.

Can patients with dementia apply for VAD?

  • It depends. Despite being a neurodegenerative disease, dementia in itself is not often considered an adequate reason to seek assisted dying in Australia. In the final stages of life, a person suffering from dementia will most likely have lost their decision-making capacity which is fundamental to request VAD. However, a patient who has dementia but is also suffering from a different condition that is predicted to cause death within the next six months (or 12 months for a different neurodegenerative disease), and the patient currently is deemed as still having decision-making capacity, can begin the process of VAD.

Can patients with a mental illness or disability apply for VAD?

  • Similarly, to dementia, a mental illness or disability is not deemed a sufficient reason on its own to apply for assisted dying in Australia. However, if the patient is concurrently suffering from a terminal illness that they are likely to pass away from in the next six months (or 12 months for a neurodegenerative disease), and all other criteria is met, then the patient may request to start the VAD process.

Can someone make a decision about VAD on my behalf?

  • No one else is allowed by law to make a decision about assisted dying on your behalf. This includes family, friends, carers, or any type of support person. A person who is deemed your medical decision-maker is also unable to make any decisions about VAD on your behalf. A request to access assisted dying must come from your directly, whether in verbal, written or gesture form.

Can VAD be a part of my advanced care directive?

  • No. An advanced care directive, by definition, is made in advance for if you unexpectedly lose medical decision-making capacity in the future for unforeseen circumstances. The law requires you to have medical decision-making capacity throughout the entire process of VAD.

Can I change my mind about my VAD decision?

  • Yes. There are three separate times during the process where you are asked to request access clearly and voluntarily to assisted dying. The entire process must take at least 10 days to try and ensure your decision is enduring. Even at the very end of the process, when you have been prescribed the lethal medication, you can still decide not to take it.

Where can I go for more information?