Telehealth for VAD Assessments

Dr Joanne Wright MBBS M Ger Med FRANZCP FPOA, Old Age Psychiatrist

To begin with it is important to be clear that euthanasia and physician assisted dying, collectively called Voluntary Assisted Dying (VAD) in Australian legislation, does not refer to withdrawal of futile medical care and palliation of symptoms. The latter represents ethical medical care. VAD is the administration of a poison in order to intentionally end a person’s life. VAD is an unethical practice and is inherently unsafe. It radically and detrimentally alters the role of the healthcare practitioner.

There are numerous examples worldwide of the gradual erosion of safeguards when assisted dying and euthanasia are legal. Predictably over time, important safeguards are labelled as impediments to access. Eligibility criteria are widened whilst safeguards are relaxed. The attempts to allow telehealth to assess eligibility for Voluntary Assisted Dying (VAD) in Australia are no different.

Few Australian healthcare practitioners want to be involved in the process of VAD assessment and administration. This is likely to be one reason why it’s hard to access VAD in rural areas. Efforts have been made to swell the numbers of VAD practitioners by allowing registered nurses or nurse practitioners to administer the lethal substance (in some jurisdictions). Adding telehealth assessments is an attempt to increase access to city-based assessors.

However, there is a world of difference between the use of telehealth to enhance medical care versus using it to more efficiently end people’s lives.

Telehealth for a topic as sensitive as VAD assessments is inappropriate. VAD assessors are not usually the patient's regular GP or other clinician. They don't have close familiarity with the patient, their family dynamics, the way they think or their mental health history.

At the best of times, the assessment of a patient’s decision-making capacity, assessment for coercion and the presence or absence of mental illness can be challenging for the clinician, even done face to face. Elder abuse rates are known to be at least 15% (1). The Royal Commission into Aged Care Quality and Safety 2021 described widespread and substantial lack of regulation, underfunding, elder abuse and neglect in aged care homes Australia wide (2). Sadly, there are significant rates of financial abuse in the community as well (3). The use of telehealth only increases the risk of VAD assessments missing such critical factors.

Unrecognised mental disorders

Assessing the mental state of medically unwell patients is nuanced. In our population there are high rates of mental disorders such as mood and anxiety disorders, adjustment disorders and cognitive disorders, especially delirium. These can all be subtle.

The literature shows that mental disorders are under-diagnosed in medically ill patients. Subacute delirium for example can be difficult to detect. Mood and adjustment disorders are also underdiagnosed. This can lead to errors in assessments which represent a safety risk for the patient. Such mental disorders distort the judgement of the patient.

My clinical experience is that many healthcare professionals miss the signs of these disorders when assessing face to face, let alone if the assessment were to be done via telehealth.

Unfounded fears

Palliative care and other clinicians know that a patient's fears often exceed the reality of their medical situation. With accompaniment and good communication, these fears can be allayed. In the palliative care situation, the interpersonal relationship between the patient and healthcare professional is pivotal.

Telehealth puts a physical distance between the patient and clinician, potentially impeding rapport and trust. It may be more difficult to identify emotional cues. Lack of physical touch can negatively affect the relationship and the comfort given to the patient. There can be limitations in detecting non-verbal or even subtle auditory cues and more difficulty in soothing or reassuring patients if they become acutely distressed.

In my experience, patients often express the wish to die when they are in crisis, frightened, and have a sense of hopelessness. How the doctor responds to them can profoundly shape their ongoing responses.

An excellent study by Prof Brian Kelly (4) showed that the patients of doctors with greater training in psychological therapies and who have a more positive outlook are less likely to want assisted suicide. In other words, a VAD doctor, or any doctor’s attitude, even if subtly conveyed, can influence whether the patient wants assisted suicide.

A patient who asks for VAD is often expressing suicidal ideas. For example, I have repeatedly heard elderly men say: "I'm sick of living, I wish I had a gun". Obviously, I have never handed my patient a gun. Instead, I explored the reasons behind this statement. These statements represent the way some elderly men might express their distress in what they perceive to be a hopeless situation. Asking for VAD can be another expression of distress and suicidal thinking, which requires exploration and assistance.

We have to ask what are the problems – medical , social or otherwise – that have led to this situation. It is not the healthcare provider’s job to buy into the patient's sense of hopelessness and distress but to help with solutions and comfort.

Coercion risks

The data about coercion amongst the elderly is based on survey instruments which are incident-based, so they are unable to capture the ongoing nature and more subtle forms of coercive control in everyday life. Further, given the way coercive control can restrict a person’s autonomy and deny their personhood, self-reports of controlling behaviour are likely to underestimate true prevalence.

As an old age psychiatrist, I frequently see varying degrees of coercion occurring. Often this is when finances are involved. Inheritance impatience is a known phenomenon.

Asking the patient, "are you being coerced" is clearly a very blunt instrument and likely to miss coercion and situations of emotional and financial abuse. VAD practitioners have an obligation to be highly confident on sound grounds that their assessments are correct before proceeding any further. Even if they are confident, they are still likely to get it wrong quite often. Without well-grounded confidence, they will get it wrong even more often. The problem with getting it wrong is that the act is irreversible.

A recent Australian federal court ruling, Carr versus Attorney -General 2023 (5) determined that VAD is captured by the definition of suicide in current Commonwealth criminal communications law. In Europe VAD is called exactly that - Physician assisted suicide (PAS). The Commonwealth Criminal Code (contained in Schedule 1 of the Criminal Code Act 1995) make it an offence to use a carriage service to publish or distribute material that counsels or incites committing or attempting to commit suicide (6). The high rates of suicide amongst rural and Indigenous populations are well known ( 7,8). Encouraging suicide by VAD via telehealth runs contrary to the goals of the National Suicide Prevention Strategy (9).

Telehealth assessments would mainly be used for patients dwelling in rural and regional areas. There is limited access to healthcare, aged care services, palliative care and mental healthcare in these areas but to date take up of VAD in these areas has been high. The likely increase in rates of VAD if telehealth were introduced gives the lie to the notion that individuals in these areas truly have a choice when it comes to VAD as against top quality medical care.

In short, the use of telehealth to increase the uptake of VAD in Australia would be dangerous and unethical and would lead to poor medical practice. It should not be the aim of legislation and health services to increase the uptake of VAD at the expense of patient safety and high quality medical care.

References