Voluntary Assisted Dying: The Doctors Who See Death Differently

What does it really look like to face death with choice, dignity and clarity? In this episode of Don’t Be Caught Dead, I sit down with two doctors who’ve seen death from every angle — and who aren’t afraid to talk about it.

I’m joined by Dr Nick Carr, one of the first GPs in Victoria to be involved in voluntary assisted dying, and Dr Kane Treble, a regional GP in Mildura with a background in emergency medicine, palliative care and paramedicine. Together, they pull back the curtain on how voluntary assisted dying works, why it matters, and what the system gets right (and wrong).

We dive into the personal stories that changed the way these doctors practise medicine — from patients like Beverley who died before the law was passed, to families who’ve experienced the relief and beauty of a death on their own terms. We talk openly about the barriers in the current laws, the stigma in rural communities, the gag clause that stops doctors from raising the option, and the very real impact this has on dying people and their families.

This conversation is raw, eye-opening and full of heart. It’s about the messy truth of death, why choice matters, and how doctors themselves are changed by walking alongside people at the very end.

In this episode, we cover:

• How voluntary assisted dying became law in Victoria
• The story of Beverley Broadbent and why her death sparked change
• Why doctors in Victoria are still gagged from even mentioning voluntary assisted dying
• The challenges rural and regional patients face in accessing end of life choices
• The reality of telehealth restrictions and why they make dying harder than it needs to be
• What it takes to become a VAD-trained doctor — and why more doctors need to step up
• Why every voluntary assisted dying death these doctors have witnessed has been called “beautiful”
• The role of religion, aged care facilities and advanced care directives in end of life planning
• Resources and support for anyone exploring voluntary assisted dying in Australia

Remember; You may not be ready to die, but at least you can be prepared.

Take care,
Catherine

Resources mentioned in this episode:

• Dying With Dignity Victoria: www.dwdv.org.au
• Care Navigators (Victoria): Phone (03) 8559

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Music composer: Ania Reynolds - https://www.aniareynolds.com/

Transcript

0:02

I've seen good deaths, seen some not so good deaths. Seen some terrible deaths. Having seen now numerous VAD deaths. I can tell you how I wanna go. It's peaceful, it's lovely. It's a celebration of life. You choose the time, the location, the music. We had one family that was blasting highway to hell in the background for the entire afternoon. For that person. That was their sendoff. That was the celebration of who they were. And as much as there's tears, there's often laughter and joy and people with love surrounding that person, almost at the end of the first assessment, we're hugging and crying, breaking all the kind of boundaries you're supposed to have about doctor patient interaction, but it's such an intimate, profound. Experience and it matters so much to these people. Welcome to Don't Be Caught Dead, a podcast encouraging open conversations about dying and the death of a loved one. I'm your host, Katherine Ashton, founder of Critical Info, and I'm helping to bring your stories of death back to life because while you may not be ready to die. At least you can be prepared. Don't be caught dead. Acknowledges the lands of the Coolen nations and recognizes their connection to land, sea, and community. We pay our respects to their elders past, present, and emerging, and extend that respect to all Aboriginal and Torres Strait Islander and First Nation peoples around the globe. Today I'm speaking with Dr. Nick Carr and Dr. Kane Treble. So Dr. Nick Mayer, you may have heard of before, he is a Melbourne-based general practitioner with over 30 years experience in currently practicing at St. Kilda Medical Group. He has a background in medicine from the University of Cambridge and has built a diverse clinical practice focused on men's health, psychological medicine, aged care, and ethical medical decision making. He is one of the first GPS in Victoria to be involved in the voluntary assisted dying and is a vocal advocate for compassionate end of life care beyond his clinical work. Nick is a respe respected medical educator, broadcaster, and former A BC presenter known for engaging the public in health and ethics conversations. Thanks for being with us, Nick. Oh, thank you for having me on, Catherine. And now Kane, we move to you. Dr. Kane Treble is a general practitioner based in Mildura Victoria with special interests in emergency medicine, palliative care, and medical education. He began his career as a paramedic before training in medicine and has worked across rural and regional settings, gaining extensive experience in both hospital and community care. Kane is passionate about teaching and mentoring the next generation of doctors having received recognition for ECU excellence in clinical education. His work bridges the gap between frontline care and medical training with a strong focus on delivering quality healthcare in underserved communities. Thanks for being with US Kane, and to be here. Thanks very much. Now, tell me what motivated you, firstly to become medical practitioners. Nick, if we can start with you. Oh, it's terribly dull. I'm afraid. I, my dad was a doctor and I saw what he was doing and I thought that looks quite fun. And as a sort of dumb English schoolboy, I never really thought of doing anything else. And I was fascinated right from the side. Actually, I wasn't too good at science at school. Languages were really my thing. And so my teacher said, well, you'll be doing French, German, Italian, Latin for A levels. And I said, no. So I'm going to do chemistry, biology, and physics. Whoa. We somehow managed to scrape through, became a doctor, which was actually the best decision I'll ever made. How about you, Kate? I actually took the exact opposite path where I actually started off as a scientist, a research scientist in biochemistry, but it doesn't get you invited to as many parties as you might believe. I ended up jumping ship, becoming a paramedic, as you mentioned before, but before long was, was dropping patients off to emergency and I thought that that next bit looks like fun. So that's what actually made me decide. I, I did want to become a doctor, do medicine and then after my wife had children, I realized I wasn't spending much time with them. I thought I'd give this general practice thing a go some work life balance just fell absolutely head over heels in love with you a bit of a more. Bendy path, but, uh, I think I've ended up exactly where I need to be. And I'm, I'm actually with you on that, Kane. I mean, I loved every bit of medicine. I did. I loved doing pediatrics. I miss the old people. I really enjoyed geriatrics. But where were the other people? Psychiatry fascinated me, but, oh. Sometimes I launch someone, just have a sore throat. General practice was obviously begging for me and best, best decision I ever made because you'd probably say the same thing. I've worked in general practice for nearly 40 years. Never had a dull day yet. How many, how many people can have the privilege of saying that about their work? Definitely very few. I would say, Nick, to be perfectly honest. So tell me as a, as a gp, what, when was the first point in time where you heard about voluntary assisted dying, where you became involved in, in the process? I would love to say that it was a lifelong passion of mine, but it would be completely false. It was a patient of mine and. This is often the case that it's patient experience that brings doctors into this kind of field, and it was a wonderful patient mine called Beverly Broadband, who's very well known in the news for having taken her own life because voluntary assisted dying wasn't available, and did a series of interviews with the age newspaper. To be published after her death. Uh, Beverly was a profoundly independent, very bright and determined person. We didn't have voluntary assisted dying when she died, and it was Beverly's death was one of the sparks that really began the conversation said, began. It's not quite been talking about it for a long time. But Beverly's death and publicity around it was one of the factors that built the momentum towards us getting to the law here in Victoria, 1970, up to 1920. And just some. So Beverly, if you can remind us what, what your sort of period that we're talking about that Beverly's articles were published in the age, I think it was 2012, something like that. So, well before we had VAD legislation in, in the state or in this country at all. And she, she didn't have a. Terminal illness, so she wouldn't have qualified for voluntary assisted dying, but she knew her faculties were failing. She was absolutely determined, not trained up in aged care. She'd seen that happen to her best friend Betty, who was also a patient of mine and talked to me many, many times about the fact that that was simply not gonna happen to her. She had no dependent, she was a single woman and she was able to make her own decisions and wow, what an impact she had. And Nick, do you mind sort of setting the scene for, for someone who may be unfamiliar with just how voluntary assisted dying, what it looked like before it was introduced and then and what options were available and then the period of when for what it meant for you as a GP when it was introduced. If you can just sort of set that scene for us, that would be great. Because before we had the legislation, which was passed at the end of 2017, there was no option for people who said, I've done my time, and palliative care has always been available, and they do a magnificent job. And they believe a huge amount of suffering prop. Palliative care can't relieve all suffering and really struggle sometimes with what we call the existential suffering of when it's all too much, and getting the choice back is something that voluntary assisted diet has done for people prior to it being a legal option. The choice people sometimes made was suicide. This was one of the factors that was used to bring in the law. The fact that the coroner reported the number of deaths by suicide of people who had terminal illness, and to say, I can't wait for this disease to take its course. I have to have another way out. That was one of the factors that helped people push this legislation through. Rodney Simon was another very powerful advocate for voluntary assisted dying, and he counseled a lot of people at the end of their lives prior to the legislation being available. But that was one man doing this and doing an amazing job for people. But there was no legislation to help him. So of course, where the law began, this was an enormous relief to some of the people suffering from terminal illness who said, I do not want to grind through to the end of this process. I would like to have the option. And so has been to this day. It's worked very well for this small number of people who need it. And tell me, Kane, you are more in a regional area, being in Mildura currently, how have you seen or have, have you seen an increase in your patients expressing interest in that as a, a voluntary assisted toine? As a, as an option. Coming from a rural background, it's always interesting to find out how the rural grapevine work. That's ultimately how most of the news gets out, and particularly when at the moment, it isn't something that we're really loudly allowed to advertise. As doctors, we're not allowed to initiate the discussion, and so in many ways, we're actually, depending on our patients to kinda get the word out for us when we come from the stoic pharma mindset of don't worry, she'll be right. That becomes a real struggle and I think a lot of rural Australians don't even know that this is an option. This is something that's even open to them and. There are times when you can see the suffering, you see the pain and you just wish, if only I could say these words that might alleviate that suffering. And again, with that arm stoicism, we, we'll get people saying things like, oh geez, can't we just hurry it up? Or Can't we pull up a top and it doesn't count? We, we need to kind of tease out a very specific request. And when you often try to engage them and say, you know, Hey, what do you mean by that? I might be able to, to talk about some things. Oh, no, don't worry about it. Wow. That's must be challenging 'cause, because as the current law stands from my limited understanding is that you, you cannot mention the, the topic of voluntary assisted dying as an option to a patient that comes and speaks to you at, at the current stage as it is. Yeah. So I, I think while Victoria were, was really pioneering in the space of voluntary assisted dying. I feel like we're lagging a little bit behind other states. Yeah, we still can't actually initiate the discussion, whereas other states have opened it up to to allow for exactly that. It was actually one of the recommendations that came up on recent review of the VAD legislation to see if that's something that we may be able to change, and fingers crossed, we're still waiting for the outcome of what those changes could. When that clause was put into the law, it's called the gag clause to, for convenience. Just to explain, doctors cannot initiate the conversation about voluntary assisted dying. It's seen as a protection for patients because it's thought that us nefarious doctors were going to say, come on. You know, why don't you get on? Just bump yourself off. Why would we bother all this expensive and complicated palliative care? It's so insulting. To the medical profession to think that we would do that sort of thing. We want what's best for our patients and I don't know a doctor in the world who's going to be saying to someone that they should have this path, but turn it around the other way. There's no other area of medicine where we are legally not allowed to tell people all their available options in any other area. Ofit, we would be negligent from not giving people all their medically available options. And yet in this end of life space, we, in Victoria and South Australia's the other state that has a gang clause are legally not allowed. Bring that up. And it's really a, a terrible disadvantage. Exactly. As you say, Kate, I see patients who are old and failed and unwell and they simply don't know. And it disadvantages people with lower levels of education maybe aren't aware of it. People, maybe it's English, it's not their first language. And so they haven't come across this in the news. Victoria and South Australia are the only places that have it. All the other states and the a CT do not have a gag clause, and it's not as if they've been dragging people out in those other states and, and taking'em through VAD against their well, that simply isn't going to happen. So we really have to get rid of this gag clause because it, it is legal option. And so I, I suppose for, for any other legal options that are on the table, you, you're allowed to speak about them. So for me, who is someone on the outside looking in, it's kind of crazy that you can't actually mention a legal option, which is a valid option and choice for, for people in, in the community. You're probably aware that the legislation in Victoria only passed by two votes, and a lot of these restrictions and extra clauses were put in to make sure it got across the line. Uh, was wide. He described as being the most restrictive, voluntary assisted dying legislation of any place in the world. With the 68 safeguards, it was better to get it through than not get it through at all. But I think we're now recognizing exactly as you're saying, Kate, having been at the Vanguard, we're now the lag arts and really we now know that some of those protections are not actually protections. They're actually barriers for people who need this care. And just on that, Kane, sorry. I'll let you let you go. I think that also ties into issues we have around the telecommunications act at the moment, whereby, regardless of whether the conversation's been started by the patient, we can't continue it using telephone, email, or electronic communication. And so again, from a rural setting, I have patients that are two hours away. We have to do this little song and dance when we try to organize an appointment where I'll say, I'm calling you up to say we need to catch up face to face to have a discussion. But I can't tell you why. And it's this ludicrous thing we have to go through where we all know what we're planning, what we're talking about, but we're restricted by the current legislation, current communication. For people who don't know quite why that is, it's because there is a Commonwealth legislation called the Criminal Codes Act minted in 2005, which bans any discussion or facilitation, suicide by carriage service, text message, internet, telephone, that sort of thing. And it's a federal law. And so federal law trumps any state or territory law, and. Dying with Dignity Victoria. We've been making strenuous efforts to try and get this sorted out because the federal legislation talks about suicide. In the end, I end up in the federal court with Mark DRS testing this in the federal court, and it was found that the legislation does in fact apply to voluntary assisted dying legislation. So it's been clarified legally. You're quite right, Kate. In the legal sense, we're not allowed to do any of this work. By telehealth, and of course that's an immense imposition on frail older people, particularly our more regional areas. We then have to travel for every aspect of this assessment. We do telehealth, but really complicated medical problems. We, we become expert at that over COVID and there's no reason why we shouldn't be able to do some aspects of voluntary assisted. I don't need to do all of it, but at least some of it, the patients will be no via telehealth. And, and that exactly what you were just saying, Nick, about the advancements that we've seen during that COVID period, how we have moved everything online. We have moved it to do just about everything we possibly do remotely where possible. And, and it, it's a, seems to be a case where, again, where life is more forward than the laws that actually govern it. So, so just talk me through Kane. The challenges that you were saying that if you want to speak to a patient about voluntary assisted dying, you have to do this in person. Talk me through what that looks like. Like you mentioned that you may have to travel a few hours. Yes. I mean the, the first issue we encounter is the patient needs to know we exist in the first place. And I actually do run a VAD clinic, but we're not allowed to advertise it in case it's seen as initiating the discussion. And so we are again, dependent on the word of mouth of, of patients to kind of let it be known that this is something that even exists. They will have to attend in person to actually initiate and, and start that whole process, assess for their eligibility. For the multiple assessments that are involved, these all have to remain face to face, and again, these are patients that are often suffering. They're frail and traveling. What can be hours and hours just to see us in the first place, let alone the trip home again, after what can be some really difficult discussions. It's incredibly taxing and incredibly infuriating to be frank. We can't help these people in, in a way that would actually benefit the most in this day and age when we have so many other advances through healthcare, through telehealth and to feel like we aren't actually servicing rural Victoria. And we know that the majority of cases that are put through VAD come from more metropolitan settings. Uh. Then once we do get through their initial assessments, trying to find additional doctors or specialists to become involved, to agree with the assessments that are made, the, the current Victorian requirements, so that two doctors be involved to come to consensus around their eligibility. Again, if these are patients that struggle to, to travel, and then sometimes we have to say, not only have you had to travel two hours to get to this regional hospital. Now going to ask you to travel six hours. You get to a metropolitan hospital to be assessed by another doctor again, and these are people who have been diagnosed with a life limiting illness. So they're obviously trying to manage their health at the same time that they're, or, you know, being involved in these appointments and, and traveling. I'm, as I'm assuming that that's, that's what the challenge some of the challenges are as well. And coordinating all of the, the friends, family, carers that are around them as well, that also often have to travel with them just to, to make it safe for them to travel as. Even if someone doesn't live a long distance away in city environments, these people remember these people are often very infirm. Some of them are bit bound, and just getting someone out of the bed and into a car can be a major struggle and it doesn't matter if sometimes if the travel is only 10, 20, 30 minutes. The whole process can be painful, exhausting, and a massive imposition. So it's, it has a very big impact on people, rural, regional, and also metropolitan. Look, I, I, when you're, when you're both talking, it reminds me of just the appointments I used to have at the Vic Rehab Center after my car accident and, and you know, they were an ordeal and, and I was. In recovery, you know, and, and going through rehabilitation. So I was improving my health and wellbeing and, but they were really hard and I was having to catch a taxi and, but just to coordinate each, those two days that I was doing each week for the 16 weeks, that was a huge toll that it not only took on me, but all my family.'cause it it is, it's a, it's a family commitment, isn't it? Yeah. Yes. Agreement very much. So tell me when you have referred to the, the differences between, obviously Victoria being the first state to introduce voluntary assisted dying, and then we have, I think the last state that will introduce it currently is as. Canberra, is that correct? This year and yet we've still to have it passed in Northern Territory. So what are the difference you is between, for someone who is unfamiliar between, you know, Victorian laws and, and what's, you know, being introduced into Canberra. You've mentioned that the gag clause is obviously one, one issue. Then, you know, you've gotta love Australia with all of our different laws in each states, don't you? And then the. The federal overarching law makes, makes death and, and health so much fun to navigate and, and you are qualified. So, so what are the other, other things that is, is sort of have, I suppose you could say, say we're a bit more progressive than what we have in Victoria that we're, we find that's challenging in our lovely little state. Katie, are you across the details of the differences in a CT versus Victoria? Not particularly, but Mildura is a, a border a town. We border a New South Wales and South Australia is just a stone's throwaway. But I'm acutely aware that the one of the Victorian restrictions that you is, that you need to be a Victorian resident for the preceding 12 months. And so when our health service catchment includes other states. We have residents of other states that attend our health service and try to seek VAD as an option. We unfortunately have to turn them away or redirect them rather to their home state for for assessment there. Oh wow. That's super challenging and I think I'm right in saying that in a CT, they don't have the prognosis requirement of six months or 12 months from neurodegenerative disorders. You just have to have a illness that is going to end your life. So one of the concerns we have is that we're asking in Victoria to give a prognosis and has to be six months or less, unless it's a neuro neurodegenerative disorder when it's 12 months. And this sometimes is a very significant impediment because I frankly, we doctors a hopeless at prognosis and it's often said that doctors won't give you six months as a timeline until you've only got six weeks. And this sometimes does mean people come to the process too late.'cause the specialists are doing best job in the world that they can do and they say, no, we could try this and let's there's hope here. And, and they don't want to say to someone, you know what, I think we're not doing too badly. However, I think in's six months time, this is not gonna work. They, they keep trying and keep putting it off and then say, oh, things are not looking so good. And then the timelines get a bit short. And I believe in a CT, that prognosis requirement isn't there. And I think that will free the process to, to make it possible to start a bit earlier. Ideally, what we like to see, when people ask me about it and they say, well, when should I start? I say, as soon as possible.'cause the best possible thing you can do is go through this process, get it done, get your medication permit in place, and then don't need to use it. Nothing I love more than someone getting their little black box, stick it on the shelf and it gathers dust.'cause they get on with life. And I think there's a concern that people will get this stuff and then take it too soon. I dunno, anyone who's ever done that, what It's really the other way round. And I remember perfect phrase from someone who said, once that little black pop, black pops arrived. And he said, now I've got the dying sorted out. I can get on with living. But that's so true, isn't it? That it, it seems to be a common story that I've heard is when people are diagnosed with a life limiting illness, they, they don't get in contact with the services for that support, whether it be palliative care support or whether it actually be, you know, looking at, into voluntary assisted dying because. You know, the words that you were using then Nick were the, the author, Leah Kaminsky refers to it as militarizing, you know, the Battle of Cancer. And, you know, we've gotta wage the war. And, and, and the whole way in which we talk about death and dying is like, it's, it's something that we, you know, we don't want to lose the fight and all of this, this rhetoric around it, but. It really does come down to the end of the day about choices and making informed choices about what's available and, and it sounds like that there's an added layer upon those conversations that you have because it's not just palliative care. There's another layer that you need to take into consideration because. Of the, the, the real process that you seem to have to go to once you, you actually decide to go with voluntary assisted dying. Can perhaps, Kane, would you like to just give us an indication of, I think it was 68 sort of guidelines or checklists that are associated with the, the process? Can you just give us people a snapshot of what is involved and what, what are the checks and balances in place for those that are unaware? Definitely. So probably focusing a little bit more on the the patient perspective. The first point is where the patient first voices that request, the first request say, I would like you to help me in my life. From there, an initial assessment can be made by that doctor if they are VAD trained. Or more often than not, I think referrals have to be made through to doctors who are VAD trained. From that first assessment, there's a a very thorough assessment of not only their medical history, their current diagnosis, the quality of life, as well as their other eligibility requirement, which again, speaking from Victoria, they need to be 18 years of age, a Australian citizen, or holding permanent residency. They need to have resided in Victoria for the preceding 12 months, and they need to, oh, there's one more there. I'm forgetting. Can you help me out there? Yes. Well, they need to have decision making capacity. Thank you. Yes. And that's actually a massive part of that. That first, first assessment is to find out what is the intent behind their request. I've had a lot of people that come in and say, look, I actually just want the information. I just want to know what all the options are. And they don't necessarily want to proceed with, um, actually obtaining VAD medication. Sometimes I think they just want to know that it's there. Tied into that as well. We do get a lot of people that actually don't qualify and I, I would say I've had ballpark 25% of people that have actually said, look, I'm not entirely sure you, you do want this. I think you have symptoms that we can actually get on top of. Or, you know, there may be an understandable depression in this situation or a mental health condition that may be contributing. Let's address that first. And the, the majority of those kinds of cases I actually choose in the end not to proceed with VAD because we can actually improve their quality of life. And again, that's really what we're trying to achieve here is maximizing quality of life, acknowledging that we, we often can't change the outcome, but we can change the journey. For those that do decide, actually no, this, this is an option I would like to pursue. We then, then to need to link into a second doctor. We have one doctor that acts as a coordinating practitioner who essentially holds the hand through the journey, makes sure all the proper boxes are ticked, the forms are filled, all the requirements are met. And another doctor that acts as a consulting doctor, their job is to make sure that yes they agree, diagnosis, prognosis, and that all those same kind of. Important safeguards are being met. Um, important to point out again in Victoria that at least one of these doctors has to beed in their specialty for at least five years, and they have, there has to be at least one person who is a specialist in that specific condition as well. Making sure there is that expertise behind the, the diagnosis, the prognosis, acknowledging that the prognosis is incredibly difficult to determine, and it's often that, you know, how long is a piece of string kind of guesstimation. In the best of our ability. Once that second assessment's been submitted, we can then actually go through and there's a compulsory kind of pause between that second assessment through to, or the first assessment, second assessment, and then a, uh, written declaration, a written request, which is that formal request, then to say, this is an ongoing request from the patient, made freely without coercion, and this isn't just a spur of the moment decision. One opportunity to get this right. And so it's that kind of forced benchmark to make sure that the time is taken to consider all options. Yes, there are ways to speed things up if we do think that the prognosis is within the, the nine day compulsory kind of pause there, but I would say the vast majority of cases, taking that nine days is achievable, is done. And I think the really important part of the process. Once that's gone through, we can finally put in an application for the permit to have the medication. There's an appointment of a contact person Out of their role is to also act as a safeguard around the, the storage and return of medications as well. And depending on what form of medication that patient's actually going to receive, we tend to prefer generally speaking that the patient's able to self-administer the medication to themselves. That can be orally. It does have quite a bitter taste. I hear. I've never tried it myself, but an incredibly bitter taste. I've tried it. You, you have and lift a tail. The tail, yes. I, I decided I needed to taste this stuff to see what it is that people are having as the very last thing they tasted and oh my goodness, it is outrageously bitter. I did only have a very small dose. Good to hear. I might just stick to coffee if it's all the same. Yeah. Yep, definitely. And, and so I'm just trying to mentally, as you are, you are going through all of these steps to Kane. I'm mentally trying to think from just a, from my perspective, it. It took me months to get in to see a specialist. Is, is that the case in some of these scenarios, like especially like it doesn't matter whether you're in a rural area or whether you're in a metropolitan area. Sometimes the waiting lists for these specialists are extensively long. Is that also part of that timeline and process? How does that work? Well, yes, there can be extensive weights. But that's even if there is a specialist in that condition who is VD trained? Yeah. Do you believe we have specialties where that is not? That was gonna be my next question. Yeah, so there are some understanding, some agreements with the secretariat around where that is the case. What other things might we be able to do? What other specialties may be able to weigh in acknowledging that it's, it's not as ideal, but it certainly does add that extra complexity, that extra delay more often than not, as well as I think making it more difficult and frustrating for the patients involved. To hear that there aren't doctors available or, or trained in VAD for something that's obviously going to have such a big impact on their life and ultimately their death is a source of great frustration and, and particularly from a rural setting where we struggle to have specialists at the best of times. Then trying to say, you know, Hey, we also need you to travel to see a specialist who may not even be a specialist of their condition. This bit of insult to injury, I think. I do have to say that many specialists who work in this field of voluntary assisted dying, bend over backwards to accommodate these patients. They know that they can't reasonably ask someone with a prognosis of six months to come and see 'em in seven months time. So I have found that people are extraordinarily kind. They go out their way and. I mean, I have the privilege of working in the city environment where we have more options, but the devotion of some of the people working in this area, their preparedness to do, do the extras, to see people when they simply do not have appointments to do so, but they get people in and they go and see them at home. They, they really go to extraordinary lengths to make this possible for people. I will highlight up here. Obviously we've had many occasions where we've actually flown a specialist in to be able to see that patient, that's someone who's not only taken the time to come up, but that's essentially a full day list of other patients they could have seen in that time. And to their absolute credit, I'm unaware of any of the specialists I've worked with that have actually charged the patient anything for any of these assessments or, or any of their time involved. Wow, that's amazing. And Nick, do you mind talking me through what is the process for someone to a doctor to become A-A-V-A-D, you know, trained doctor? First thing is to want to do it. So please adopt this out there. Don't just be interested, be passionate. Let's get involved. You'll find if you do do it, it's possibly some of the most rewarding work I have ever done. Not something I would've expected, but it's so true. So it's, it's people being prepared to do it is the number one huge hurdle then It's actually, it's not that hard. It's a, it's an online training. It takes most of the day and. Another areas of this work is, there's very little incentive for this because it's, it's a day away from your work. There's, there's really no reward for doing that work other than being able to become a VAD practitioner. But that's, but that trendy is very thorough. It's actually very interesting, and we've had people who do it because they want to find out more about voluntary assisted dying. They don't necessarily want to become the ad practitioners. But they think this is an important area of healthcare I should know about. So the training is the number one. It's very easy. You sign up online and get that done. And once you've done that, you are then a VAD trained pop up. And like most training, you do that and you have absolutely no idea how to do the real work. So the real training comes with you actually see a patient for the first time. I did the training in April of 2019 before the law had even been implemented in the first group that did the training. And then the law began in June, 2019, and eight days later, a patient rang up who had seen me in the news and said, oh, VAD had pancreatic cancer, and came along. And that's when I really started learning. How this works. He actually was a very good example of one things you were saying, Kane, about the criteria because the Victorian legislation said he must be an Australian citizen or permanent resident. This man, Julian, was his name here to lived in Australia for over 40 years, and I was doing his first assessment. The very first patient I'd ever done, done it for, he brought in his passport and it was British. He had never taken out citizenship, so he'd lived here 42 years. He paid his taxes. He was registered to vote. He was now on an Australian pension, but because he didn't have Australian citizenship, he did not qualify for royals to die. My very first patient. Oh, wow. That's it. That's sort of going sidetracking from how you track. But Nick, how did, how did that make you feel? Oh, it was devastating. You had to tell him, absolutely devastating. This, this, he was a lonely man. He had pancreatic cancer. He was going to die from this. It was a horrendous disease and. He, and of course I'd never met him before this. I met him twice the second time I met him. And we just, it was all brand new. We thought there must be a way around this. And we talked to lawyers and the navigators and Peter McCallum lawyers, but I said, no, I now realize it's very clear if you're not a citizen, you're not eligible. And Julian was absolutely devastated'cause he'd hung his hopes, he'd followed the legislation. He had this disease, and that's why as soon as it passed, he got in touch with me and Julian suicide. It. It was devastating. It was one of the most distressing days of my life when I heard that. And instead of being able to go through a, a medical process where it was all legitimate, he could do it with whoever he wanted there. He had to do it on his own. Leaving a note from his, for his neighbor who had the keys said, do not come into my house. Just call the ambos. And of course then those first responders had to find a man who had suicided on his own. Horrible for them. Devastating for Julian. And what was a technicality in the law? Oh, I'm so sorry to to hear that. Thank you for sharing. It's not uncommon. We've got, we've got a lot of Kiwis and, and Brits in this country. You've lived here a long time, haven't taken out citizenship. You've probably come across that, Kate. Yeah, I was just going to say, having been a paramedic myself and walked into exactly that kind of house, you know, it, it devastates everyone around and that impact is ongoing. Ultimately, at the end of the day, for a lot of people, and again, farming communities, if they're going to do something, they're going to do it proper. A lot of people will suicide if this isn't a, a seen to be a valid, accessible option for them. And again, at the end of the day, we're not changing the outcome for these patients. We're changing that journey. We're giving them that sense of control back again. Often in times where they don't feel like they have control over their symptoms, their disease or their death. I think you can't emphasize that too much, Kane, because one of the things often to say when people start the voluntary assisted dying process mean know only around about 30 or 40% go through to end. End up taking the medication. They get sick, they die. Almost all never changes their mind, but 100% of the people who take part in the process get the comfort of getting back some of that control and use that word ca. And I think it's so, so important.'cause these hideous diseases rob us of our control. They take over ravage our bodies. Do terrible things to our minds and to snatch back some little morsel of control towards the end is such a huge comfort. And the VAD process gives people that comfort, even if they never end up using. It's so, so important. I think it's one of the most important things about it. There was a, a beautiful exhibition and I, I think that you were, were there Nick by Julian Kinga earlier this this year, and beautiful black and white photography. And he had followed the families of people who had chosen to go down the voluntary assisted dying path. And there was this amazing photo of this woman, and I can't recall her name right now, but. She had, she was still alive. She had not chosen to go down voluntary assisted dying and, and take the open, the black box, as you say, at, at that point when we had the exhibition. But what really clearly showed to me is that. The, the people that were being highlighted, they're all people who have their own individual stories and their families and the impact that, and the, the, the flow on effect that the option and the choice has given those people. And, you know, the, the Julian, the name of the book and the exhibition was the Power of Choice and, and it just highlights that so beautifully and. It brings me to, to ask you about, you know, we, we have in our healthcare system in Australia, the, a lot of religious organizations that are actually, you know, either patrons or they're actually involved in healthcare. And what sort of things do people need to consider when they're thinking about voluntary assisted dying and the care facility that they're actually choosing or that is nearby them? Because I'm, I'm assuming that that would, there would be some tension there as well. The majority of palliative care in this country is provided by the Catholic sector and quite a lot of residential care also. And some of those places are more inclined to look favorably at voluntary assisted dying, and some of them are very vehemently against voluntary assisted dying. And we encourage our older patients who are looking at aged care who might think about this for the future, to take that in mind and die with Dignity. Victoria, we've actually set up a. Which will show you which aged care facilities are on board with voluntary assisted dying, which are a bit equivocal and which are against, and it's not comprehensive 'cause we haven't managed to get that information from some of them. And it's a very important thing. If it, if you're considering aged care and voluntary assisted dying is something which you might want to have as an option for yourself, then that's a question that needs to be asked at The Aged Care. I, I dunno, you may not have so many options as in the community where you work, Kate. No, and we have had, uh, several cases now of VAD in the aged care setting. I'm a little bit grateful that the, the first question we kind of get is, oh, well, tell me more about it. It's often that lack of information or lack of knowing about the process. Once we sit down with the people that run the facilities, explain it through. Fortunately, we've, we've actually had a lot of success and a lot of people being on board with the, the process. You know, we appreciate that people are going to object to VAD on moral, religious, or philosophical grounds, and we respect that. But the hope is that they also respect patient's ability to be able to choose and, and be involved and make that choice for themselves. And just anecdotally, I was doing a, a teaching session for GP registrars just last week. It was about 40 registrars and one of the first questions I asked, this was about voluntary system. One of the first questions I asked anonymously was a did little poll and I dropped people to rate where they. Felt about voluntary assisted dying from fully supportive through to objecting. And one of my options was I object on the grounds of my faith, and 15% of the registrars at that meeting ticked that particular box. So we must remember that objection on the grounds of. Philosophical or faith-based beliefs is very common. And I've often said that there is only one really true, strong argument against voluntary cys dying. And that's the one of of moral philosophical belief or faith. Because when you look at data, when you look at the science, when you look at research around the world, there's almost no other reason why you would be opposed to it because it works well at every jurisdiction where it's studied. But if you. Don't believe that it's right for you or it's not right for your religion, then absolutely. Of course you should have the right to say no. I would just say exactly like you did Kane earlier, just now that, that's fine. You can have that decision for yourself, but please don't, don't try and impose it on others. And so for someone who is interested in voluntary assisted dying, where can they go to receive information and, and sort of navigate, you know, this space? Hopefully there's already a bit of knowledge amongst the general practitioners in the area or the, the health practitioners, and I think at the moment at least the, the majority of referrals that I get are actually from colleagues where I've let them know that I, I do participate in practice VAD, and so I get referrals from that in Victoria. Thankfully we have, and most states do, a incredible team of care navigators. That if you are not sure where to go or who to contact, a quick little Google search can find them out. But they're based out of the Peter Mac cancer center and are available via phone, hypothetically. It might be 0385595823, but to, to give people a way to at least link into the service. While lists of BAD doctors aren't publicized anywhere, they do have a, a list behind the scenes where they can say. You are in this area, you have this condition. Hey, let's try and link you in with these people to get your assessment started. And it is something that we'll definitely include in the show notes. And you, you've also, we've also mentioned the resources that are available on Dying, dying With Dignity Victoria's website, which is, is exceptionally good. One thing that I find that a lot of people ask about is, you know. The advanced care directives, how do, how do they fill those out when it's about voluntary assisted dying? How do they cover off on that? How do they even start that process? So do you have any, any thoughts on that? Very simply, you cannot put voluntary assisted dying into advance care directive. So you could state that that would be your preference, but it has no legal weight at all. Advanced care directive is a very useful document to help doctors know how you want to be treated towards you, your life. But it can't include voluntary assisted diet. Uh, and so for, for those people, they, they have to go through that formal process. It's not something that they can just pop on that form. Is it? I think one of the most common questions I get about that is. Everything's going okay now, but if I develop a dementia or I'm in that position where I can't make these decisions, why can't I do it? And again, it kind of highlights at the moment the, the importance of those safety checks to make sure, and, and one of those criteria is you need to be of sound mind. The whole point of voluntary assisted dying is that it's voluntary. And so if you're not in the position to be able to make that decision, the rest of the framework kind of falls apart. So change's raised the funny question of dementia and the commonest reason my patients come to me saying that they may want to consider bone assisted dying in the future is if I develop dementia and I've yet to meet anyone who sits. If I develop dementia, look after me, keep me going at all costs, and don't worry about how. Bad. I am on how much I've lost. My marbles just keep me alive. I've yet to meet that person. They probably do exist, but they haven't spoken to me about it. Nearly everybody says if I'm in that situation, I would like to have voluntary assisted dying. That's not an option in this country anywhere. It's not likely to be anytime soon, but so the area which we are dealing with dignity Victoria, are talking about a lot. We plan to try and address it. It is an option In some countries it's very hard to make it work. It's done on very few occasions, but I'm gonna work at it furiously hard.'cause I want it for when I need it. And so tell me as the sort of final sort of thoughts on the topic Ni and Kane. What can I, what can I ask you that you've, you've learned through your. Patients and taking them through this process, what have, what have they taught you? Happy I'll, I'll start. Sure. EAD. I've been a relatively recent practitioner. I only started at the beginning of last year and already it has profoundly changed the way I practice day-to-day through my roles with ambulance, through my roles as an ed doctor, then through general practice. Death is a bit of an old friend. I've seen good deaths, seen some not so good deaths. Seen some terrible deaths. Having seen now numerous VAD deaths. I can tell you how I wanna go. It's peaceful, it's lovely. It's a celebration of life. You choose the time, the location, the music. We had one family that was blasting highway to hell in the background for the entire afternoon. For that person. That was their sendoff, that was the celebration of, of who they were, such as, there's tears, there's often laughter and joy and, and just people with love surrounding that person. Uh, you put that so beautifully, Cain. I could not agree more. It's, it's one of the astonishing things I found about this work is I meet someone maybe only two or three times, but. Almost at the end of the first assessment, we're hugging and crying, breaking all the kind of boundaries you're supposed to have about doctor patient interaction.'cause it's such an intimate, profound experience and it matters so much to these people. They're so grateful. And it sounds weird to talk about death as beautiful, but like you K and I've seen, I've never been a paramedic, so I haven't seen it the way you have, but I've seen lousy deaths. I've seen okay deaths. But every single. VAD. Death has been beautiful and I actually had the experience from the other side just a few months ago.'cause my own beloved sister-in-law died through voluntary assisted dying, developed a hideous cancer. She knew she was going to die. A very practical person. She'd been an ICU nurse herself. She also knew that this cancer could erode something nasty. She could die by ex San grating at two in the morning or something really hideous like that. And she wasn't prepared to. To, to have that happen. And instead she died, had to be intravenous administration. The lovely VAD came along, team came along and we had this beautiful day and we all remember it as, as you say, came very sad, lots of tears, but with this fond memory of this gorgeous last day. And her last words were, she looked at me and she said, I cannot wait for this sleep. And then she had her sleep and it was beautiful. So. Immensely moving. Very powerful. And like you Kane, I think it's completely changed how I feel about being a doctor and the work and given me a, an area that I now absolutely love working in, which I would never have expected. And I think that. Those beautiful photos that we saw at that Julian King and, and what's in that book, the Power of Choice are a real testament to that, that it shows beautifully and has captured beautifully, those stories and that. Those final moments where they've had the choice and they've made it and they're supported by family. I can't thank you enough, both you, Nick and Kane, for sharing your stories with us today. And yeah, and just letting us know some of the challenge that that still exists when it comes to voluntary assisted dying in Victoria. Thank you, Catherine, and thank you for your great work with your podcast. Thank you so much. Thank you, Catherine. Um. Absolutely massive fan of your work and hope to hear more in the future. Thank you. We hope you enjoyed today's episode of Don't Be Caught Dead, brought to you by Critical Info. If you liked the episode, learn something new, or were touched by a story you heard, we'd love for you to let us know. Send us an email, even tell your friends, subscribe so you don't miss out on new episodes. If you can spare a few moments. Please rate and review us as it helps other people to find the show. Are you dying to know more? Stay up to date with. 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