Voluntary assisted dying: impacts on health professionals

Introduction

New legislation allowing voluntary assisted dying (VAD) passed in each Australian state and the Australian Captial Territory (ACT) between 2017 and 2024, with the Northern Territory (NT) expected to follow.¹ A range of clinical health professionals, including doctors, nurses, pharmacists, care navigators and other allied health professionals, are involved in VAD care. These professionals are facing challenges as they navigate this unfamiliar area of care.¹

State-specific training is mandated under legislation for VAD practitioners and, at a minimum, this provides an overview of each state’s legal VAD requirements.² VAD practitioners may serve in three roles: consulting and coordinating practitioners assess patient eligibility, while administering practitioners may administer VAD substances. Only doctors may fulfil coordinating and consulting roles in all states, however, the ACT allows one to be a nurse practitioner. Western Australia (WA), Tasmania, Queensland and New South Wales (NSW) permit trained nurse practitioners as administering practitioners, unlike Victoria. Training varies between states, with some focusing on legislative obligations rather than clinical communication or ethics.³ Training in Holland and Belgium includes communication skills and an ethical end-of-life framework respectively.⁴ Non-VAD clinicians, such as junior doctors and nurses, may also receive VAD training from health services or professional organisations, although this is not legislatively mandated.⁵

Statewide services, including care navigators and pharmacy, receive government funding, but VAD medical practitioners lack standardised remuneration.⁶ Salaried doctors, such as public hospital specialists, may include VAD in their duties. Most general practitioners (GPs), however, use a fee-for-service model. Without specific VAD item numbers in the Medicare Benefits Schedule (MBS), practitioners use alternatives. Administration of VAD is specifically excluded from receiving Medicare benefits.⁷ Some doctors provide VAD services for free or bill patients privately. Providing compassionate and well-informed care and completing compliance paperwork can take several hours, which literature demonstrates is unsustainable if unpaid.^6,8 Some doctors have expressed reluctance to privately bill VAD, considering it insensitive, although private billing will likely increase as demand grows.² In New Zealand, practitioners can claim for assisted dying services,¹ and the Netherlands compensates assisted dying physicians through patients’ health insurance.⁴ Studies have proposed incorporating ‘fair’ remuneration for VAD practitioners, based on services provided and time required, into the MBS.²

Doctors have found VAD processes complex and difficult to navigate.^6,9 Health professionals in Australia and globally have experienced diverse emotional impacts of VAD.^5,6,9,10 The education and training of many health professionals has traditionally focused on supporting or extending life; the concept of VAD can challenge this.⁶ Some doctors and nurses find it ‘satisfying’⁶ to prioritise patient autonomy and find VAD professionally rewarding.¹¹ However, some studies find VAD prompts doctors to reflect on their existential beliefs, which can be challenging.^6,9,10,12 In Victoria, doctors, nurses and allied health staff have experienced fear of conflict when their personal views differ to others in the workplace and have reported moral distress around VAD, expressing a need for psychological and educational support as a result.⁵ Debriefing, mentoring and peer support is currently being sought from colleagues and peers, including from a recently established national VAD organisation, Voluntary Assisted Dying Australia and New Zealand (VADANZ).^13,14

There is limited evidence around the adequacy of training, support and remuneration for Australian clinicians involved in VAD care. Research to date focuses on specific professional groups, such as doctors,^1,6 with little information regarding the effect on nurses, allied health staff and pharmacists. Furthermore the impact on those not directly involved, including conscientious objectors, is unknown.

There has been calls for studies comparing different Australian regions on VAD,¹⁵ however, quantitative comparisons do not yet exist. To address this gap, this study aims to understand some impacts of VAD on health professionals, including doctors, nurses, pharmacists and other allied health professionals, focusing on and comparing Victoria and WA.

Methods

Results

Table 2 summarises three key themes related to impacts on health professionals identified from data analysis: costs, training and emotional impacts, with illustrative quotes. They are identified separately for clarity, however, they are inter-related and may influence each other. Table 2 also presents several subthemes.

Training

Mandatory training

Among surveyed doctors, 51% completed mandatory VAD training. Fig. 1 presents sources of training offered to doctors and nurses in Victoria and Western Australia (Fig. 1).

Fig. 1.

Sources of training offered in WA and Victoria to doctors and nurses.

Barriers to mandatory training

Barriers included an unfriendly online system, lack of remuneration, lack of professional development points, time constraints and clinical opportunity costs. Participants 169, 154 and 220 (Table 2) provide details. Doctors indicated that funding and allocating non-clinical time to training would likely increase participation in training (Table 3).

Table 3.I would be more likely to complete mandatory training (required to assess patient eligibility) if:

Strategy to overcome barriers	National %
It was funded by my organisation/clinic	55.7
It was eligible for Continuing Medical Education	43.0
My organisation/clinic allocated non-clinical time	55.1
No opportunity cost for my patient load	34.8
Delivered face-to-face	22.8
I would not complete the training irrespective	25.3

Impacts of barriers to training

Participants reported training barriers contribute to the limited numbers of VAD practitioners, particularly in specific specialties and regions (Participant 106, Table 2).

Mandatory training is only required for certain groups

Mandatory training is generally limited to VAD practitioner trainees, although some jurisdictions are expanding access to training to promote awareness.²⁶ Consequently, nurses and junior doctors such as Participant 40 may feel undertrained. Participant 89 describes knowledge of VAD among the general medical community as ‘poor’.

Supplementary training

A total of 52% of respondents were offered training by their organisation or clinic. More nurses (66%) were offered training than doctors (38%). More Western Australians were offered training from a state-funded service compared to Victorians, who were more frequently offered training from their organisation or clinic.

Participant 271 sought additional communication skills training. Participant 210 found their institution’s communication training ‘useful’ highlighting training variability between institutions.

Need for support

In Victoria and WA, clinicians reported various emotional impacts of VAD. This paper focuses on distressing impacts and support availability, with positive impacts out of scope. Table 2 indicates four sub-themes. Participants 135 and 60 report an emotional burden on clinicians. Additionally, Participant 138 found conflicting views on VAD in the workplace can be distressing. Managers needed to manage workforce distress (Participant 81).

Participant 87 highlights VAD-related workload pressure and Participant 232 sought ‘respite’. Both describe that the majority of the burden fell on the few practitioners handling most cases.

Fig. 2 illustrates that 65% of respondents received no psychological support, with doctors (33%) receiving less than nurses (52%). Support mechanisms include employee assistance programs, VAD communities of practice and organisation-led debriefs.

Fig. 2.

Sources of support offered in WA and Victoria to doctors and nurses.

Discussion

Inadequate remuneration, a need for support and training barriers impact health professionals, increasing burnout risk and threatening workforce sustainability if unresolved.

Findings highlight inadequate remuneration for VAD practitioners, disproportionately affecting fee-for-service practitioners, which is consistent with international literature.^6,8–10,27 Literature suggests the lack of remuneration may disincentivise doctors from providing VAD services, impacting sustainability. Haining et al. argue that without MBS item numbers, practitioners may resort to privately billing VAD patients,² raising ethical issues. Developing specific MBS item numbers for VAD services, akin to New Zealand’s model,²³ could address these challenges. With VAD legislation expanding across Australia, national harmonisation of VAD funding through Medicare reforms could be considered.

Barriers to completing mandatory training included it often being unpaid and unrecognised for Continuing Medical Education (CME),¹⁵ discouraging potential practitioners. There are small numbers of VAD practitioners handling most VAD requests, risking burnout. Spreading the workload between more trained clinicians may benefit individuals and support sustainable service delivery. Incentives could include offering CME, allocating non-clinical training time and providing funding. Tasmanian training is accredited by both the Australian College of Rural and Remote Medicine (ACCRM) and the Royal Australian College of General Practitioners (RACGP).²⁶ VAD Awareness units, available in NSW and Tasmania, have been developed for an intended audience of any health professional, regardless of their involvement in VAD.^26,28 Evaluation of these initiatives could be beneficial.

Current mandatory training focuses more on governance and legal issues, rather than communication skills, consistent with the literature.¹⁵ Australian clinicians are seeking guidance on novel and challenging issues. Sandham et al. have shown that communication training is necessary for nurses,²⁹ and in the Netherlands, actors for communication skills training have been beneficial.⁴ Communication training may also help Australian clinicians.

VAD has both rewarding and distressing impacts on clinicians, consistent with Victorian and international research.^6,10,30 Support for VAD practitioners and conscientious objectors is often inadequate.⁶ Some peer support strategies, such as VAD communities of practice, were in place during data collection for this study,¹³ and centralised organisations, such as VADANZ, established after data collection, offer promising avenues for support.¹⁴ Internationally, peer-support has been valuable³¹ and strategies such as debriefing sessions and mentoring, implemented in specific Australian institutions, are suggested by Oczkowski et al.¹²

International literature shows conscientious objectors can experience strained workplace relationships.¹⁰ Support mechanisms include staff education programs and fostering safe, non-coercive workplace cultures.^5,32 Creating respectful pathways for conscientious objectors while meeting patient needs is essential.¹²

Remuneration, training and workforce support are interconnected. Improving remuneration may influence clinicians’ willingness to undertake training, which may expand the VAD practitioner workforce and reduce pressure on the current cohort, thereby improving sustainability.

Conclusion

With VAD now legal in most Australian jurisdictions, understanding and addressing impacts on clinicians is crucial. Financial reimbursement for VAD practitioners remains inadequate and inconsistent. National harmonisation and Medicare reform may become a realistic priority. Encouraging CME-accredited and adequately funded training and including communication skills development is essential to increase the number of trained practitioners. Improved support for staff through government, institutional and individual strategies may include debriefing, mentoring, peer support and psychological consultation. Strategies addressing these impacts may help to distribute clinical workload and prevent burnout, positively influencing service sustainability.

Supplementary material

Supplementary material is available online.