What psychologists should know about voluntary assisted dying

Voluntary assisted dying became legal in Victoria in June 2019 after much debate and social change (O’Connor et al., 2018). This could be closely followed by Western Australia and Queensland, whose governments are currently considering similar laws.

As a discipline, psychology’s role in end-of-life care is developing (Breen & Ugalde, 2017). The APS has demonstrated considerable leadership in this space. In anticipating the moves toward potential legalisation of voluntary assisted dying, the APS Public Interest Advisory Group identified end-of-life care and choices as a priority area for 2017–18. In October 2017, the APS National Office hosted the APS End-of-Life Care and Choices Roundtable to start the conversations needed for psychologists to participate fully in considering the implications and potential roles for psychologists should voluntary assisted dying become legal.

Since then, the APS has provided written submissions to Queensland and ACT parliamentary inquiries and reviewed draft training for medical practitioners developed by the Australian Centre for Health Law Research. In terms of CPD offerings, the APS Institute hosted a webinar on voluntary assisted dying, there was a symposium titled, ‘End-of-life care and choices: Roles for psychologists’ at the 2018 APS Congress, and APS members contributed to Palliative Care Australia’s process of developing guiding principles for the palliative care sector in light of the introduction of voluntary assisted dying.

Palliative care is the most well-developed approach to care for those with a life-limiting illness. It is multidisciplinary and provides holistic support to people with terminal illnesses, for their families throughout the illness and for family and carers following bereavement. Traditionally palliative care services did not include psychologists but with the increased evidence-based interventions psychologists are now core to the delivery of best practice end-of-life care. Articles on the role of psychologists in palliative care appeared in the April and June editions of InPsych.

There is research showing palliative care increases people’s quality of life, decreases their symptoms and potentially increases length of survival (Temel et al., 2017). Unfortunately, the promotion of palliative care is sorely needed because there is Australian research showing that some patients and carers think palliative care offers diminished care and weakens possibilities and choices (Collins et al., 2017).

Psychology and voluntary assisted dying

It is important that psychologists identify their own personal attitudes and values towards voluntary assisted dying. Many health professionals are uncertain about their stance on voluntary assisted dying (e.g., Yoong, Franco, William, & Poon, 2018). However, identifying as a conscientious objector, a conscientious supporter, or conscientiously neutral can support professional practice (even if not stated publically). Wherever psychologists position themselves on this spectrum, there are a number of potential roles available to them.

In jurisdictions where voluntary assisted dying is legal, psychologists have a role to support terminally ill clients who request, or plan to request, voluntary assisted dying. It is important to acknowledge and respect that people’s decisions about voluntary assisted dying are rarely taken lightly, and rather, have involved a considered process over a long time. It may or may not be appropriate to explore their reasons and options, and work through the questions that a voluntary assisted dying request could raise. Psychologists could be involved in potentially assessing decision-making capacity and the presence of mental illness and other issues that could affect a client’s decision-making. They would be liaising potentially with the medical team or the psychiatrist or whoever is involved, and they would be supporting clients and family members throughout the process to maximise options and promote choices so that voluntary assisted dying is never a default option in lieu of true choice.

“In jurisdictions where voluntary assisted dying is legal, psychologists have a role to support terminally ill clients who request, or plan to request, voluntary assisted dying”

Psychologists could be involved in supporting family and friends of people who request and complete a voluntary assisted dying death. One study showed that family members are often unprepared for the possibility of adverse events or complications and may find themselves on “uncertain legal, emotional, and moral grounds” (Starks, et al., 2007, p. 127). Following bereavement, studies in jurisdictions where assisted dying is legal show that families bereaved in this way report positive experiences (Buchbinder, Ojo, Knio, & Brassfield, 2018) and they do not face an increased risk of symptoms of grief, post-traumatic stress, or depression (Ganzini, Goy, Dobscha, & Prigerson, 2009; Swarte, van der Lee, van der Bom, van der Bout, & Heintz, 2003).

However, a recurring theme in the relatively small number of studies in this area is that bereaved people express concern over the potential for social disapproval and social stigma because of the manner of death (e.g., Gamondi, Pott, Forbes, & Payne, 2013). Engagement in secrecy management could lead to receiving less social support, which could exacerbate their grief (Wagner, Keller, Knaevelsrud, & Maercker, 2011). As Gamondi, Pott, Preston and Payne (2018) noted, “most participants felt unable to share their story after the death, this appeared to be due largely to fears of people’s possible reactions and of feeling judged” (p. 1090).

Irrespective of the legal status of voluntary assisted dying, and psychologists’ own position on it, an additional role for psychologists may include advocating for greater access to palliative care. Palliative care is not often available to all people who might benefit from it and psychologists should play a role in advocating for more palliative care funding. A 2012 Senate review highlighted the “variance in the standard and quality of palliative care” across Australia (Community Affairs References Committee, 2012, p. 18). Similar criticism has been made in subsequent years. These state of affairs prompted Stephen Duckett, the Director of the Health Program at the Grattan Institute, to write, “while assisted dying is contentious, access to palliative care should not be” (Duckett, 2017, para. 2).

Implications for psychologists

There are several issues voluntary assisted dying legislation will likely raise and that psychologists might encounter in their practice. First, there is the distinction between decision-making capacity to request voluntary assisted dying and the right to request it. It is possible for a client to have decision-making capacity but not the right to request voluntary assisted dying, as well as the right to request voluntary assisted dying but not decision-making capacity.

Dementia is the best example of this distinction – a person with early dementia is likely to have decision-making capacity but would not be eligible for voluntary assisted dying, because the death is not expected within the requisite time period of six to 12 months; however, when the same person has the right to request it they would no longer have decision-making capacity. The essential need to have both the right and capacity to choose voluntary assisted dying is important because many people with dementia or complex, serious illnesses who might think voluntary assisted dying could be an option available to them might need psychological assistance to deal with not having the right to request it.

Under the Voluntary Assisted Dying Act 2017 when a patient makes a request for voluntary assisted dying and their medical practitioner is unable to determine whether their patient has decision-making capacity, they must refer them to a registered health practitioner (which includes psychologists) with appropriate skills or training for a specialist opinion. Psychologists accepting referrals should ensure they are competent to do so and are familiar with the validated tools to guide such assessments (Victoria State Government, 2019). Determining capacity is complicated, because people with life-limiting and terminal illnesses may experience psychological impairment, which may be longstanding or a consequence of their illnesses, and/or cognitive decline due to ageing, disease or medication (Allan & Allan, 2019).

When considering their personal values about voluntary assisted dying, and weighing them up against their client’s perspective, psychologists should seek relevant training. Psychologists who conscientiously object to being involved in voluntary assisted dying are encouraged to refer clients on as appropriate. If psychologists choose to conscientiously object, they might still find that in some circumstances they are ethically obliged to provide support. Consider a psychologist who is seeing a client with issues completely unrelated to voluntary assisted dying, and then the client is diagnosed with a terminal illness.

After working with this client and assisting them to cope with this diagnosis, the client expresses an interest in voluntary assisted dying. Although it is completely within the psychologist’s rights to conscientiously object, the psychologist must do so in a way that ensures appropriate services to the client continue (see APS Code of Ethics Sections B.11 and B.9). These issues of non-abandonment are being considered very thoughtfully by Palliative Care Australia and are addressed in their recently released guiding principles concerning voluntary assisted dying (Palliative Care Australia, 2019).

Psychologists may also be asked by their clients about voluntary assisted dying, and it will be important for them to know how to work within the limits of the law. Psychologists in Victoria must be mindful that health professionals are expressly prohibited by the Act from raising the topic of voluntary assisted dying with their clients. However, if a client asks about voluntary assisted dying, whether eligible or ineligible, psychologists could have an important role in exploring their reasons and options and work through the questions that a voluntary assisted dying request could raise.

Currently, there is no ethical guideline to assist psychologists who work within a context where voluntary assisted dying is legal. Development of such a guideline would be valuable, particularly to highlight relevant issues such as working within the bounds of competence, complying with legislation, and being aware of your own personal attitudes and values.

Other potential implications include supporting people who reside in a jurisdiction where voluntary assisted dying is illegal, or clients whose applications of voluntary assisted dying have been denied; supporting staff (both conscientious supporters and objectors), as well as those staff who don’t have the right to conscientiously object (e.g., volunteers, care workers, and others who are not health practitioners in the legislation). It is important to know that Victoria is not establishing a ‘right’ to voluntary assisted dying. This means there will not be universal access, and people cannot demand voluntary assisted dying.

Furthermore, access to voluntary assisted dying will depend on the availability and willingness of participating health services and medical practitioners. Organisations have the right to conscientiously object to providing voluntary assisted dying services, which means that employees (including psychologists), regardless of their personal values and position, will need to be aware of relevant organisational policies should a person make a request.

Future directions

Voluntary assisted dying is a new terrain of potential practice in Australia with specific learning needs and competencies and ethical issues for practitioners who choose to work in the area. This is why the APS is taking a proactive approach to promoting relevant knowledge and skills. Psychologists practising in Victoria do so in a context within which voluntary assisted dying is legal. Other jurisdictions might soon legalise their version of voluntary assisted dying (White & Willmott, 2018), with psychologists in those areas having to adapt to the legislative requirements on a state-by-state basis. Other psychologists elsewhere in Australia practise in jurisdictions where there is no legal right to hasten one’s death.

The APS Code of Ethics (the Code) may not help psychologists resolve the complex issues they might face when working with clients who may request voluntary assisted dying (Allan & Allan, 2019). Psychological practice would be best supported by the development of ethical guidelines to complement the Code. Just like other areas of practice, engaging in education and training, peer support, self-care, consultation, and supervision with senior colleagues is essential.

The first author can be contacted at [email protected]