The cyclical peaks in discussion around the pros and cons of euthanasia laws around the country have been marked by the predictable, the passionate, and the intensely personal. As it should be, for the ideas around our own dying, and the myriad experiences surrounding the death of family members and friends, are powerful in a society that largely avoids the topic of death. It is unfortunate then that it is only around this “debate” that this discussion seems to occur, for as emotive and compelling as it may seem, euthanasia is a very small part of the wider end of life care discussion that goes unexplored.
Advocates of euthanasia create certain impressions with their arguments that need to be examined if a common language is to be used in any end of life care discussion. In talking about overseas examples both physician assisted suicide (Oregon) and voluntary active euthanasia (The Netherlands) are spoken about as being the same. While the result is similar, the party administering the final medication is significantly different – the individual themselves in one, an external third party in the other. These models need to be kept distinct in this discussion.
Proponents often welcome examples from across a range of health conditions to lend weight to their position, yet neither of the above two models would apply for persons with advanced dementia who have lost the capacity to give consent to such an action. With Dementia now the third leading cause of death in Australia how will this group best be helped during their end of life phase? This touches on the issue of who will use any possible future euthanasia or physician assisted suicide law. Many proponents acknowledge that it is often about having the option (for themselves) that matters, that a "right to die" principle is paramount. In the Netherlands the number of persons who used the euthanasia option in 2010 was less than 3% of all deaths. In Oregon in 2009 the percentage of persons who died under that model was less than 0.2%.
The euthanasia debate often finds Palliative Care cast in the role of the alternative strategy, and this is not how many Palliative Care clinicians see themselves. A range of views can be found in this group as in the wider community, though the majority of these professionals, who encounter death often daily and who seek to make it as comfortable as possible, remain concerned about legalisation of voluntary euthanasia for a host of reasons. It is inappropriate for proponents of euthanasia laws to cast those with a different view merely as religious ideologues. Many palliative care clinicians opposing these laws do so based on their long experience of caring for the dying, and the complexities they have witnessed, rather than any religious world view.
In saying that the euthanasia debate is a limited end of life care debate I would in no way disregard or diminish the views of those on both sides who participate. The "debate" is a distraction as it hides the question of who will best care for the estimated 31,000 persons in NSW who will have an anticipated death this year, and the next and the next. The intensity of the euthanasia discussion is inversely proportional to the general level of discussion about end of life care as it would apply to the 30,000 plus persons who, based on the Netherlands figure would not follow (or be able to choose) a euthanasia option.
However, this debate is valuable in that it provides a moment when the true state of Palliative and end of life care services might be made visible. NSW has under invested in palliative care services for decades. Last year’s report into Palliative Care in Australia by the AIHW shows NSW to have the lowest ratio to population of Palliative Care Physicians of the mainland states; the third lowest ratio of palliative care nurses (after Queensland and the ACT), and has had a 14% decrease in palliative care units in public hospitals. Palliative Care services have never had their historical cancer funding model amended to support the up to 35% growth in demand for palliative care support from persons dying from non-cancer conditions other than AIDS. Palliative Care NSW estimates that at least $25 million additional dollars annually are required to address these gaps and to permit specialist palliative care service to play their appropriate end of life care role in this state. If additional palliative care beds are required that figure jumps accordingly.
My plea is this. After this round of euthanasia law discussion and activity has settled don’t walk away. Regardless of your view, bring some energy and attention to the palliative and end of life care services that need to be available for all of our dying population. If the quality of care at the end of life matters to you, agitate for better palliative and end of life care for all, whether they die at home, in a hospital, a hospice or an aged care facility. NSW has much ground to make up.