Euthanasia not the Solution to Chronic Pain

Victoria’s Parliament was the scene for a powerful speech delivered by the Honourable Member for Ringwood, Ms. Dee Ryall. As a former nurse, she’s cared for many patients with chronic pain and approaching death.

In this speech, grounded in long personal experience of the care of patients nearing the end of their lives, she advocates for proper funding of palliative care services and not the passage of a deeply flawed voluntary euthanasia bill.

International experience has shown that Assisted Suicide Legislation is often accompanied by tremendous decreases in funding of palliative care services, yet they are already significantly underfunded in Victoria. Should the Voluntary Assisted Dying Bill 2017 be passed by Victoria’s Legislative Council we would likely face a similar situation here in Victoria.

Please read what Dee Ryall had to say about the Voluntary Assisted Dying Bill 2017.

The Honourable Member for Ringwood, Dee Ryall —
Speaking against the Voluntary Assisted Dying Bill 2017 

I rise to speak to the Voluntary Assisted Dying bill 2017. I am deeply troubled by the stories of pain and distress that so many have spoken of over recent weeks and here in the Parliament as this bill is debated. There have been stories of people crying out for help, crying out for relief, yet they suffered. There is no valid reason that people with a terminal illness in Victoria today should suffer. I am so alarmed that such stories exist when they need not. People suffering has been horrendous and the impact on those they love is etched within their memories forever. In today's world, in this state of Victoria, we have the knowledge, the medication, the methods of administration and the expertise of palliative care and other specialist doctors, nurses, oncologists and allied health professionals to prevent this pain and suffering.

Why have we failed them? We have failed them because we have not funded palliative care to the extent that those in need have access to it for their specific needs, be it pain, distress, fear or depression.

We have failed them, and I say sorry to all of those people and their families. We have prioritised resources for so much in our health system from birth, but we have neglected the end of life.

The Minister for Health said in her opening statement in her second-reading speech: "Far too many Victorians have suffered too much and for too long at the end of their lives."

And I agree. What I disagree with is the response to that very opening statement, which is this bill, a bill that provides for state-sanctioned suicide, rather than the solution to the problem, which is the necessary funding of palliative treatment to ensure those suffering are alleviated of this, those with terminal illness.

What has happened, I believe, is that two very different issues have melded. One is the appropriate resourcing for preventing and alleviating suffering, and the other is autonomy to end one's life. Our specialists in palliative care, oncology, palliative care nursing and other associated professions are experts in dealing with the opening statement of the minister's second-reading speech. Yet there was no full-blown inquiry into palliative care, its availability, whether it meets the World Health Organisation's definition and whether it is being resourced properly as the treatment of the problem. The message that sends the palliative care profession, I believe, is one that says, 'Your professional expertise and practice is inadequate, so the Parliament must step in and fund state-sanctioned suicide'.

However, what everyone knows and everyone who has ever had involvement with palliative care knows, is that it is grossly underfunded and under-resourced, and that is what has led to the minister's opening statement. Many people do not know about palliative care. They have never heard of it. They may never have had a need for it, or if their family member did, they may not have known it existed. Indeed, referrals are not always given, and if they are, you soon find out what I and many others found out, and which is that, while we have the best oncologists and palliative care physicians and the best palliative care nurses, they are so under-resourced that they cannot provide the services that they need to people with terminal illness. How heartbreaking that must be, to know that the services you and your colleagues are able to provide can be the difference between the terrible stories we hear and the gentle and peaceful passing that others experience. I find that incredibly heartbreaking.

The World Health Organization's definition of palliative care is as follows:

Palliative care is an approach that improves the quality of life for patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

It goes on to say:

Palliative care:

• provides relief from pain and other distressing symptoms;
• affirms life and regards dying as a normal process;
• intends neither to hasten or postpone death;
• integrates the psychological and spiritual aspects of patient care;
• offers a support system to help patients live as actively as possible until death;
• offers a support system to help the family cope during the patient's illness and in their own bereavement;
• uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
• will enhance quality of life, and may also positively influence the course of illness;
• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

As a former nurse, I have cared for people and their families at stages of terminal illness. I have supported and cared for my father, my mother-in-law and a dear friend through to their last breath and very peaceful passing. We need to properly resource palliative care so that all Victorians who need it, no matter where they live, have access to it and are referred to it as early as possible after diagnosis. That is because palliative care is as much about dealing with the fear, allaying concerns and making sure that a person's psychological state is as well looked after as their physical state as changes happen as the disease progresses. And it is as much about supporting the family through this as the patient.

My concern for doctors and nurses looking after patients when they do not have palliative care expertise or palliative care involvement in the treatment of the person is that their patient can suffer intolerably right in front of them and they are powerless to do anything about it.

Palliative care is not just general medical and nursing knowledge. It is an expert field of medicine and practice. I have seen one very shocking and distressing end-of-life video of a person suffering. I do not for a moment believe that any palliative care specialist or nurse would ever allow such suffering and distress to happen. What is intolerable is if this is being allowed to happen without appropriate medical palliative care expertise. When we find out that 10 000 Victorians are without access to palliative care, we start to understand just how big this problem is and that we have let them and their loved ones down. Palliative Care Victoria estimates that the unmet need for their services in Victoria at the end of life is a factor in 75 per cent of all deaths. That is devastating.

I have also heard the shocking accounts of suicide that have been mentioned. Can I say this: Australia and Victoria have a very tragic and devastating problem of suicide, one that cuts lives short, one that leaves loved ones and friends with the consequences — the questions about what they could have done, and the irreversible pain and loss. The descriptions of suicide by members in this debate are not limited to only those with terminal illness. I was at home with my daughter the day a neighbour committed one of the most shocking suicides. The shrieks of family members are still with me to this day. The helplessness to do anything was so profound. This person did not have a terminal illness.

When examples of suicides and the graphic details of how they are carried out are just as common in the wider community outside of end of life and are then brought forward to justify this euthanasia bill, we need to be very, very careful. The whole problem of suicide and the shocking circumstances of each one is much wider than the examples used to support this bill. Yet we have not had an inquiry into how to prevent it. When a person attempts suicide, they receive mental health assessment, support and treatment. I cared for a number of such people, including those with gunshot wounds and one who had stabbed herself so many times that she almost lost her life.

The examples used in this debate suggest that state-sanctioned suicide is the answer — not detection and prevention of depression and early intervention to deal with it and enable quality of life. Dr Jeremy Dwyer, manager, coroners prevention unit, Coroners Court of Victoria, in his contribution to the end-of-life choices inquiry, said that:

In a lot of these suicides there is a trajectory over time. It is not like something suddenly happens and they make a decision. There is this trajectory, and there are attempts to engage in treatment. It would be interesting to get some kind of review of whether earlier and different treatment might have made a difference …

So we need to be clear: this bill is about the autonomy to end one's life, not about treatment or palliation in the lead-up to the end of life. To that end I have grave concerns about this bill; in particular I have concerns for the vulnerable and the elderly. Two of the predominant factors in elder abuse are reported to be financial and psychological abuse. The opportunity of financial gain opens up very serious implications for the vulnerable and the elderly with the passing of this bill. For them such abuse can be very subtle or very extreme, and it is virtually impossible to be detected. What happens behind closed doors seldom sees the light of day, especially when the perpetrator accompanies the person to their medical appointments. For every person who is given autonomy, how many vulnerable people with no voice will have their lives cut short prematurely? What makes the rights of one person with a voice more valuable than the one who has none?

There will be statements, just like overseas — and they are repeated over here — that coercion and abuse are not a problem in this situation. That is because what goes on behind closed doors stays there and is very difficult to prove.

I am concerned about undiagnosed and untreated depression. Examples in research literature and life experience show that undiagnosed and untreated depression is prevalent in people with a terminal illness, yet no mental health assessment is required to access euthanasia. We picked it up with my father and treatment was sought. But what about those who are alone — those with depression where it is not picked up? Will they seek out euthanasia instead of receiving the treatment and support they need?

I am concerned that two doctors, neither of which are required to have any experience in palliative care, are able to sign the authority for euthanasia.

That is two doctors who are not specialists in the prevention or alleviation of both physical and psychological pain, and nor are they required to refer a patient for such assessments before approving euthanasia.

I am concerned with the 12 months to death requirement. The family was advised that my mother-in-law would likely die on a particular night and that if she did not die that night she would die within a month because of her extensive cancer. Four years later and after the birth of my daughter she passed away very peacefully. Everyone has a story about the inability to predict how long a person has to live.

Hearing words like 'most conservative' and 'safe' has so many in the medical and legal profession shaking their heads. Some of these so-called safeguards are not safeguards at all. Prosecution after the fact is not a safeguard, and the chances of proving coercion or bullying behind closed doors are virtually non-existent. The dead cannot speak, particularly after they have been given a lethal cocktail to take or they have swallowed it to escape abuse or the feeling of being a burden.

I have heard from hundreds of doctors, including oncologists, palliative care specialists, geriatricians and other medical experts, who are vehemently opposed to this bill. I have heard from palliative care nurses in my own community who are threatening to walk away if this legislation passes. I cannot support this flawed bill. We need to stop, rethink and do much better than what this bill offers vulnerable Victorians.

Learn more

• The conversation we all need to have: Advance Care Planning Australia
• All about Palliative Care: Palliative Care Australia
• Euthanasia causes real harm
• 10 Dangerous Euthanasia Myths
• What the Orthodox Church teaches on Euthanasia

This speech delivered to Victoria’s Legislative Assembly on 18 October 2017 by the Honourable Member for Ringwood, Ms Dee Ryall.