Why I’m running for the Victorian Senate

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In seventeen days it will be a year since the Andrews government passed Australia’s first state* legalising Voluntary Assisted Dying for adults who are competent, suffering, and have a life expectancy of six months or less (twelve months or less for those with neurodegenerative conditions). It comes into effect mid-June of next year – unless the state election in twelve days changes Victoria’s MP composition, as a number of parties (including the Liberal party and the Shooters and Fishers) want to overturn it before the system and processed have even been completed.

Last year I put my money where my mouth is as a project officer for the Victorian branch of the Australian Nursing and Midwifery Federation, working to get the legislation through; this month I’m working to keep the legislation intact by campaigning as a candidate for the Voluntary Euthanasia Party in the Eastern Metro region.

Ballot paper

The Voluntary Euthanasia Party has four, interrelated national policies: to campaign for the legal right for competent, dying people to choose how and when they will die, without fear or pain; to improve the status of Advanced Care Directives so they are binding, educate health staff about their use, and have completed ACDs available on a statewide database for ready access by health practitioners when required; to support improved research and funding for quality palliative care; and improve access to medical marijuana.

As everyone who knows me, follows this blog, or follows me on Twitter knows, I am passionate about a number of things, primarily around health, education, justice, and equity. These policies are all consistent with mine, and my ethical position as a casuist is also consistent with the VEP’s platform of determining positions on other matters as they arrive.

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My position on this has been consistent since high school, informed by almost thirty years as a nurse in Victoria’s acute public sector, and honed by my three post-graduate qualifications in health care ethics.

I firmly believe that Voluntary Assisted Dying should be an option only after specialist medical review, and if palliative care interventions have proven inadequate. To ensure this is not just a pleasant theory, I strongly support and have long advocated for increased funding and support for palliative care services, particularly for non-oncological conditions (like end-stage organ failure), and in regional and remote areas.

To listen to me speak about the VAD legislation, listen to this podcast of my address at the Melbourne Unitarian Peace Memorial Church last month: http://melbourneunitarian.org.au/index.php/mp3-service-podcasts/549-tara-nipe-registered-nurse-voluntary-assisted-dying

Over the next week and a half I’ll discuss my positions on alcohol and other drugs, post-secondary education, energy and the environment, the health care system (with additional entries covering the Indigenous health gap, mental health, and sexual health), social support systems, taxation, and workers rights.

* Australia’s first legislation, enacted in 1996 and overturned in 1997, was in the Northern Territory

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Assessment tips for undergraduate students

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Introduction
The following brief essay covers four sections that undergraduate students often have difficulty with when writing essays or assessments with long answers: how to tackle an assessment (Tactics), what to keep in mind when creating an essay plan (Key Concepts), how to support your argument (Referencing), and what to remember before submitting (Finishing Touches). The most important aspects of each of these sections are then listed, in point form. Though this was written with nursing and midwifery students in mind, as indicated by some examples, much of this advice is transferable to other disciplines that include essay and long answer forms of assessment.

Tactics
As soon as you can after receiving the assessment, read through it. You’re looking for several things: what kind of work is needed (a 1,000-word essay, or eight responses of around 200 words each?), what the parameters or conditions are (anything the subject coordinator brings to your attention, like not including subject headings, or requiring an introduction and conclusion), and the general scope of the project (will you be exploring a particular disease, creating and supporting a diagnostic hypothesis, or crafting an individualised plan or care?).

When you’re ready to start work on the assessment, read through the directions carefully, identifying the key requirements – this is what the marks will be allocated on, so you want to make sure what you submit addresses them. It may be helpful to summarise your requirement/s to refer to throughout the writing and reviewing process, to make sure everything you’ve written addresses the requirements of the task.

Key concepts
Whatever the content of your writing, at its heart you are creating an argument: why to administer drug X instead of drug Y; why diagnosis A fits better with the case study that diagnosis B; or how guideline S can be applied to this situation T to achieve desired outcomes U and V. When writing an academic piece, every statement and fact should be either building, illustrating, or supporting the argument you’re making – if it doesn’t do that, then it is irrelevant, and a waste of time and word count. Make sure each sentence is clear, strong, and logically leads on from and to the next, with each paragraph containing a new but related idea.

It is essential that you clearly and explicitly connect theory, or information from sources, to the requirements for your paper. This means writing things like:

Culturally safe care has been shown to increase Indigenous patients’ trust in health care institutions (reference); Bloggs’ (2017) examples of culturally-safe practices include X, Y, and Z, while staff education addressed at reflection and awareness of how our cultures affect our perspectives (reference) also contributes to health care facilities that are more welcoming to Aboriginal and/or Torres Strait Islander people. Incorporating these changes will therefore facilitate greater participation in western health care by these marginalised Australians, improving their health outcomes.

Write for a reader who is educated, but don’t assume they have any underlying knowledge of your topic. This means defining or explaining every relevant term, and ensuring that your work doesn’t contain gaps. A gap is anything that leads your reader to ask a question, and good academic writing should address potential questions before they arise. For example, the reader shouldn’t be let wondering ‘But how does implementing that intervention lead to that outcome?’ or ‘If a CT scan and an MRI can both confirm this diagnosis, are both needed? If so, why; if not, why has the writer mentioned both?’ or ‘Did I miss something in the case study about low vitamin C in the patient’s diet?’

Pay attention to any feedback you’ve received from markers, particularly for the same subject as the current assessment. Even relatively small errors (like forgetting to capitalise ‘Aboriginal’) can make a difference, yet many of my students repeated this error in a second assessment, despite being told about this in class, on line, on the assessment instructions, and in the first assessment. You can prevent this by using Spellcheck in Word, and by utilising the find/replace function at the end of your writing, to confirm that a stray ‘indigenous’ or ‘Paracetamol’ (generic, so not capitalised) hasn’t snuck into your work.

Referencing
While it can seem like an afterthought, both accurate acknowledgement of sources and correct formatting are essential components of academic writing; this significance is reflected in the allocation of marks, both within assessment rubrics and (on occasion) as a separate category, for referencing. This is because everywhere that you state a fact that comes from outside your own experience should be supported by a reference (in which case you need to make that clear, while ensuring that it’s both relevant and written in an objective way). Remember from Tactics: you are presenting an argument, and the literature you cite supports that argument or position.

Referencing well is a skill that comes with practice. Your university’s style guidelines are a start, but you may also find these examples useful:

  • If you are providing several references for one or related facts, list them in the same bracket e.g.: there are three kinds of mammals: marsupial, monotreme, and placental (Farrago et al., 2017; Hepplewhite 2018).
  • If you are listing several related facts that come from a number of references, indicate the source of each one e.g.: examples of placental mammals include cats (Bornstein, Parker, and Kenan, 2012; Pederson and Geller, 2012), dogs (Pederson and Geller, 2012; O’Sullivan et al. 2014; Aaronson 2016), elephants (Singh 2011), and dolphins (Singh, 2011; Pederson and Geller, 2012; O’Sullivan et al., 2014).
  • If you are citing multiple facts from the same source, make it clear that the author/s said all the things you’re attributing to them e.g.: Pederson and Geller (2012) hypothesise that placental mammals achieved dominance over marsupial and monotreme mammals because the longer gestational period a placenta allows gives an evolutionary advantage. They add that this means young are better able to survive the death of the mother, adding that placental mammals are ambulant at birth, while monotreme and marsupial young are still essentially foetal. Of course, humans are the exception to this independence-from-birth advantage (Singh 2011), due to “a necessary compromise between foetal head/maternal pelvic circumference on one hand, and longer dependent rearing on the other” (Singh 2011).

An easy way to ensure your references are appropriately formatted is to download EndNote (or another referencing software program); it should be available to you for free, and though it requires a little set up at first, once you’ve put in the information for each reference (including directly importing them from online sources), it will insert in-text and listed references, with every one in the required format.

Finally, make sure your reference list is alphabetised. You can do this by highlighting the entire list, then hitting the A-Z↓ icon, which is about half way along the control bar when Word is in home mode; this will automatically alphabetise your list, provided you have a new line between each entry.

Finishing touches
When you’ve completed your work, and if you have time, put it aside for a few hours, to give yourself some distance from what you’ve written. Then read it aloud, slowly, or ask someone who doesn’t know the subject matter as well as you do, to do it for you, as they’ll pick up problems you may overlook because you know what you meant to write.

You’re listening for grammatical errors (e.g. ‘is’ where you should have written ‘are’), spelling mistakes (e.g. ‘separate’ instead of ‘separate’) and typos (e.g. ‘on’ instead of ‘in’), and signals for punctuation (a small pause indicates a comma, a longer pause a full stop, and a change of topic often means a new paragraph). Most importantly, you’re also checking for gaps in your work (see Key Concepts) and making sure that your writing is consistently academic in tone.

Take home points

    • Start preliminary thinking about the assessment as soon as you receive it
    • Identify the assessment requirements, and write to them
    • Remember that you’re making an argument: everything you include must support or advance your case
    • Make sure your formatting and referencing meet the instructions given and your department’s requirements
    • Everything that comes from anywhere but your own experience must be referenced
    • Take the time to review your work before submission

Conclusion
This short essay has outlines strategies that, if followed, will allow students to both achieve higher marks on their submission, and develop a stronger relationship with the subject material they’re working with. The key areas covered were tactics, key concepts, the importance of referencing, and finishing touches; these were then summarised in a list of take-home points. As this is not an academic work, there is no reference list, and not all references, formatting, or language are consistent with tertiary-level expectations for academic writing.

On the matter of privilege

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In the last 72 (or so) hours I’ve had six conversations about privilege. Each time I’ve been annoyed that whichever academic articulated the truth that attributes over which we have little or no control play a significant role in how we are perceived and how much (or little) we have to overcome didn’t choose a more palatable word to describe it.

Here are some of my privileges:

• I’m white, in a country and a dominant culture that prize caucasoid heritage and appearance

• I have been able-bodied for all but a small percentage of my life

• my parents were married and lived together throughout my childhood and adolescence

• my father was employed the entire time I was dependent on him

• I grew up never knowing food scarcity, and never worrying about a roof over my head

• my parents prized education, and read to me from birth

• I am intelligent and literate

• I am cis-gender

• I am middle-class and well-spoken

• I did not grow up at risk of or exposed to crime or illicit drugs

These privileges, which I had no input into and cannot take credit for, do not mean my life has been a cake walk, or that I haven’t worked hard for where I am now. They do mean that I had, and have, things easier that someone else who, all other things being equal, didn’t have those unearned advantages.

Acknowledging my privilege doesn’t mean denying or ignoring aspects of myself or my life that were disadvantageous. I experienced abuse; was raised by an alcoholic and a narcissist; spent much of my teens, all of my twenties, and some of my thirties with an eating disorder that’s now in remission; I am female, fat, and queer in a country and a culture that repudiates these to various degrees.

These and other aspects of who I am and what I’ve experienced don’t cancel out my privilege.

We live in a society that prioritises straight, white, cis, able-bodied, wealthy men. The more closely one fits that ideal, the more credit one is given – to be more readily heard, believed, perceived as honest/intelligent/promotable; the further away one is, the more likely one is to be ignored, mistrusted, arrested, convicted, attacked.

This doesn’t mean every straight, white, cis, able-bodied man has been handed life on a plate, has experienced no hardship, or lives a life of luxury.

It means that being aware of fortune makes us more compassionate. Noticing the distance we have to travel compared to those with less congenital luck makes us more likely to extend a hand to those with further journeys. Seeing systemic injustice makes us work to level out what we can, to increase fairness, equity, the proverbial fair go Australia prides itself on.

Surely there’s nothing so threatening in that?

Victoria’s Voluntary Assisted Dying Bill – it’s hanging in the balance (and I kinda know how it feels)

A shared post by Victorian Nia Sims, whose father died in distress despite palliative care involvement, and who writes from the perspective of both witnessing this and having scleroderma, a rare autoimmune disease that may result in her applying for voluntary assisted dying herself.

via Victoria’s Voluntary Assisted Dying Bill – it’s hanging in the balance (and I kinda know how it feels)

What do AMA members really think about voluntary assisted dying?

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In my previous post I wrote about why we (including the media) should pay less attention to the pronouncements of the AMA on voluntary assisted dying, and instead look at organisations that better represent the population/s for which they speak. While there’s a general belief that the AMA represents most, or at least many, doctors, that’s far from true. Even taking that into account, however, the AMA’s stated position on behalf of its members isn’t as representative as it appears.

In 2015, the AMA (Federal) announced that it would review its policy on ‘euthanasia and doctor-assisted suicide’ , which had previously been unremittingly negative – a position that had, in turn, affected the willingness of politicians and the public alike to support various incarnations of assisted dying legislation. The review process, which concluded in 2016, included an online survey in which 3700 members participated. The conclusion? The AMA continues to oppose any legislation around assisted dying, but wants its members involved should such legislation come to pass.

A logical assumption from this is that the majority of AMA members, if not Australian doctors in toto, oppose voluntary assisted dying. But Neil Francis of Dying for Choice analysed the review process, in a fascinating report titled AMA Uncovered,  in which he examines design flaws that encouraged desired responses, on the analysis of results, and on the way the survey was selectively publicized to justify the policy. The full report runs to 50 pages, but I’ve summarised what I see as the key aspects to take into account when assessing the AMA’s ‘revised’ position.

Doctors often underestimate the severity of patient symptoms but want significantly less medical end-of-life care for themselves. Nearly nine out of ten USA doctors would not want intensive end-of-life treatment they provide to others. Yet patient death, despite its inevitability, is often regarded by doctors as a ‘failure’ of medicine, with many still uneasy even about withholding and withdrawing life-preserving interventions. – p.15

There are three main areas to appreciate about the original report, as unpacked by Francis.

First, the data comes from an opt-in survey that captured just over 3,700 AMA-affiliated doctors; as the AMA represents just under 30% of Australian medical practitioners, respondents to the survey represent 12% of AMA membership, and only 3.6% of Australian doctors.

What the methodology variations suggest is deeply-entrenched hostility towards assisted dying that has flowed through to substantial biases is the survey design. These in turn will result in significantly more negative responses toward assisted dying in later questions than if the AMA’s policy had been revealed later in the questionnaire, after doctors had been asked their attitudes about various facets of assisted dying. – p. 21

Second, the survey is multiply flawed, a fact that was brought to the AMA Executive’s attention and dismissed.  The most important of these flaws are briefly listed below:

  • the way questions are worded means responses are less likely to be genuine reflections of respondents’ beliefs and more likely to be weighted toward an anti-assisted dying response (see p. 16 of the critique for specific analysis)
  • the survey omits suffering or intolerable pain from its definition of euthanasia/assisted dying
  • the survey definition of euthanasia/assisted dying includes neither voluntariness or competence, both of which are key requirements
  • some established life-limiting practices (withholding/withdrawing treatment, the doctrine of double effect) are defined as separate to euthanasia/assisted dying
  • the introductory statements prime participants to lean towards then-current, anti-euthanasia/assisted dying policy
  • multiple questions presuppose a response in the framing of the question (e.g. “Do you agree…” or “To what extent do you agree…”
  • the first two questions separate ‘good medical practice’ and ‘clinically appropriate’ treatment when they’re dependent components of appropriate professional practice
  • similar, often successive, questions are differently constructed for no apparent reason
  • at least one question rolls two aspects of euthanasia/assisted dying together: being compelled to participate in the practice and (if unwilling) being compelled to refer a patient to another practitioner
  • Third, despite these significant methodological flaws, Francis notes these outcomes, which don’t correlate with the AMA’s ‘revised’ position:

  • 68% of respondents agreed suffering can’t always be relieved with even optimal palliative care
  • 60% want doctors to perform lawful assisted dying (i.e. be involved if it’s legislated)
  • just over half of those (32% of respondents) were prepared to be involved
  • 52% said this is a legitimate intervention
  • 50% disagreed with the AMA policy against E/AD “under any circumstances”
  • over half of 20-29 year old respondents agree with euthanasia/assisted dying, compared with a third of those 70+
  • when a question was reframed to ask about legalized euthanasia/assisted dying, approval rates jumped, indicating some resistance is because of illegality, not the act itself
  • 35% of respondents thought euthanasia/assisted dying should be lawful
  • A couple of additional notes:

  • Swiss, Dutch, and Belgian populations rank in the top 3 when it comes to trust in doctors (Aus is tenth); they have AD laws
  • the AMA has published and not corrected information about E/AD that they know is false, including that palliative care deteriorated in Belgium; the opposite is true
  • despite claims by many opponents, including AMA President Dr. Gannon, there has been no slippery slope targeting minors, incompetent people, or the vulnerable, in any jurisdiction (see pp. 31-32)
  • an overwhelming majority of Australian doctors (SA: 89%, Vic 93%, NSW: 96%) believe patient suicide can be rational

 

Many Australian doctors don’t believe that the law is as important as medical and family consensus when making such decisions, and are inclined to ignore the law anyhow. – p. 19

Finally, and worryingly, it seems as though much of the opposition to or concern about this legislation is that a sizeable proportion of doctors don’t want this practice legalized. From the report, Francis notes that:

  • complementary research demonstrates 25% of Aus MDs support E/AD but don’t want it regulated/performed with oversight!
  • a significant proportion of doctors already deliberately assist patients to die, with neither protection of law nor, necessarily, patient consent
  •  

    In a 2006 study “25% doctors were not opposed to euthanasia itself yet were opposed to its legalisation. In other words, a quarter of doctors thought ‘private’ euthanasia practice acceptable, but didn’t want the practice legalised.” The researchers said this was “in significant part due to ‘the resistance of doctors to further intrusion by the law and bureaucracy on their clinical and professional autonomy.’” – p. 25

    I leave you with this observation by Francis, which should be particularly alarming for all of us (including opponents to voluntary assisted dying) who champion voluntariness, competence, and consent:

    Francis 1Francis, p. 39

    Medical support for voluntary assisted dying

    Much has been made of the AMA’s divided stances on voluntary assisted dying: while the Federal Association seems somewhat united, both past and present (the Federal president and three former Federal Presidents) have strongly come out against voluntary assisted dying.

    On another the Victorian AMA President has both pushed back against this, and released a non-committal statement that neither supports nor opposes the Bill.

    The AMA represents some 28,400 practicing Australian doctors, of some 66,660 registered medical practitioners and, as I’ll discuss in the next post, the official position does not so much represent the plurality, or even majority, of those members it has.

    In contrast, the Royal Australian College of General Practitioners has over 35,000 members (making it “Australia’s largest professional general practice organisation”) and has come out in full support of the legislation:

    (Source)

    In addition, almost 80% of the Australian Medical Student Association support the Bill, demonstrating that the next generation of doctors appreciate the autonomy of patients whose dying suffering can’t be eased.

    View from the ‘accessible’ section: Victoria’s delirious, heartening euthanasia vote

    Nia has a highly informed perspective – an experienced nurse, she watched the protracted death of her father with cerebral cancer (recreated by Go Gentle in Stop The Horror), and is living with and dying from the autoimmune connective tissue disease scleroderma. For her, voluntary assisted dying is not hypothetical or professional but as personal as it gets.

    Nia Sims

    Image: View from a red velvet couch, Parliament House library, 6am, Friday 20.10.17

    First published – Crikey.com, 23.10.17

    By the wee hours of Friday morning, the mood in the house was slightly delirious. My friend, colleague and registered nurse Jane Morris and many others cried when the vote on voluntary assisted dying, 47-37, was finally declared to a packed house at 11am after a record 22 hour sitting in Victorian Parliament. It was met with a weary but fulsome round of applause from most in attendance.

    My vantage point from the “accessible” section of the public gallery was one of the few perks of being, as far as I know, the only visibly seriously physically sick or disabled person to attend the sitting. I could see the entire public gallery, press gallery, and members to the right of the speaker. If I craned my neck forward, I could watch the…

    View original post 694 more words

    Dear palliative care nurses

    I take pride in the calibre of nursing I provide – I’m good at what I do, thanks to a combination of aptitude, experience, education, compassion, intellect, and reflective practice.

    So I understand why many palliative care nurses are upset, offended, angered, and otherwise unhappy about the voluntary assisted dying movement in general, and Go Gentle’s Stop The Horror film in particular – it seems to say that palliative care isn’t good enough, that too many people suffer at the end of life, that patients and families can’t trust their expertise, and that their expert, skilled, informed care isn’t valued or valuable.

    I’m sorry that this is how the push for VAD is perceived. It’s not the belief held by anyone I’ve communicated with; without exception, their position is the same as mine – quality palliative care is the best, more effective, most appropriate intervention for the overwhelming majority of dying patients; we need to improve access to and funding for palliative care; and there are a small number of cases (industry estimates vary from 2-4% of patients) where symptom management is ineffective or inadequate, despite the best interventions available. These are the patients for whom another option is appropriate.

    Acknowledging that there is still room for improvement is part of reflective professionalism and best practice. Responding to first-hand experiences of colleagues and family members with, “That wasn’t good palliative care!” is defensive and unhelpful – it means their experience is dismissed, along with a learning opportunity. Often that’s right – there were gaps in care, or in knowledge, or prescribing, or in anticipating how rapidly the patient’s dying trajectory would escalate.

    And sometimes the person received the very best care possible, but their intractable nausea, terminal dyspnoea, restlessness and agitation, seizures, neurological pain, or distress couldn’t be resolved. That happens. It really does. Not often, but not never.

    Transplanted organs reject. Antibiotics don’t succeed. Wounds don’t heal. Surgery is unsuccessful. Hypertension doesn’t resolve. Asthma doesn’t respond. Intubation isn’t enough. Labile BGL’s don’t stabilise. DIC runs rampant. HBO is ineffective. Chemotherapy fails. Autoimmune diseases rampage. HIV progresses. The flu kills.

    Mostly we win the battle, if not the war; we never win the war – eventually, all our patients die. But whatever our specialty, we’re never effective all of the time. We’re just not. And that’s as true for those who midwife death as it is for those who work to defeat it.

    Acknowledging that doesn’t invalidate our work, our value, our effectiveness, our professionalism, or the difference we make. It just means that we still have room for better.

    I hope we’ll one day have no need for voluntary assisted dying – that nobody will suffer, and that all anticipated deaths are gentle. We’re not there yet, and it’s cruel to deny peace to those we can’t help enough.

    7.30 – a response

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    Last night, ABC’s 7.30 aired stories on two contentious issues that I support – marriage equality and voluntary assisted dying. It is the later I’ll address today, and starts at the 8-minute mark.

    http://iview.abc.net.au/programs/7-30/NC1705H141S00

    There were a couple of issues – first of all, Ms. Sales repeatedly refers to voluntary assisted suicide as “euthanasia;” the legislation soon to be introduced to parliament does not, except in exceptional circumstances, require or even allow physicians to administer the medication.

    Second, the statistic of less than half of doctors supporting it comes from the AMA, which represents around 30% of Australian doctors, not even a majority of them. That said, I strongly suspect approval rates of assisted dying are very much lower in this group than in the general population.

    I agree with Dr. Kaminsky that her “profession very much places an emphasis on ‘death equals failure,’ because our whole edict is to cure, to save life” – I’ve witnessed first-hand the distressing effects on patients, family members, nurses, and doctors themselves when they can’t accept the inevitability of death. It’s often said that doctors cure and nurses care, which I think does a disservice to to both our professions, and the impact of this inaccurate, divisive binary is worse for my medical colleagues. Doctors care, too, and they have an important role to play at the end of life, as is evident by the specialties of gerontology, general practice, and palliative care.

    The problem is that Dr. Kaminsky is not distinguishing here between people who could be cured but aren’t being treated, and people who are inexorably, imminently, irreversibly approaching death – there is no saving available for them, only prolonging. And this ethos places the doctor at the centre of the situation, not the patient.

    I wholly agree with Dr. Gold, with whom I’ve previously worked, that deliberately causing someone’s death would feel very uncomfortable. Even providing the means for a patient to do so themselves, even when they themselves have assessed that the person is choosing this, is competent, is dying, and is suffering, I do not imagine it will be easy. That in itself is one of the strongest, least slippery safeguards we have – doctors, like nurses, did not enter their profession to bring death, even to willing, eligible, pleading people; they study and work to make peoples’ lives better. It’s what ensures that applicants in Oregon are more often directed to other measures, including better palliative care interventions, than are prescribed medication to help them die.

    Justine Martin, the multiply-unfortunate woman with MS, CLL, and SLL, articulates the desires of many people who have seen loved ones die badly: “I don’t want to end my life at the moment, but I want to know that if and when the time comes, that I will definitely have a choice.”

    I agree with Michelle when she says that assisted dying can only be a real choice if excellent, expert palliative care is available. In addition to the Andrews’ government’s palliative care plan announced in 2016, palliative care services (from funding and resources to education and access) improve when assisted dying legislation is introduced, for that very reason – patients are better and more comprehensively assessed, and alternatives to assisted dying explored, including additional refersals to specialists and services.

    And she’s right that coercion presents a genuine risk of influencing decision-making – which is why, as Dr. Carr points out, this legislation provides more safeguards for the vulnerable that they currently have. Assessing applicants, ensuring their requests are genuine, consistent, and uncoerced, will be a major part of the coordinator and consultant roles for doctors under the legislation, and of the legislation doctors will be mandated to undertake before playing any part in the process.

    I fear that Dr. Kaminsky has not reviewed the advisory panel’s final report, because the concerns she raises are comprehensively addressed, from up-skilling doctors (a contributing factor in the 18-month period between the Bill passing both houses, and the Act going into effect), to how the medication is to be stored and who is responsible for returning it to the dispensing pharmacist if unused. There is more danger of unused narcotics “falling into the hands of a child” than a bitter liquid in a locked metal box, particularly as MS Contin and OxyContin are small and brightly coloured, Fentanyl patches can look like stickers or bandaids, and morphine mixture is sweet.

    This is not an easy or straightforward issue. It shouldn’t be – it’s too nuanced, too important, and too open to misuse and error if not rigorously and robustly constructed. The Bill proposed in Victoria is tighter than any anywhere else in the world, incorporating the safeguards used in North America and Europe, in addition to measures unique to this legislation.

    23/8/17 09:40
    Edited to add: in a brief exchange on Twitter, Leah Kaminsky reported that she’d been quoted out of context, and has written a book about the realities of facing death; I have a copy on my teetering To Be Read pile – it looks particularly light-hearted and reassuring, given the subject matter, so I was a little surprised.
    The ABC has a second item about the positions of the same three Victorian doctors, for those who are interested in a little more on this: http://www.abc.net.au/news/2017-08-21/doctors-divided-over-voluntary-assisted-dying-legislation/8827204

    Caring at the end of life

    A guest post by Victorian nurse Elisabeth Hall, who has changed identifying features about this patient whose dying, she says, is not atypical of her nursing experience.

    I walk quickly, efficiently down the corridor, checking the six patients in my care this evening.

    My lady in 24’s still with us. Drifting in and out of consciousness, her mouth hanging wide open revealing naked, pale gums, her dentures have been soaking in a plastic container on the bedside table for the last few weeks. It’s been a while since she could chew, and anything thinner than honey will slide into her lungs. All she can tolerate now are teaspoons of water mixed with thickened and, on good days, finely crushed tablets mixed with strawberry jam.

    I wipe the corners of her dry lips clean of the white crusts remnants from the last time she tried to swallow some medication, reminders of how little dignity she has left; so little autonomy she can no longer dab her mouth with the monogrammed linen hanky she used to tuck up her sleeve, long since relegated to a bedside drawer, by the clothes she wore when she could still choose, and the large print mysteries she once used to escape the hospital.

    At least she looks peaceful for the moment. Last night I gave her all of her prescribed ‘as needed’ morphine and midazolam, and still she cried out for her mum, long gone from this 90 year old woman’s life, to help relieve her pain.

    Her bed has been lowered to the ground, with a mat on the floor beside it, just in case she falls while she’s trying desperately to find a position that is, if not comfortable, at least bearable.

    I check on her often, gently changing her position, moistening her dry mouth with damp cotton swabs and minty lip balm, cleaning her frail body in stages so it doesn’t exhaust her. Jutting bones lie beneath parchment soft skin that I assess for signs of pressure injury, as I talk to her about what I’m doing, and the setting sun only I see through the curtained window.

    I don’t know if she can hear me any more. Before she was so far along, when she asked me to please help her die, she told me she would have no visitors, had outlived most of her relatives and friends, had no children of her own.

    Her wasted muscles are rigid, and she moans when I move her. Her face shows the pain, the discomfort and the utter aloneness that has dragged on for so long.

    When my shift finally slows down, I go in and sit in the dark on the mat next to her. I hold her cold, gnarled hands and talk to her quietly, trying to soothe her; this intimate moment feels like a single drop of comfort in an ocean of unrelenting suffering.

    I pump hospital-stock moisturiser and massage her hands, comb her shock of white hair. Her breathing is uncomfortable to watch but I’m certain it’s much more uncomfortable to experience.

    This woman, with her brow furrowed in mostly quiet suffering, is a palliative care patient. She has been cared for by nurses, visited by doctors, ministered to by a chaplain. They have all done what they can to ease her pain, her breathlessness and her distress. We do our best to care for her, but cannot release her and end her terminal suffering.

    All we can do is wait, watch her deteriorate and hope we never have to see a loved one in the same situation, swear to ourselves that we’ll find a way to end it if it ever happens to us.

    We go home, make our family or friends promise them that they’ll help if we ever end up in such a way. We go to bed at night and replay our shift, cry quietly to ourselves, feeling both silly and useless. This isn’t even one of the awful ones.

    Many of us will think of assisted dying, and hope that one day the laws will have changed so that we can help other patients end their journey on their own terms, without pain and with their dignity. With someone holding their hands, in the place of their choosing, and with relief in their heart.