Voluntary Assisted Dying activity (Voluntary Assisted Dying Board Annual Report 2022-23)

Under Section 124 of the Act, the Voluntary Assisted Dying Review Board collects and reports on voluntary assisted dying statistics in South Australia.

Data is collected through the submission of forms and information to the Voluntary Assisted Dying Clinical Portal by Medical Practitioners, Pharmacists, Care Navigators, VAD Liaisons and the Voluntary Assisted Dying Review Board Secretariat at each stage of the 11 step voluntary assisted dying pathway:

1. Make a first request for voluntary assisted dying
   
2. Doctor completes a first assessment
3. A consulting doctor completes a second assessment
4. Complete a written declaration to access voluntary assisted dying
5. Make a final request for voluntary assisted dying
6. Choose a contact person
7. Doctor completes a final review
8. Doctor prescribes substance once permit approved
9. Arrange supply of substance with pharmacist
10. Decide to administer substance
11. Death certification

Make a first request for voluntary assisted dying

The first step in the voluntary assisted dying pathway is when a person makes a first request to their medical practitioner.

First requests

Between 31 January and 30 June 2023, a total of 116 people made a valid first request for voluntary assisted dying submitted to the Voluntary Assisted Dying Clinical Portal. Of these, 115 people had their first request accepted by an eligible medical practitioner and 1 person had their first request refused.

A medical practitioner is not required to provide a reason for declining a first request and a refusal does not relate to the persons eligibility for voluntary assisted dying. Reasons for a practitioner refusing a first request can include the practitioner:

• not meeting the minimum requirements to act as a voluntary assisted dying medical practitioner
• not having undertaken or not planning to undertake the mandatory practitioner training
• having a conscientious objection to voluntary assisted dying; or
• not having the time required to support a patient through the pathway.

A person who had a first request refused may make another first request.

Doctor completes a first assessment

Once a person has had their first request accepted by a participating medical practitioner, that practitioner becomes the Coordinating Practitioner for the patient. The Coordinating Practitioner must undertake a first assessment to determine whether the person meets the eligibility criteria for voluntary assisted dying as defined under section 26 of the Act.

First assessments

Of the 115 people who had a first request to access voluntary assisted dying accepted, 109 underwent a first assessment. Reasons for not proceeding from a first request to a first assessment include deciding to withdraw from the pathway or dying prior to the first assessment. Of the 109 people who had a first assessment, 101 were assessed as eligible for voluntary assisted dying after the first assessment.

If a person has been deemed eligible for voluntary assisted dying by their Coordinating Practitioner, the Coordinating Practitioner must, refer the patient to another participating practitioner to undertake a consulting assessment. If the second practitioner accepts the referral, they become the Consulting Practitioner.

A consulting doctor completes a second assessment

The Consulting Practitioner must undertake a consulting assessment (which is similar to a first assessment) to determine whether the patient is eligible for voluntary assisted dying. This is because the Act requires that two appropriately qualified and trained medical practitioners separately assess a person’s eligibility for voluntary assisted dying.

Of the 101 people who were assessed as eligible for voluntary assisted dying at a first assessment, 88 people went on to have a consulting assessment. Of these, 87 were assessed as eligible for voluntary assisted dying after the consulting assessment.

Reasons for not progressing from a first assessment to a consulting assessment include:

• dying prior to the consulting assessment
• withdrawing from the pathway
• being assessed as ineligible for voluntary assisted dying

Once a person has been deemed eligible for voluntary assisted dying by both a Coordinating and Consulting Practitioner, the Coordinating Practitioner supports the person to complete the necessary next steps in the pathway in order to be able to apply for a voluntary assisted dying permit. These include:

4. complete a written declaration to access voluntary assisted dying
5. make a final request for voluntary assisted dying
6. choose a contact person
7. doctor completes a final review

Voluntary assisted dying permits

Once a Coordinating Practitioner has completed a final review, they can submit an application for a voluntary assisted dying permit to SA Health.

A permit application can either be for a self-administration permit or for a practitioner administration permit. Under the Act, a person can only apply for a practitioner administration permit if the Coordinating Practitioner is satisfied that the person is physically incapable of self administration or digestion of the voluntary assisted dying substance.

Of the 77 permit applications submitted by a Coordinating Practitioner to SA Health between 31 January and 30 June 2023 a total of 71 voluntary assisted dying permits were issued to 68 people.

Reasons why a person may not be issued with a voluntary assisted dying permit include:

• the person died prior to the permit being issued
• the person withdrew from the pathway
• the person was assessed as ineligible for voluntary assisted dying.

It is important to note that in some circumstances a patient may be issued with two permits. For example, a patient may be granted a self-administration permit and later lose the capability to self-administer, requiring them to request a change to a practitioner administration permit. In these instances, the first permit is revoked, and a new permit is issued.

Of the 68 people who were issued with a permit, 51 people were issued with a self-administration permit and 17 were issued with a practitioner administration permit.

The number of permit applications per month is shown below:

Demographics of people who made an application for voluntary assisted dying

Of the 109 people who underwent a first assessment for voluntary assisted dying between 31 January and 30 June 2023:

• 82 (75%) were aged 65 years or older
• 61 were male and 48 were female
• 72% lived in metropolitan Adelaide and 28% lived in regional South Australia
• 73% were born in Australia
• 72% were currently accessing palliative care
• 1 person accessed an interpreter

Doctor prescribes substance once permit approved

Once a voluntary assisted dying permit has been issued, the Coordinating Practitioner must submit a prescription for the voluntary assisted dying substance to the SA Voluntary Assisted Dying Pharmacy Service (SAVAD-PS).

Arrange supply of substance with pharmacist

In order to take delivery of the substance after the prescription has been sent to the SAVAD-PS, a person who is the subject of a self-administration permit must contact the SAVAD-PS to arrange for a supply visit from the pharmacy team. During the supply visit the pharmacist provides comprehensive education regarding the storage and administration of the substance, as well as the role of the contact person in returning the locked box and its contents after the person has self-administered.

In the case of a practitioner administration permit, once the prescription has been sent to the pharmacy the Coordinating Practitioner can contact the pharmacy to arrange for delivery of the practitioner administration kit.

Between 31 January and 30 June 2023, the SAVAD-PS completed 56 visits across South Australia to supply the voluntary assisted dying substance. 100% of these visits were completed within two days of the persons preferred day of supply.

Decide to administer substance

Between 31 January and 30 June 2023, 45 of the 68 people who were issued with a voluntary assisted dying permit died for one of the following reasons:

• 28 died from self-administration of the voluntary assisted dying substance
• 11 died from practitioner administration of the voluntary assisted dying substance
• 6 died without taking the voluntary assisted dying substance

Of the 45 people who died who were the subject of a permit, 27 had cancer as the disease, illness or medical condition for which they were eligible for voluntary assisted dying and 10 had a neurodegenerative disease.

Of the 45 people who died who were the subject of a permit between 31 January and 30 June 2023:

• 24 were female and 21 were male
• 29 lived in metropolitan Adelaide and 16 lived in regional South Australia

• 39 were aged over 60 years at the time of their death
• 34 were born in Australia
• 23 died at home, 18 died in a hospital and 4 died in a residential aged care facility
• 31 were receiving a palliative care service while accessing voluntary assisted dying

People who commenced but did not complete the voluntary assisted dying pathway

For a range of reasons some people commence but do not complete the voluntary assisted dying pathway prior to the issue of a permit. Of the 109 people who underwent a first assessment for voluntary assisted dying between 31 January and 30 June 2023, 41 did not complete the voluntary assisted dying pathway prior to the issue of a permit for one of the following reasons:

• 18 died prior to the issue of a permit
• 9 were assessed as ineligible for voluntary assisted dying prior to the issue of a permit
• 14 people withdrew from the pathway prior to the issue of a permit.

Death certification

The Registrar of Births Deaths and Marriages notifies the Review Board of all voluntary assisted dying deaths on receipt of a Doctors Certificate of Cause of Death (Certificate).

The Doctors Certificate of Cause of Death now allows for the certifying doctor to indicate whether the person who has died was the subject of a voluntary assisted dying permit and, if so record both the manner and cause of death.

In the case of a person who has administered the voluntary assisted dying substance, the manner of death recorded is voluntary assisted dying and the cause of death recorded is the underlying disease, illness, or condition for which the person was eligible for voluntary assisted dying. To uphold the privacy of patients and families, only the cause of death is listed on the official death certificate issued by Births Deaths and Marriages.

For those people who die on the pathway prior to receiving a permit, deaths are recorded on the monthly Births, Deaths and Marriages SA Death Report that is provided to the Review Board. This ensures that data is kept up to date and supports accurate record keeping.

How long does the voluntary assisted dying application process take?

• The average number of days elapsed between a person making a first request to access voluntary assisted dying and receiving an outcome regarding an application for a voluntary assisted dying permit was 26 days.
• the average number of days from a person being issued with a permit to a person’s death from administration of the voluntary assisted dying substance was 14 days.
• the percentage of permit applications that were reviewed and a decision regarding the application provided within the 3 business days required by regulation was 100%.

A person seeking to access voluntary assisted dying maintains control over the timing within which they proceed along the pathway. Once a person has been issued with a voluntary assisted dying permit, that person has full autonomy and control over the timing of the next steps on the pathway. This means that there can a significant variability in the time it takes between being issued with a permit and a person making the decision to administer the substance.

Between 31 January and 30 June 2023, the average length of time between a person being issued with a permit and choosing to administer the substance was 14 days.

Medical practitioner involvement in voluntary assisted dying

As of 30 June 2023, a total of 111 medical practitioners were registered to undertake the mandatory practitioner training to support access to voluntary assisted dying. Of those, 73 percent resided in metropolitan Adelaide with the remaining 27 percent in regional South Australia.

• registered practitioners: 111
• trained practitioners: 66

Of the 111 practitioners who registered to undertake the mandatory training, 66 (59%) had completed the training by 30 June 2023 becoming eligible to support access to voluntary assisted dying in South Australia. Of those 74 percent reside in metropolitan Adelaide and 26 percent reside in regional South Australia.

Medical practitioner roles in voluntary assisted dying

In order to access voluntary assisted dying in South Australia, a person must have their eligibility for voluntary assisted dying assessed by two medical practitioners who have both undertaken the mandatory training.

A medical practitioner who has undertaken the mandatory training is eligible to undertake either role. Not all registered medical practitioners are actively engaged in providing access to voluntary assisted dying.

For the period 31 January to 30 June 2023:

• 32 of the 66 trained medical practitioners accepted a first request from a person seeking access to voluntary assisted dying becoming the Coordinating Practitioner for that person.
• 36 of the 66 trained medical practitioners accepted a referral from a Coordinating Practitioner to be a Consulting Practitioner. Some practitioners have undertaken both roles for different patients.

Registered practitioners by specialty

Of the 111 medical practitioners who registered to complete the mandatory training to support access to voluntary assisted dying in South Australia by 30 June 2023, 65 are General Practitioners with the remaining 67 from a range of medical specialties including Oncology (11), Neurology (7), General medicine (5), Palliative medicine (5), Emergency medicine (4), and other specialties (14).

Support provided to patients on the voluntary assisted dying pathway

During 2022-23 Care Navigators and VAD Liaisons provided individualised support to each person on the voluntary assisted dying pathway, from providing information to assisting them to identify a suitable medical practitioner, and providing assistance and support for family and loved ones. In addition, the Care Navigator Service and VAD Liaisons provided a significant number of education sessions to service providers to support them to understand and engage with the voluntary assisted dying pathway.

Requests for service, patient consultations and education sessions provided to health services by the Care Navigator Service and the VAD Liaisons during 2022-23 are shown in the figure below: