Euthanasia debate raises awareness over palliative care challenges

The palliative care sector says it is happy the euthanasia debate has raised awareness over the inequities and challenges it faces.

The End of Life Choice bill allows for people in unbearable suffering or with an incurable, grievous condition to ask a doctor to help end their life.

A select committee has considered the legislation but could not agree on whether to recommend that it become law. 

The Aotearoa committee chair of the Australia and New Zealand Society of Palliative Medicine, Dr Rachel Wiseman, said members of the organisation were mainly against the idea. 

"Our position is that euthanasia and assisted suicide is not part of palliative medicine and members of the society do not support the legalization of assisted dying in any form."

"I think the fact that this bill isn't workable highlights to me that there are remains significant safety concerns." 

Concerns highlighted around the current palliative care system was a welcomed aspect of the report, however. 

"The [Ministry of Health] acknowledged that recent work has indicated shortfalls, " the report said. 

"[The Ministry] said that projected need will continue to exceed current service levels, access to palliative care is inequitable, and the quality of care varies across settings and regions. The ministry is developing indicative options to address these challenges."

It also pointed to a common theme from submissions that palliative care should be better resourced and more accessible, and that if this were to happen, demand for assisted dying would decrease. 

Dr Wiseman said the government's own action plan published in 2017 estimated a 51 percent increase in the need for palliative care services over the next 22 years. 

"That's going to have a significant impact on the workforce," she said. 

"We know that they are already inequities in service provision, although there are many areas of excellence, that's not translatable to all areas across the country.  

"What we don't want is for euthanasia to be the stop gap for an inadequately resourced palliative care service. We don't want people to see that as the option that they're taking because they don't have ready access to good palliative care support."

She said that while it was difficult to say how things would change for the sector if the Bill became law, it could serve to highlight "the existing inequities within palliative care provision particularly in the more rural and remote areas".

About 18,000 people receive palliative care at hospices each year. Hospice New Zealand was another group to voice its opposition to the Bill.

"The philosophy of palliative care is that we don't hasten or postpone death so it's the antithesis of that," its chief executive Mary Schumacher.

"Because our focus is really on [ensuring] a person can have a palliative care, can have a good quality of life with their dignity maintained and their symptoms managed, we don't really see it [euthanasia] having any part in good palliative care. Euthanasia and physician assisted suicide is kind of against the core values of palliative care." 

She said there were real challenges ahead, including workforce shortages, and an increase in demand for their services that needed to be acted on. 

"[The report] talks about the inadequacies of the current systems for end of life care across New Zealand so we want to make sure that access is really addressed," Ms Schumacher said. 

"We want to see that happening before we start thinking about changing the laws so there's equitable, fair, access to all New Zealanders for end of life and palliative care."

There were also questions about whether hospices would have the right to refuse to do voluntary euthanasia if the Bill passed. 

"A doctor can opt out, conscientiously object, but what we understand is organisations can't."

"We see that will be very difficult for us given that the majority of our staff don't support a change to the law, given that it's contrary to the core philosophy of palliative care. It's the antithesis of what it is that we do because we don't postpone, nor do we hasten death. So this doesn't sit with palliative care so for hospices it could be a real issue." 

Ms Schumacher said she would be considering the Justice Committee's report carefully and her board, as well as individual hospices, would be considering the impact on their services. 

"Certainly some hospices are saying that they would not provide assisted suicide or euthanasia, but that would be something that individual hospices would consider alongside their clinicians. Certainly the clinicians that I've spoken to across the country say this is not something they would be prepared to do, they don't see it as being part of palliative care, and they don't see it as part of what they'll do."

End of Life Choice Society president Maryan Street agreed there were serious shortfalls in palliative care that needed looking at. 

"Palliative care in New Zealand is neither universally accessible, nor universally high standard. I think that has been true for a long time. The other thing that I'm very convinced of is that palliative care and assisted dying are not mutually exclusive.

"It's true to say that there are palliative care specialists in favor of assisted dying and palliative care specialist who oppose it."

Ms Street said she doubted people would opt for assisted dying because of being unable to access palliative care. 

"I'm not sure that that's how it's going to happen. I just think people will go to hospices as required and they will have to talk with individual specialists and health professionals about assisted dying if that's what they want. 

"Palliative care doesn't fix all the situations that people find themselves in at the end of their life, and palliative care specialists who say otherwise are being disingenuous." 

She said it would be "irresponsible" for Hospice New Zealand to exclude hospices from the law if it passed. 

"It is not going to be possible legally, anyway, because a lot of this depends on the rights of an individual to access terminal medication at the time of their own choosing, under certain circumstances, certain particular criteria, and regulated stringently by the safeguards that are in place in David Seymour's bill."

She said overseas some places had said they wouldn't do it on site, and most were privately funded. 

"If they're privately funded then ... they have every right to do that. If people are accessing government funding, however, I would suggest that ... it would breach that contract with the government ... if they were to exclude people who were legitimately entitled to assisted dying by the terms of the law.

"I would suggest that if they are to continue to receive government funding - and I believe they should get more -  they need to recognize that there are also bound by the laws and New Zealand."

Ms Street said hospice and palliative care providers would have contradictions that would need to be worked through, doctor by doctor.