What actually happens in the process of assisted dying? In this article we hear from GP Rebekah Kilpatrick who unpacks the approximately 40 hours of work that will go into every application for assisted death. This series of articles is being produced to resource and support our churches at this time.
Other articles in The End of Life Choice Act series:
- Being a carer by Donna Denmead
- Faithful Christianity by Jonathan Robinson
- Pastoral responses by Phil Halstead
My aim here is not to debate the ethics of assisted dying, but to highlight some of the practicalities of the Act as it stands and some of my musings about where the church fits. I write with several hats on, each contributing to my views - I’m a GP on the Kapiti Coast, married to the amazing Vince Kilpatrick who is Pastor of Ōtaki Baptist Church. I have both grown up and worked as a doctor in Papua New Guinea, witnessing some of what life is like without comprehensive healthcare, and am inching my way through a Graduate Diploma of Applied Theology at Carey Baptist College.
Let’s start by working our way through the process of accessing assisted dying, as it currently stands in New Zealand.
Raising the conversation
Legally, no medical practitioner can raise assisted dying with a patient; it must be explicitly raised by the person before any conversation can take place.1 This is an important safeguard which over-rides a person’s usual right to receive an explanation of all the available options when considering medical treatment.
Once the assisted dying conversation has been raised, health practitioners who conscientiously object or who are unable to provide care due to inadequate skills or experience, must inform the person where they can get further information and access assisted dying.2 It is unclear how many practitioners will put their hands up to offer this service and is estimated that there will be approximately 40 hours of work for practitioners for each person who goes through with assisted dying. Given the pressure on the health system, and particularly general practice where many of these conversations are expected to take place, it is hard to see where the capacity exists to provide this service.
Assessing eligibility for assisted dying
Once the conversation has been raised with a practitioner who offers assisted dying assessment, the process begins to determine whether the person is eligible to receive assisted dying, as they must meet all the following criteria:3
- be aged 18 years or over
- be a citizen or permanent resident of New Zealand
- suffer from a terminal illness that is likely to end their life within six months
- be in an advanced state of irreversible decline in physical capability
- experience unbearable suffering that cannot be relieved in a manner that the person considers tolerable
- be competent to make an informed decision about assisted dying
There are several things to note here. Firstly, in contrast to other medical procedures, competence to make this decision is not assumed, it must be assessed and found to be present.4 The person must understand their situation, what they are asking for, alternate courses of action, the consequences of their decision, and be making the decision of their own accord without pressure from others. This competence is required both at the time the person is assessed to be eligible, and at the time when the procedure goes ahead. An advanced care plan, where someone’s wishes are recorded prior to them being unable to decide, is not sufficient in the Act at this stage, neither is an Enduring Power of Attorney (EPOA).5
Secondly, the criteria are quite narrow, so it is anticipated that only a small proportion of those who die in New Zealand each year will be eligible for assisted dying at this stage. Most commonly this will be in the case of terminal cancer and progressive, degenerative neurological conditions, where competence is retained.
Eligibility – meeting all the criteria including having competence - will be assessed by two practitioners – the person’s attending medical practitioner, and an independent medical practitioner. If there is any disagreement, a psychiatrist’s assessment of competence is required to confirm whether the person is competent to make this decision.
Once eligibility is confirmed
If eligibility is confirmed and the options have been discussed, the person will set a date and time of their choosing, where the administering health professional will meet them for assisted dying to take place. This will likely happen in the community rather than hospital, most commonly in someone’s home. The person can choose to have whomever they wish present with them. At least 48 hours prior to the agreed time, the practitioner will write the prescription and submit everything to the Assisted Dying Registrar, who confirms that the process has been followed correctly. There are several ways the medication can be administered – orally, via feeding tube or intravenously, with further details about this only available to those who will be administering the medication for safety reasons. As these are lethal medications, it is very important they are strictly controlled. The script will be sent to a designated pharmacist, who will then dispense the medication securely to the administering doctor or nurse practitioner. Medications will be returned if not used, with strict controls over the whole process.
At the agreed time and place, the person will confirm again that they wish to proceed, and then the doctor or nurse practitioner will give them the medication. They will be available until the person dies, then sign the death certificate and complete the required paperwork.
Some practicalities/surrounding questions
Whānau (which the definition of this is broad enough to encompass any support people the person wishes), are encouraged but not required to be a part of the conversation about assisted dying.6 Cultural and spiritual support are considered an important part of the whole process.7 If a person requests, their pastor could be involved for any part of the process, from early conversations to being present before or during their death.
There is no cost for any assisted dying service, it is fully funded by the Ministry of Health, which is an important ethical safeguard. Throughout the process, all other aspects of the person’s healthcare and particularly end of life care, such as palliative care, are continued and should be optimised.8 Palliative care focuses on quality of life, rather than shortening or prolonging life, with hospice services making up a large part of this. One important concern that has been raised about assisted dying, is the contrasting lack of funding provided for palliative care in New Zealand. From a GP point of view, funding is usually quite limited, and relies on the good will of GPs providing much of their care without payment. Similarly, hospice and the range of services they provide – from beds in their inpatient units, to grief counselling for family members, home visits and intense support to keep those who wish to die at home comfortable there – are not fully government funded. They are supported by fundraising and the many second-hand shops around. Advocating for full funding for palliative care or supporting hospices in their work is a great way to support end of life care.
A good death
One of the things it is important to consider, is why someone would choose assisted dying. Two words that come up a lot in the conversation are suffering and dignity. It is estimated that a significant proportion of people who request assisted dying and meet the criteria, choose not to go through with their request. For many, it is a way of wrestling back some control in the dying process, and they can rest in the knowledge that if things become too much to bear, they have an out. This is one area I believe that rather than being a voice of judgement, the church has so much offer in the conversation about suffering and dignity.
We are often so removed from death and suffering in the Western world, we don’t see death, we just don’t expect it to happen to us until we’re old. At times, the church doesn’t seem to have much more to offer – everyone can seem to have it all together, and sails through pain because God is good and is in control. But death has a way of cutting straight through the clichés and pat answers. As we wrestle together in the muck of life, we have the opportunity to learn to lament and grieve well, to develop our theology of suffering and find God amongst the hurt. We have a God who isn’t distant, who entered our world and suffered like we do. A Comforter who walks with us through the pain and unknowing, who brings peace that passes understanding and who is our Hope beyond this life.
Reflecting on dignity, I was reminded about a discussion with a friend who talked about the privilege of changing, feeding and washing her grandma in her grandma’s last few days. Reframing the loss of dignity as an opportunity to love her grandmother and repay some of the care she has been shown over her life really touched me. As the church, we can speak to the inherent dignity of each person, as we recognise their status as being made in the image of God. Each interaction we have with someone potentially considered “less-than” by society – those who are differently abled, who are homeless or powerless – is an opportunity to demonstrate this dignity we believe each person holds.
Conclusion
There are those in our congregations suffering with terminal illnesses, and you may be asked to walk alongside those who wish to consider or go through with assisted dying. My hope in writing is that you understand more of the process and some of the checks and balances in place. As you walk alongside those who are dying, ask them what they consider would be a good death. What are they most afraid of happening? Where do they see God in their journey?
May you be bringers of God’s peace and comfort as you shepherd those in your flock in their last days, however they end.
Contributor Rebekah Kilpatrick is a GP on the Kapiti Coast, has been a doctor in Papua New Guinea, and attends Ōtaki Baptst Church.
References
- Ministry of Health, “Assisted Dying Care Pathways for Health Practitioners,” September 2021, 10, https://www.health.govt.nz/system/files/documents/pages/3-assisted-dying-care-pathways-sep21_0.pdf
- Ministry of Health, “Assisted Dying Care Pathways for Health Practitioners,” 17.
- Ministry of Health, “Responding When a Person Raises Assisted Dying: A Handbook for Registered Health Professionals,” 2021, 2, https://www.health.govt.nz/system/files/documents/pages/responding-when-a-person-raises-assisted-dying-a-handbook-for-registered-health-professionals-sep21_0.pdf
- Ministry of Health, “Assisted Dying Care Pathways for Health Practitioners,” 10.
- Ministry of Health, “Responding When a Person Raises Assisted Dying: A Handbook for Registered Health Professionals,” 3.
- Ministry of Health, “Assisted Dying Care Pathways for Health Practitioners,” 7.
- Ministry of Health, “Assisted Dying Care Pathways for Health Practitioners,” 15.
- Ministry of Health, “Assisted Dying Care Pathways for Health Practitioners,” 7.
Other articles in The End of Life Choice Act series:
- Being a carer by Donna Denmead
- Faithful Christianity by Jonathan Robinson
- Pastoral responses by Phil Halstead
