Voluntary Assisted Dying

Statewide Pharmacy Service

Professor Michael Dooley

Pharmacy Department, Alfred Health, Melbourne
Statewide Pharmacy Service

This presentation focusing specifically on the role of the Statewide

Pharmacy Service

All aspects of this presentation are detailed in the relevant documents

available on the DHHS website

www2.health.vic.gov.au
21 June 2019
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21 June 2019
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21 June 2019
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21 June 2019
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 Introduction
§ The Voluntary Assisted Dying Act 2017 was passed by the Victorian Parliament on 29 November
2017.

§ The Act will commence operation on 19 June 2019.

§ The Act followed two years of consultation and development, and reflects a balance between giving
people choices at the end of their life and ensuring community safety.

§ The policy in the Act is now settled and the focus has shifted to implementation of the Act.

§ Jan 2018 asked to lead development of medication protocol for implementation

§ Mid 2018 Alfred Board asked to consider Alfred as Statewide Service

§ Medication Protocol endorsed November 2018

§ Alfred Statewide Service Announced Jan 2019

Guiding Principles

– Every human life has equal value.

– A person’s autonomy should be respected.

– Informed decision making.

– Quality care that minimises suffering and maximises quality of life.

– Therapeutic relationships be supported and maintained.

– Open discussions about death and dying, treatment and care preferences.

– Genuine choice balanced with safeguards.

– All people have the right to be shown respect for their culture, beliefs, values and
personal characteristics.
 Eligibility Criteria
To access voluntary assisted dying, a person must meet all of the following:

§ be aged 18 years or more; and

§ be an Australian citizen or permanent resident; and be ordinarily resident in Victoria for at
least 12 months; and
§ have decision-making capacity in relation to voluntary assisted dying; and
§ be diagnosed with a disease, illness or medical condition that:
o is incurable; and

o is advanced, progressive and will cause death; and

o is expected to cause death within weeks or months, not exceeding 6 months (12 months
for people with a neurodegenerative condition); and

o is causing suffering that cannot be relieved in a manner the person considers tolerable.
Information for health practitioners

§ A health practitioner is not required to participate.

§ A health practitioner must not initiate the discussion about voluntary assisted dying with a patient
while providing a health service.
§ There are protections for health practitioners and paramedics who act in good faith and in
accordance with the Act.
- This includes not providing life-sustaining treatment that has not been requested if they believe the
person has accessed voluntary assisted dying.

§ There are a range of offences, including offences to induce a request or self-administration,

falsify records or make a false statement, and to provide or administer voluntary assisted dying
medication without a permit.
Information for health practitioners

§ A health practitioner is not required to participate.

§ A health practitioner must not initiate the discussion about voluntary assisted dying with a patient
while providing a health service.
§ There are protections for health practitioners and paramedics who act in good faith and in
accordance with the Act.
- This includes not providing life-sustaining treatment that has not been requested if they believe the
person has accessed voluntary assisted dying.

§ There are a range of offences, including offences to induce a request or self-administration,

falsify records or make a false statement, and to provide or administer voluntary assisted dying
medication without a permit.
Statewide Pharmacy Service

§ Role of Statewide Pharmacy Service

§ Process for getting access to medications

§ Self-administration medications

§ Practitioner administration medications

§ Frequency asked questions

§ Developing patient and healthcare provider information.

§ Educating medical practitioners regarding prescribing and

administration of medications.

§ Reviewing prescribed medications.

§ Dispensing voluntary assisted dying medications and other

supportive medications.

§ Going to patients (wherever they are in Victoria) to provide

face to face information regarding medications and how to
administer.

§ Supporting medical practitioners, patients, families and carers

throughout the process.
Statewide Pharmacy Service

§ Role of Statewide Pharmacy Service

§ Process for getting access to medications

§ Self-administration medications

§ Practitioner administration medications

§ Frequency asked questions

Medications

§ There are two approaches that patients can access:

1. Self administered (oral)

2. Practitioner administered (oral or intravenous)

§ Protocols have been developed and are based on international experience.

§ Protocols will be made available to medical practitioners who have completed the voluntary
assisted dying training.

§ Permit applications and prescriptions must comply with the medication protocols.

§ All medications are secured for use in Victoria.

§ Medications are funded by the DHHS.

Medications

Medication Protocol
9

Medications for self-administration

Patient Coordinating doctor Pharmacy Service

Request to self-
Permit
administer

Prescription Prescription
The coordinating medical practitioner and the statewide pharmacy service must discuss

the following before dispensing the prescription:

§ the protocol, including all medications, doses and administration

§ information provided by the coordinating medical practitioner to the patient

§ the patient’s history and all clinically relevant patient factors

§ the patient’s ability to self-administer

§ any factors that are relevant to the patient/carer(s)/contact person understanding the steps
associated with self-administration
§ the steps in self-administration

§ the contents of the Self-administration protocol kit

§ patient education to be undertaken (Self-administration protocol patient education checklist)

§ procedures for disposal and return of unused medications.
9

Medications for self-administration

Patient Coordinating doctor Pharmacy Service

Request to self-
Permit
administer

Prescription Prescription

Request for medications

Medications
9

Medications for practitioner administration

Patient Coordinating doctor Pharmacy Service

Request for practitioner

Permit
to administer

Prescription Prescription

Request for
Request for medications
administration

Medications Medications
Request for
administration
Medications
administered
Statewide Pharmacy Service

§ Role of Statewide Pharmacy Service

§ Process for getting access to medications

§ Self-administration medications

§ Practitioner administration medications

§ Frequency asked questions

Characteristics of medication: self-administered

§ Easy to be prepared
§ Easy for patient to self-administer
§ Predictable onset of action
§ Proven effectiveness
§ Available
§ Able to be stored for a long time
§ Easy storage
§ Not cost prohibitive
Characteristics of medication: self-administered

§ Oral medication
§ Easy to be prepared
§ Provided as a powder to be easily mixed
§ Easy for patient to self-administer
§ Swallowed over a few minutes
§ Predictable onset of action
§ Dose used overseas effectively for many years
§ Proven effectiveness
§ Palatable
§ Available
§ Rapid onset
§ Able to be stored for a long time
§ Provided in a ready to use kit
§ Easy storage
§ Able to be stored for over a year
§ Not cost prohibitive
§ No requirement for refrigeration
§ Funded by the DHHS
Characteristics of medication: self-administered
Returning unused medication

As required by the Voluntary Assisted Dying Act, the patient will have nominated a contact person.

The contact person’s responsibility is to return any unused voluntary assisted dying medication to the
statewide pharmacy service within 15 days of the patient’s death.

Only unused voluntary assisted dying medication needs to be returned to the statewide pharmacy
service.

The remaining contents of the self-administration or practitioner administration kit may be disposed. This
includes medications in the kit other than the voluntary assisted dying medication.
Statewide Pharmacy Service

§ Role of Statewide Pharmacy Service

§ Process for getting access to medications

§ Self-administration medications

§ Practitioner administration medications

§ Frequency asked questions

Characteristics of medication:
practitioner administered

§ Easy to be prepared
§ Easy for administration
§ Predictable onset of action
§ Proven effectiveness
§ Available
§ Able to be prepared in advance
§ Easy storage
§ Not cost prohibitive
Characteristics of medication:
practitioner administered
§ Easy to be prepared
§ Easy for administration
§ Predictable onset of action
§ Proven effectiveness
§ Available
§ Able to be prepared in advance
§ Easy storage
§ Not cost prohibitive
• Intravenous administration
• Protocol consisting of a number of medications
• Provided in pre-filled syringes
• Medications and doses used overseas effectively
for many years
• Provided in a ready to use kit
• Provided directly to coordinating doctor on day
of administration
Characteristics of medication:
practitioner administered
Statewide Pharmacy Service

§ Role of Statewide Pharmacy Service

§ Process for getting access to medications

§ Self-administration medications

§ Practitioner administration medications

§ Frequency asked questions

Health Practitioners
Health Services
Health Services
Health Services
 Health Services

Storage of voluntary assisted dying medication dispensed to the patient

If the patient agrees, the health service may store their voluntary assisted dying medication in accordance with standard
medication management policies and practices, for example:

§ self-medication policies (where present)

§ locked box in the patient’s possession

§ secure storage of S8 and S11 drugs on the ward

§ secure storage within the pharmacy department

§ secure storage in the locked medication room on the ward

§ secure storage in lockable bedside locker.

Patients
Patients
Statewide Pharmacy Service

Website: www2.health.vic.gov.au

Email: statewidepharmacy@alfred.org.au

Phone: 9076 5270

47
 Age of respondents N=77
35
30
25
20
15
Knowledge of legislation
10
5
0
30 or 31-40 41-50 51-60 60+ not
below stated

Yes, extensive knowledge

 Overall position

Willingness to dispense and inform about

use

Support Oppose
Unsure Prefer not to answer

Yes No Unsure
 How important are the following reasons to your willingness or
unwillingness to participate in Voluntary Assisted Dying ?

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
Giving patients access Respecting a patients Allowing patient to Relieving patient Your personal values Your cultural beliefs Your
right to request VAD choose time of death suffering religion/spirituality
Utmost importance Very important Somewhat important Not important
How important are the following reasons to your willingness
or unwillingness to participate in Voluntary Assisted Dying ?

100%
90%
80%

70%
60%

50%
40%
30%

20%
10%
0%
Obligations to Obligations to Concerns Emotional Relationships Relationship Obligation to Obligation to Uncertainty
the patient other patients about burden with with other colleagues the hospital about
requesting increased colleagues patients practicalities
VAD workload

Utmost importance Very important Somewhat important Not important