Ethical Diversity and Practical Uncertainty: A Qualitative Interview Study of Clinicians’ Experiences in the Implementation Period Prior to Voluntary Assisted Dying Becoming Available in their Hospital in Victoria, Australia

Abstract

In the Australian state of Victoria, legislation allowing voluntary assisted dying (VAD) passed through parliament in November 2017. There was then an eighteen-month period before the start date for patient access to VAD, referred to as the “implementation period.” The implementation period was intended to allow time for the relevant government department and affected organizations to develop processes before the Act came into effect in June 2019. This qualitative interview study investigates the perspectives of a multidisciplinary sample of twelve clinicians from a single metropolitan hospital during this implementation period. Maximum variation sampling was utilized to ensure breadth across discipline (medical, nursing, allied health), speciality, and stated level of support for the VAD legislation. Four key themes were identified from the interview data: preparing for the unknown, ethical diversity within the organization, building a respectful culture, and concerns about the inability of the legislated approach to capture clinical nuances. Overall, these clinicians’ workplace experiences during the implementation period were shaped by the ethical diversity within their organization and a sense of uncertainty about how the VAD legislation would integrate with the practical realities of their clinical setting. The concept of “ethical diversity” could be a useful one for supporting staff in an organization during a VAD implementation period.

Clinician perspectives on voluntary assisted dying and willingness to be involved: a multisite, cross‐sectional survey during implementation in New South Wales, Australia

“…Emerging Australian data are consistent with prior international findings and with data from Australian jurisdictions where VAD is in operation, suggesting that a majority of clinicians support VAD legalisation (>70%), although support is less among medical specialists (51%), compared to nurses (79%) and allied health staff (78%), and that a minority of medical specialists report being willing to participate in formal VAD roles (<45%) 16,17 . Research also demonstrates that during VAD implementation, clinicians identify a range of expected challenges to do with increased conflict, emotional burden, clinical uncertainty, logistics and the prospect of moral distress and uncertainty 19–23 …”

“…However, appreciation both of local clinicians' knowledge of and attitudes to VAD and their willingness to be involved in the care of patients who choose to access VAD at the end of their life remain critically important because they may determine the success of implementation, inform protocols and policies, provide 'baseline information' about available clinical resources and facilitate greater participation of clinicians in order to address potential patient access issues. [16][17][18] There are limited data regarding health care professionals' (HCPs) views and willingness during a VAD implementation period 19 that being 'the specific time window between legislative change and patient access' 19 which is important because HCPs' views may be very different before VAD is legislated and after it has been implemented. Emerging Australian data are consistent with prior international findings and with data from Australian jurisdictions where VAD is in operation, suggesting that a majority of clinicians support VAD legalisation (>70%), although support is less among medical specialists (51%), compared to nurses (79%) and allied health staff (78%), and that a minority of medical specialists report being willing to participate in formal VAD roles (<45%).…”

“…16,17 Research also demonstrates that during VAD implementation, clinicians identify a range of expected challenges to do with increased conflict, emotional burden, clinical uncertainty, logistics and the prospect of moral distress and uncertainty. [19][20][21][22][23] Broad similarities in VAD laws in Australian states and the context of their implementationsuch as federal regulations, health funding demands, technical clinical issues, shared professional values and knowledge sharing between state health bureaucraciessuggest that similar issues may emerge in the NSW context of VAD implementation.…”

“…There are limited data regarding health care professionals’ (HCPs) views and willingness during a VAD implementation period 19 – that being ‘the specific time window between legislative change and patient access’ 19 – which is important because HCPs’ views may be very different before VAD is legislated and after it has been implemented. Emerging Australian data are consistent with prior international findings and with data from Australian jurisdictions where VAD is in operation, suggesting that a majority of clinicians support VAD legalisation (>70%), although support is less among medical specialists (51%), compared to nurses (79%) and allied health staff (78%), and that a minority of medical specialists report being willing to participate in formal VAD roles (<45%) 16,17 .…”