Should self-administered voluntary assisted dying be supervised? A Queensland case

Abstract

All Australian states and the Australian Capital Territory have voluntary assisted dying (VAD) laws. Medication management will be topical in these laws’ mandatory reviews following a Queensland coronial inquest into the death of a person who consumed a VAD substance prescribed for their spouse. In a decision issued on 11 September 2024, the coroner found “operational flaws” in Queensland's VAD law, declaring current self-administration procedures “inadequate to provide for medication safety and to prevent deliberate misuse”.¹ These findings have nationwide relevance as all Australian VAD laws permit eligible persons to self-administer without a health practitioner present.²

On 16 May 2023, ABC (pseudonym), an older person, died after purposely consuming a VAD substance prescribed for their terminally ill spouse.¹ Due to the sensitive nature of the case, the coroner's report includes a ban on publishing identifying details. Accordingly, ABC, their spouse (the terminally ill patient), and adult child are referred to using neutral terms.

The circumstances leading to ABC's death are set out in Box 1.

The coroner recommended that self-administration should be supervised by a health practitioner, an option that was considered by the Queensland Law Reform Commission (prompted by a proposed VAD bill)⁴ but was not adopted.⁵

The coroner warned of “[f]urther calamity and heartbreak” for patients and families without system reform.¹ He specifically confined his critical remarks to the system rather than the individuals working within it, noting that QVAD-SPS personnel had not breached the law or any protocol.

The Australian model of VAD is characterised by narrow eligibility criteria and numerous safeguards.² One of these safeguards is that only medical practitioners (and in some states, nurses or nurse practitioners) who complete mandatory training and meet additional experience and expertise requirements can participate in key aspects of VAD (“VAD practitioners”). Two independent VAD practitioners assess whether a person is eligible for VAD (in the states, only medical practitioners can do VAD assessments; but in the ACT, one practitioner can be a nurse practitioner). If the person is eligible, the lead VAD practitioner (“coordinating practitioner”) writes the prescription for the VAD substance.

Australian VAD medication protocols are not publicly available but, as in other countries, the VAD substance is a combination of medications used in health care settings (including a Schedule 8 [S8] medicine).^{3, 6} The medication protocol differs depending on the method of administration. Self-administration involves mixing a liquid that a person drinks (or ingests via nasogastric tube), while practitioner administration typically involves intravenous injection.⁶

Victoria and South Australia require self-administration unless the person cannot swallow or digest the substance.² Other jurisdictions allow more choice and have much higher rates of practitioner administration (Box 2).^{2, 7} No Australian VAD laws require supervised self-administration, although Tasmania's law has this as an option.²

Nationally, there were 2467 VAD deaths since 2019; 1258 (51%) involved self-administration.⁷ More eligible people were issued the VAD substance for self-administration but chose not to take it.⁷ The ABC case is the sole instance of a person taking a VAD substance not prescribed for them.

Compliance with legal requirements to return the VAD substance has been high. To date, 17 cases involved a delay in returning the VAD substance: 12 from Victoria (between 2019 and 2024);^{7, 8} four from Western Australia (between 2021 and 2023);⁷ and one from Queensland (the ABC case).¹

In the ABC case, the coroner heard evidence of reports of complications after self-administration, including vomiting and an extended period to death.¹ Data on VAD complication rates is limited.⁷ In its 2022–2023 annual report, Victoria's VAD Review Board stated that it had reviewed self-administration cases with a prolonged time to death, primarily involving persons with neurodegenerative diseases causing autonomic system failure.⁹ There are no reports of the VAD substance not causing death.

Whether to require self-administration of VAD to be supervised is a policy choice informed by weighing evidence and competing values.¹⁴ A policy position that prioritises community safety and emphasises protecting human life would support the coroner's view that the system's goal must be “precisely 100% compliance and that no innocent, nor unintended, person is in any way harmed”.¹ With this view, constraints on patient autonomy to choose the timing of one's death, delays, the likelihood that some patients will be unable to access VAD, and increased burdens on practitioners, are necessary corollaries of prioritising patient and community safety and avoiding the risk of death by unlawful use of a VAD substance.

Alternatively, a policy position that takes a more pragmatic lens aims to balance safety with the burdens of supervised self-administration and accepts that adverse outcomes sometimes occur in health care. This position accepts the relatively remote risks of permitting private self-administration. As the Australian Medical Association Queensland stated, “a one-off event or death did not necessarily mean the laws were terrible or needed fundamental reform”.¹⁵ This position is also informed by impacts on the system and individual practitioners. Occasional adverse outcomes are an unavoidable consequence of having a VAD system that prioritises patient choice and access and considers the broader impacts of supervised self-administration on the VAD system and workforce. This policy position focuses on measures to mitigate risks, rather than eliminating them completely.

Whatever policy option is chosen, the government must ensure that it is adequately resourced. Experience with health care systems generally has shown that under-resourced systems with a poorly supported workforce can fail to deliver safe and high quality care. Hence, if supervised self-administration is preferred on the grounds of patient and community safety, there is a duty to provide any additional resourcing required. We urge governments to closely consider the ABC case in their VAD reviews and offer several recommendations for consideration (Box 3).

Open access publishing facilitated by Queensland University of Technology, as part of the Wiley – Queensland University of Technology agreement via the Council of Australian University Librarians.

Ben White has been engaged (with colleagues) by the Victorian, Western Australian and Queensland governments to design and provide the legislatively mandated training for health practitioners involved in voluntary assisted dying in those states. Eliana Close and Katrine Del Villar were employed on these projects. Ben White has also received funding from state governments for voluntary assisted dying research. In addition, he (with a colleague) developed a model bill for voluntary assisted dying for parliaments to consider, which was discussed in the coronial case on ABC that this article examines.

Not commissioned; externally peer reviewed.