Program: Calvary’s Response to Voluntary Assisted Dying

Calvary’s Response to Voluntary Assisted Dying

You are required to complete this program under the following criteria:

Member of audience 'Calvary’s Response to Voluntary Assisted Dying'.

Date assigned: 15 June 2023

Due date: No due date set

Progress:

Voluntary Assisted Dying laws have come or will come into effect in all Australian States & Territories and require us to understand and comply with the legislation as well as our Calvary policy when patients, residents, clients and their families are seeking information about voluntary assisted dying.

This online module will give you an understanding of Calvary’s Response to Voluntary Assisted Dying legislation and your responsibilities.

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Position Statement on Euthanasia, Physician Assisted Suicide and Voluntary Assisted Dying

Since the establishment of Calvary in 1885, with the arrival of the Sisters of the Little Company of Mary in Australia, Calvary has become well known for the provision of health care to the most vulnerable, including those reaching the end of their life. With more than 18,000 staff and volunteers, 14 public and private hospitals, 72 residential care and retirement communities, and a national network of community care service centres, we operate across seven states and territories within Australia.

Preamble

Calvary’s position regarding euthanasia and/or physician-assisted suicide (referred to as Voluntary Assisted Dying in most jurisdictions) is the same across all its sites and services, regardless of the jurisdiction in which they operate. We acknowledge that the terminology used to describe these interventions varies from place to place. In the Voluntary Assisted Dying Act 2017 (Victoria), the End-of-Life Choices (Voluntary Assisted Dying) Act 2021

(Tasmania), the Voluntary Assisted Dying Act 2021 (South Australia) and the Voluntary Assisted Dying Act 2021 (Queensland) interventions are collectively referred to as ‘voluntary assisted dying’.^{^[1]}

Calvary’s position is congruent with our own mission to bring the healing ministry of Jesus to those who are sick, dying and in need through ‘being for others’; our values of Hospitality, Healing, Stewardship and Respect; and the Code of Ethical Standards for Catholic Health and Aged Care Services in Australia.^{^[2]} Catholic health and aged care services are committed to the ethic of healing, the ethic which is found in both the longstanding Hippocratic tradition of medical practice and the longstanding Christian tradition of providing care, especially for poor and vulnerable people.^{^[3]}

The features of this ethic as it pertains to those who have a life-limiting illness and/or are nearing the end of their lives include commitments: to heal and never to harm; to relieve pain and other physical and psycho-social symptoms of illness and frailty; to withdraw life-prolonging treatments when they are futile or overly burdensome or when a person wants them withdrawn and gives informed refusal of these treatments; and to never abandon patients.⁴

Calvary Health Care does not support euthanasia or physician-assisted suicide nor do we recognise these interventions as medical treatments.

Accordingly, Calvary is not involved in the implementation of any Voluntary Assisted Dying legislation and Calvary will not provide services permitted under Voluntary Assisted Dying legislation or any similar legislation.

Calvary Health Care

• Will empower a patient, resident or client to actively participate in decision-making regarding their treatment and care, will honour their self-determination through the use of advance care planning, and will recognise the role of substitute decision makers/medical treatment decision makers and any other agents acting on behalf of the patient, resident or client.

• Will provide holistic, comprehensive end of life care; will address the physical, spiritual, psychological and social needs of patients, residents, clients and their families, including existential distress, with the goal of reducing suffering.

• Will neither hasten nor prolong death.^{^[4]}

• Will not intentionally inflict death on patients (that is, provide euthanasia), nor intentionally assist patients, residents or clients to take their own lives (that is, provide physician-assisted suicide.

• Will, in alignment with the principles set out in the Spirit of Calvary, respond openly, respectfully, without discrimination and sensitively to anyone within our care who expresses a wish to explore or consider physician-assisted suicide or Voluntary Assisted Dying.

• Will actively listen to and accompany^{^[5]} any person who is nearing end of life, and will not abandon anyone who is in need of care.

• Will not facilitate or participate in assessments undertaken for the purpose of a patient, resident or client having access to or making use of the interventions allowed under Voluntary Assisted Dying legislation in any jurisdiction, nor will we provide (or facilitate the provision of) a substance for the same purpose.

Definitions

End of Life Care^{^[6]} includes physical, spiritual and psychosocial assessment, and care and treatment delivered by health professionals and ancillary staff. It also includes support of families and carers, and care of the person’s body after their death.

People are ‘approaching the end-of-life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:

• advanced, progressive, incurable conditions;

• general frailty and co-existing conditions that mean that they are expected to die within 12 months;  existing conditions, if they are at risk of dying from a sudden acute crisis in their condition;  life-threatening acute conditions caused by sudden catastrophic events.

Palliative Care⁵ an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:

• aims to enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications;

• provides relief from pain and other distressing symptoms;

• affirms life and regards dying as a normal process;

• neither hastens nor postpones death;

• integrates the psychological and spiritual aspects of patient care;

• offers a support system to help patients live as actively as possible until death;

• offers a support system to help the family cope during the patients’ illness and in their own bereavement; and

• uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated.

Euthanasia the intentional bringing about of the death of a person in order to relieve suffering. It can be either voluntary or non-voluntary.

Physician Assisted Suicide the intentional giving of assistance, by a doctor, to someone to commit suicide.

Voluntary Assisted Dying the term used to describe physician-assisted suicide and euthanasia in Voluntary Assisted Dying legislation in Australia.

[1] Voluntary Assisted Dying Act 2017 (Vic), Part 1, Section 3.

[2] Catholic Health Australia, Code of Ethical Standards for Catholic Health and Aged Care Services in Australia (Deakin West:

Catholic Health Australia, 2001), Part 2, no. 1.13; 1.14; 1.15; 1.16; 5.21.

[3] Catholic Health Australia, Excellence in end-of-life care: A Restatement of Core Principles Revision of 5-10-18 ⁴ Code of Ethical Standards, Part 2, no. 1.13; 1.14; 1.15; 1.16; 5.21.

[4] World Health Organization, definition of palliative care, 2004 and WHO fact sheet 2015.

[5] Apostolic Exhortation Evangelii Gaudium of the Holy Father Francis to the Bishops, Clergy, Consecrated Persons and the

Lay Faithful Chapter 3, N.169-173, Personal accompaniment in process of growthⁱ

[6] Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe high quality end of life care. 2015.

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Responding to Requests for Access to

Voluntary Assisted Dying Procedure

Quick navigation to

All Services 4

Hospitals, health service establishment based and inpatient services 5

Residential Care Services 10

Community Care Services 14

ALL STAFF ‘CARE(R)’ Response Guideline 23

TIER 1 Initial Response Practice Guidance 25

Tiered Response Guideline: hospitals, health service establishment based and inpatient services 26

Tiered Response Guideline: Residential and Community Care Based Services 27

‘Desire to Die Statements’ (DTDS) Guideline 28

Approved by: National Director of Mission	Approved Date: 22/12/2022 22/12/2022
UNCONTROLLED WHEN PRINTED	Review Date: 22/12/2023

1 Applies to

This Procedure applies to:

• All Calvary staff, Visiting Medical Officers (VMO), students, volunteers, contractors and to any other persons acting on behalf of Calvary Health Care; and

• All interactions with patients/residents/clients within our care who seek information or expresses a wish to consider voluntary assisted dying (VAD), or have informed us of their engagement in the VAD assessment process or who have been approved for VAD.

2 Purpose

Consistent with the Calvary Responding to Requests for Access to Voluntary Assisted Dying Policy and our commitment to providing a consistent, ethical and compassionate approach when responding to patients/residents/clients who express a desire for information or access to VAD; this procedure outlines the steps to be followed by all Calvary staff when responding to such requests.

Calvary has adopted a tiered governance and escalation system to ensure a consistent, ethical and compassionate approach when responding to patients, residents or clients who express a desire for information or access to VAD; and to ensure all staff have the appropriate level of competency and support to respond to such requests.

3 Responsibilities

LCM Health Care Board, National CEO, National Executive and Managers

• The Board and senior management of Calvary are responsible for the governance of the organisation.

• To ensure the principles and requirements of the Calvary Responding to Requests for Access to Voluntary Assisted Dying Procedure are applied, achieved and sustained.

Regional Executive, Local Executive, Managers and Supervisors

• To ensure the principles and requirements of the Calvary Responding to Requests for Access to Voluntary Assisted Dying Procedure are applied, achieved and sustained within their services and departments, and compliance with these requirements are reported through the required governance reporting mechanisms.

• Will monitor and ensure the effectiveness of systems within their services to providing patients/clients/residents with timely access to a Tier 1 response.

• Will monitor and ensure effectiveness of Tier 2 response systems within their services as required for complex cases. This may require direct oversight of individual cases until a maturity level is reached such that Tier 2 responders are confident they no longer need the regional executive team and GM to be habitually involved.

• Will ensure a suitable support process is in place for staff involved in responding to requests for VAD appropriate to their level of training.

• Will ensure data collection processes are in place to record the quality and access to care with respect to the VAD legislation.

• Will monitor the regular reviews and reporting of the response to VAD legislation within organisational governance committees and contributions to organisation wide review of the VAD response implementation.

All employees, volunteers, students, VMO’s, Contractors

• Are compliant with this procedure in all actions and interactions whilst undertaking their role within or on behalf of Calvary Health Care across all service settings.

• Will work within the boundaries of their role and within the following governance structure:

4 Equipment

 Patient/resident/client clinical record.

Approved by: National Director of Mission

Approved Date: 22/12/2022 22/12/2022

UNCONTROLLED WHEN PRINTED

Review Date: 22/12/2023

5 All Services

The following procedure articulates the steps required for staff at each level of the tiered system and the escalation pathways between each tier. Each tier has the following capabilities and responsibilities as articulated in the Calvary Responding to Requests for Voluntary Assisted Dying Policy.

Table 1. Capability Framework for the Tiered Governance System^{^[1]}

	All Staff	Tier 1	Tier 2
	Awareness
Awareness of organisational position	YES	YES	YES
Awareness that VAD can only be initiated by patient	YES	YES	YES
Awareness of basic information provision re: VAD	YES	YES	YES
Awareness of documentation requirements	YES	YES	YES
Awareness of escalation requirements	YES	YES	YES
	Advice
Manage sensitive discussions and address end of life concerns	NO	YES	YES
Provide advice on end of life care options	NO	YES	YES
Connect patients / residents / clients to end of life care options	NO	YES	YES
	Decision Making
Management of complex cases	NO	NO	YES
Escalate and inform relevant stakeholders	NO	NO	YES
Manage risks	NO	NO	YES
Commission or seek expert advice as required	NO	NO	YES

5.1 Escalation Pathways

Due to the diversity of Calvary services, each Calvary site/service has available for their staff a localised guideline which clearly identifies the roles responsible for Tier 1 and Tier 2 responses for that site/service.

All staff should familiarise themselves with their local guideline and the national guidelines:

o Appendix 3: Calvary Hospital Based Services VAD Tiered Response Guideline o Appendix 4: Calvary Aged and Community Care VAD Tiered Response Guideline

General guidance o All staff will respond to the patient/resident/client’s requests or concerns with respect and compassion, in a manner consistent with their capabilities, as described in Table 1.

o Any staff member who has concerns regarding an interaction they have or may have with a patient should escalate their concerns to a Tier 1 response staff member for support and guidance, generally within 24 hours.

o If further guidance is required or a Tier 1 response staff member is not available or the situation is beyond the capabilities of the individual staff as descried in Table 1, the matter should be raised with a Tier 2 response staff member, generally within 24 hours.

o ALL STAFF responses should be based on the CARE(R) model, as described in Appendix 1:

C (Clarify) A (Acknowledge)

ALL STAFF

R (Respond)

E (Escalate)

R (Resources) Clinical Staff

Hospitals, health service establishment based and inpatient services

5.1.1 Not initiating discussions about ‘Voluntary Assisted Dying’ – in hospitals, health service establishment based and inpatient services

Calvary staff must not initiate discussions about VAD with patients or patient’s families. This requirement is consistent with Calvary’s Position Statement on Voluntary Assisted Dying and the legal requirements in some jurisdictions.

5.1.2 Exceptions to 5.1.1

If staff become aware that a patient has initiated a discussion about VAD, it is important that staff do not ignore this. This includes instances in which the patient has initiated a VAD discussion with a health practitioner at an external/non-Calvary health service.

Calvary staff may discuss VAD with a patient if they have confirmed that the patient has previously initiated a discussion about VAD with a health practitioner. The health practitioner can be either from within Calvary or from an external/non-Calvary health service.

This may be evidenced by the patient’s clinical record, the health practitioner with whom the patient raised the issue of VAD or other processes in standard clinical practice, e.g. hospital discharge summaries or clinic letters. However, staff must not ask the patient for confirmation, as this would be initiating a discussion about VAD, which is inconsistent with Calvary’s position and illegal in some jurisdictions.

5.1.3 Responding to ‘desire to die’ statements (DTDS) – in hospitals, health service establishment based and inpatient services

It is not uncommon for patients who are approaching the end of their lives to make statements expressing a desire to die or to have their death hastened. Whilst such statements can be confronting for staff, it is important to acknowledge the statement and to not:

o ignore the statement; o dismiss the statement as transient; o monopolise the conversation; o focus solely on physical issues/concerns; o change the topic; o offer premature or false reassurance.

Refer to Appendix 5: ‘Desire to Die Statements’ (DTDS) Guideline for further guidance.

A DTDS may not constitute a request for VAD, and should not automatically be assumed to be a request or desire for VAD.

All DTDS expressed by a patient will initiate a Tier 1 response.

NOTE FOR STAFF OF CALVARY SERVICES WHICH HAVE A SUICIDE RISK MANAGEMENT PROCEDURE IN PLACE (e.g. Calvary Health Care Bethlehem): Where the DTDS is NOT an explicit request for access to VAD, staff should also refer to the relevant suicide risk management procedure and complete a risk assessment in response to the DTDS.

• ALL STAFF: Calvary staff who receive any expressed DTDS from a patient will respond with respect and compassion and will initiate a Tier 1 response, consistent with their local guideline and in alignment with Appendix 2.

• Tier 1 responders will: o be alert to their own responses;

o through active listening, be open in their manner of hearing the patient’s concerns; o assess potential contributing factors;

o address potentially reversible issues and make appropriate referrals to other members of the treating team to support this;

o document the conversation and plan of management in the patient clinical notes;

• If concerns regarding the patient are unable to be satisfactorily addressed by the primary team and Tier 1 responders, these concerns will be escalated to a Tier 2 responder consistent with the local guideline, but generally within 24 hours.

5.1.4 Responding to requests for information about ‘Voluntary Assisted Dying’ – in hospitals, health service establishment based and inpatient services

• All requests for information about VAD must be received in a compassionate and respectful manner.

• If a patient commits to accessing further information about or assessment for VAD through appropriate channels outside of our local services, Calvary staff will continue to accompany the patient and provide all normal care to them.

• ALL STAFF: If a patient requests information about VAD, Calvary staff will disclose the following: a. That our services do not provide VAD;

b. That they can be referred to a health professional within our services who is qualified to engage in discussions about their concerns and their end of life care;

c. That the relevant Department of Health provides information regarding VAD. At a patient’s request, Calvary staff will provide available contact information for the relevant VAD navigator service.

• Patients who agree to engage in further discussions will be directed to a Tier 1 responder for further consultation.

• All requests for information about VAD and any further discussions will be recorded in the patient’s clinical record.

5.1.5 Responding to formal and informal requests for access to ‘Voluntary Assisted Dying’ – in hospitals, health service establishment based and inpatient services

• All requests for VAD must be received in a compassionate and respectful manner.

• Any request for VAD will activate a Tier 1 response, generally within 24 hours.

• If a Calvary credentialed medical practitioner is responding to a formal request for access to VAD, they must:

a. Receive the request in a compassionate and respectful manner;

b. Inform the patient that they are declining the request because they are not credentialed to offer access to VAD and Calvary services do not provide access to VAD;

c. Document the request in the patient’s clinical record;

d. Inform the patient that a medical practitioner outside Calvary services may be able to assist them with this request;

e. Provide the patient with the contact details of the VAD navigator service;

f. If required by the relevant legislation, provide the patient with information about VAD in a form approved by the Voluntary Assisted Dying Review Board (or equivalent) (TAS, NSW);

g. If required by the relevant legislation, notify the Voluntary Assisted Dying Review Board (or equivalent) within 5 days using the approved form that they have refused a first request from the patient (TAS, NSW);

h. Notify a Tier 1 responder of the request generally within 24 hours.

• A Tier 1 responder will:

a. Ensure, as appropriate, that the admitting medical consultant and the clinical manager in the inpatient setting has been notified;

b. Document the request in the patient’s clinical record;

c. Respond to the patient request for VAD in a manner consistent with their capabilities, as described in Table 1 and per the Tier 1 Initial Response Practice Guidance Appendix 2.

• If, after discussion with a Tier 1 responder, the patient still expresses a desire to further explore VAD, alternatives will be explored with clear communication that VAD is not provided in Calvary facilities or by Calvary services. The patient may choose to contact the VAD navigator service.

• Once the patient has had a discussion with the VAD navigator service, they may request a transfer from inpatient care in order to access external providers.

• For transfer to another service or leave from care for the purpose of accessing VAD, Calvary staff will follow the procedure listed in 5.1.6.

5.1.6 Responding to requests for transfers, discharge and leave from care for the purpose of accessing ‘Voluntary Assisted Dying’ – hospitals, health service establishment based and inpatient services

• If a patient requests transfer to another service for the purpose of accessing VAD, Calvary inpatient facilities will continue to care for the patient until such time as that care has been assumed by an appropriate receiving provider. This may include being involved with arrangements for the patient to be transferred to their preferred location, including any normal clinical handover processes.

• If a patient requests discharge or leave from care for a period of time for the purpose of accessing VAD, Calvary inpatient facilities shall follow normal protocols for leave from care.

• If a patient care team determines that it is unsafe or overly burdensome for the patient to undergo transfer or be approved for discharge or leave from care, this will be escalated, generally within 24 hours, to a Tier 2 responder for further assessment.

• A Tier 2 responder will work with the patient, other Tier 2 responders, regional executive team and the GM to determine an acceptable and prudent resolution, taking into account their preferences for care as well as clinical, ethical and legal advice as necessary.

5.1.7 Responding to a patient in possession of lethal VAD substance – hospitals, health service establishment based and inpatient services

• ALL STAFF: Where a patient, their nominated ‘Contact Person’ or their ‘Coordinating Practitioner’ is known to be in possession of the VAD substance, Calvary facilities will request that patient refrains from bringing substances intended to cause death under the VAD legislation into our services.

• If a patient brings the VAD substance into a Calvary facility or has the substance delivered, the issue will be immediately escalated to a Tier 2 responder.

• The Tier 2 responder will work with the patient, other Tier 2 responders, regional executive team and GM to determine an acceptable and prudent resolution, taking into account their preferences for care as well as clinical, ethical and legal advice as necessary.

• Document the plan of management in the patient clinical record.

• TASMANIA ONLY: In consultation with the patient, Tier 2 responders, regional executive team and GM, the Tasmania Health Service Protocol for Voluntary Assisted Dying: Medication Management in THS Medical Facilities must be followed whilst the substance is in a Calvary facility.

5.1.8 Responding to requests to be present or assist whilst person self-administers or is assisted to administer the lethal VAD substance – hospitals, health service establishment based and inpatient services

• ALL STAFF: Calvary staff must NOT be present or assist whilst a person self- administers or is supported to administer the VAD substance.

• Calvary staff must respond to the patient’s request with respect and compassion, in a manner consistent with their capabilities, as described in Table 1 and in alignment with Appendix 1.

• Calvary staff must disclose the following:

a. That our staff are not permitted to facilitate or be present whilst a person is undertaking VAD;

b. That the patient can be referred to a health professional within our services who is qualified to engage in discussions about end of life care;

c. That the patient may wish to discuss their request with members of their own support network, their nominated ‘Contact Person’ as prescribed in the relevant VAD legislation or the VAD navigator service.

• Any request to be present whilst a person self-administers or is assisted to administer the VAD substance will activate a Tier 1 response generally within 24 hours.

• A Tier 1 responder will:

a. Ensure, as appropriate, that the admitting medical consultant and the clinical manager are notified.

b. Document the request and management plan in the patient’s clinical record;

c. Respond to the patient’s request for VAD in a manner consistent with their capabilities, as described in Table 1;

d. Reassure the patient that we will continue to provide usual care to them and will also provide necessary care and bereavement support to those who may require support in this situation, including medical treatment decision maker, support person, family and friends of the patient and staff.

5.1.9 Care of the patient following ingestion or intravenous administration of lethal VAD substance – hospitals, health service establishment based and inpatient services

• ALL STAFF: Any instance involving the care of a patient following ingestion or intravenous administration of VAD substance will activate an immediate Tier 2 response if not already activated.

• ALL STAFF: If a patient under the care of any Calvary service has ingested or been administered the VAD substance and it has not caused death, Calvary staff will continue to provide care to the person. Normal decision-making protocols relevant to the patient’s clinical condition and wishes and preferences regarding treatment will be followed.

• ALL STAFF: If a patient under the care of any Calvary service has ingested the VAD substance and it has caused death, Calvary staff will follow all normal decision making protocols relevant to deceased persons, including any specific reporting requirements related to VAD under the relevant VAD Act or as required by Calvary.

• Calvary staff should refer management of any unused substance or the locked box to the nominated ‘Contact Person’ as appointed by the patient under the relevant VAD legislation.

• Calvary staff will not assume responsibility for any unused substance or the locked box, unless it poses an immediate danger to patients, visitors or staff which will be immediately escalated to a Tier 2 responder.

• TASMANIA ONLY:, In consultation with the patient, Tier 2 responders, regional executive team and GM, the Tasmania Health Service Protocol for Voluntary Assisted Dying: Medication Management in THS Medical Facilities must be followed whilst substance is in a Calvary facility.

• In each of these cases, Calvary will provide necessary care and bereavement support to those who may be distressed by the situation, including the medical treatment decision makers, family and friends of the patient and staff. It may also be appropriate to referral people to their spiritual advisors for care.

• Staff involved in the care of a patient following ingestion or intravenous administration of VAD substance should be offered appropriate support and provided with the contact details for the Employee Assistance Program.

5.1.10 Responding to requests for specialist opinion by the VAD ‘Consulting Practitioner’ – hospitals, health service establishment based and inpatient services

Calvary employs a range of specialist health practitioners with appropriate skills and training to provide specialist clinical care to patients registered with our services. From time to time, under the normal course of our care for a patient, our specialists may be called upon with the consent of the patient to provide information to a third party to assess and confirm whether a person has decision-making capacity, to confirm the person’s disease/illness, to confirm the impacts of the person’s disease/illness and to confirm prognosis.

In all jurisdictions with VAD legislation, the relevant VAD legislation provides for a ‘Consulting Practitioner’ or equivalent who is undertaking the task of assessing a person’s eligibility for VAD, to refer to other specialist medical practitioners or other healthcare practitioners for a specialist opinion relating to a person’s capacity to make decisions and their disease/illness to support their own assessment of the person’s eligibility for accessing VAD.

• ALL requests for such an opinion will be escalated, generally within 24 hours, to a Tier 2 responder for discussion to ensure an appropriate plan of action is undertaken and that further clinical, ethical and legal advice is sought as necessary.

• Under no circumstances, may a Calvary specialist medical practitioner or other health practitioner provide a specialist opinion regarding a person for whom Calvary are not already providing services. Under no circumstances can a new external referral be accepted specifically for this purpose. Such an action would be viewed as formal cooperation and constitute the purposeful or intentional facilitation of someone accessing or undertaking VAD.

• Where a referral has been received for a patient with their consent who is known to and receiving services from Calvary; in consultation with the Tier 2 responder, other Tier 2 responders, regional executive team and the GM,^{^[2]} the specialist may provide information to confirm whether a person has decision-making capacity, to confirm the person’s disease/illness, to confirm the impacts of the person’s disease/illness and to confirm prognosis. This is consistent with the usual care provisions for a Calvary patient and is recognised as licit material cooperation. For further explanation of material cooperation, see 7.1.  All referrals and responses will be documented in the patient’s clinical record.

5.1.11 Evaluation of Outcomes – hospitals, health service establishment based and inpatient services Calvary services involved in responding to the VAD legislation will:

• Have in place data collection processes to record the quality and access to care with respect to the VAD legislation;

• Participate in reviews and reporting of the response to VAD legislation within organisational governance committees;

• Contribute to organisation wide review with regard to VAD response implementation.

Residential Care Services

5.1.12 Not initiating discussions about ‘Voluntary Assisted Dying’ – residential care services

Calvary staff must not initiate discussions about VAD with residents or residents’ families. This requirement is consistent with Calvary’s Position Statement on Voluntary Assisted Dying and the legal requirements in some jurisdictions.

5.1.13 Exceptions to 5.1.12

If staff become aware that a resident has initiated a discussion about VAD, it is important that staff do not ignore this. This includes instances in which the resident has initiated a VAD discussion with a health practitioner at an external/non-Calvary health service.

Calvary staff may discuss VAD with a resident if they have confirmed that the resident has previously initiated a discussion about VAD with a health practitioner. The health practitioner can be either from within Calvary or from an external/non-Calvary health service.

This may be confirmed by the resident’s clinical record, the health practitioner with whom the resident raised the issue of VAD or other processes in standard clinical practice, e.g. hospital discharge summaries or clinic letters. However, staff must not ask the resident for confirmation, as this would be initiating a discussion about VAD, which is inconsistent with Calvary’s position and illegal in some jurisdictions.

5.1.14 Responding to ‘desire to die’ statements (DTDS) – residential care services

It is not uncommon for residents who are approaching the end of their lives to make statements expressing a desire to die or to have their death hastened. Whilst such statements can be confronting for staff, it is important to acknowledge the statement and to not:

o ignore the statement; o dismiss the statement as transient; o monopolise the conversation; o focus solely on physical issues/concerns; o change the topic; o offer premature or false reassurance.

Refer to Appendix 5: ‘Desire to Die Statements’ (DTDS) Guideline for further guidance.

A DTDS may not constitute a request for VAD, and should not automatically be assumed to be a request or desire for VAD.

All DTDS expressed by a resident will initiate a Tier 1 response.

NOTE FOR STAFF OF CALVARY SERVICES WHICH HAVE A SUICIDE RISK MANAGEMENT PROCEDURE IN PLACE:

Where the DTDS is NOT an explicit request for access to VAD, staff should also refer to the relevant suicide risk management procedure and complete a risk assessment in response to the DTDS.

• ALL STAFF: Calvary staff who receive any expressed DTDS from a resident will respond with respect and compassion and will initiate a Tier 1 response consistent with their local guideline and in alignment with Appendix 2.

• Tier 1 responders will:

o be alert to their own responses;

o through active listening, be open in their manner of hearing the resident’s concerns; o assess potential contributing factors;

o address potentially reversible issues and make appropriate referrals to other members of the treating team to support this;

o document the conversation and plan of management in the resident’s clinical record;

• If concerns regarding the resident are unable to be satisfactorily addressed by the primary team and Tier 1 responders, these concerns will be escalated to a Tier 2 responder consistent with the local guideline, but generally within 24 hours.

5.1.15 Responding to requests for information about ‘Voluntary Assisted Dying’

• All requests for information about VAD must be received in a compassionate and respectful manner.

• If a resident commits to accessing further information about or assessment for VAD through appropriate channels outside of our local services, Calvary staff will continue to accompany the resident and provide all normal care to them.

• ALL STAFF: If a resident requests information about VAD, Calvary staff will disclose the following: a. That our services do not provide VAD;

b. That they can be referred to a health professional within our services who is qualified to engage in discussions about their concerns and their end of life care;

c. That the relevant Department of Health provides information regarding VAD. At a resident’s request, Calvary staff will provide available contact information for the relevant VAD navigator service.

• Residents who agree to engage in further discussions will be directed to a Tier 1 responder for further consultation.

• All requests for information about VAD and any further discussions will be recorded in the resident’s clinical record.

5.1.16 Responding to formal and informal requests for access to ‘Voluntary Assisted Dying’ – residential care services

• All requests for VAD must be received in a compassionate and respectful manner.

• Any request for VAD will activate a Tier 1 response, generally within 24 hours.

• If a Calvary credentialed medical practitioner is responding to a formal request for access to VAD, they must:

a. Receive the request in a compassionate and respectful manner;

b. Inform the resident that they are declining the request because they are not credentialed to offer access to VAD and Calvary services do not provide access to VAD;

c. Document the request in the resident’s clinical record;

d. Inform the resident that a medical practitioner outside Calvary services may be able to assist them with this request;

e. Provide the resident with the contact details of the VAD navigator service;

f. If required by the relevant legislation, provide the resident with information about VAD in a form approved by the Voluntary Assisted Dying Review Board (or equivalent) (TAS, NSW);

h. If the medical practitioner is not a Tier 1 responder, notify a Tier 1 responder of the request generally within 24 hours.

• A Tier 1 responder will:

a. Ensure, as appropriate, that the HM and GM have been notified. It is the responsibility of the HM and GM to ensure that the resident’s GP or the appropriate person on the healthcare team are notified.

b. Document the request in the resident’s clinical record;

c. Respond to the resident’s request for VAD in a manner consistent with their capabilities, as described in Table 1 and per the Tier 1 Initial Response Practice Guidance Appendix 2.

• If, after discussion with the Tier 1 responder, a resident still expresses a desire to further explore VAD, alternatives will be explored with clear communication that VAD is not provided in Calvary homes or by Calvary services. The resident may choose to contact the VAD navigator service.

• Once the resident has had a discussion with the VAD navigator service, they may request social leave from care in order to access external providers.

• For social leave from care for the purpose of accessing ‘Voluntary Assisted Dying’, Calvary staff will follow the procedure listed in 5.1.17.

5.1.17 Responding to requests for transfer or leave from care – residential care services

• If a resident requests transfer to another service for the purpose of accessing VAD, Calvary residential homes will continue to care for the resident until such time as that care has been assumed by an appropriate receiving provider. This may include being involved with arrangements for the resident to be transferred to their preferred location, including any normal clinical handover processes.

• If a resident requests leave from care for a period of time for the purpose of accessing VAD, Calvary residential facilities will follow normal protocols for leave from care.

• If a resident’s care team determines that it is unsafe or overly burdensome for the resident to undergo transfer or be approved for leave from care, this will be escalated, generally within 24 hours, to a Tier 2 responder for further assessment.

• A Tier 2 responder will work with the resident, other Tier 2 responders, HM, regional executive team and GM to determine an acceptable and prudent resolution, taking into account their preferences for care as well as clinical, ethical and legal advice as necessary.

5.1.18 Responding to a resident in possession of lethal ‘Voluntary Assisted Dying’ substance – residential care services

• ALL STAFF: Where a resident, their nominated ‘Contact Person’ or their ‘Coordinating Practitioner’ is known to be in possession of the VAD substance, Calvary facilities will request that they refrain from bringing substances intended to cause death under the VAD legislation into the home.

• If a resident brings the VAD substance into a Calvary home or has the substance delivered, the issue will be immediately escalated to a Tier 2 responder.

• The Tier 2 responder will work with the resident, other Tier 2 responders, HM, regional executive team and GM to determine an acceptable and prudent resolution, taking into account their preferences for care as well as clinical, ethical and legal advice as necessary.

• Document the plan of management in the resident clinical record.

• TASMANIA ONLY: In Tasmania, VAD substances are considered Schedule 4 or Schedule 8 drugs. Normal decision-making protocols for the storage of Schedule 4 and Schedule 8 drugs should be followed, in consultation with the resident, Tier 2 responders, regional executive team and GM.

5.1.19 Responding to a resident planning to ingest lethal ‘Voluntary Assisted Dying’ substance or have the substance administered intravenously – residential care services

• ALL STAFF: If a resident has indicated that they are planning to ingest a VAD substance or have a VAD substance administered by an ‘Administering Practitioner,’ the issue will be immediately escalated to a Tier 2 responder.

• A Tier 2 responder will ensure that the HM and GM are notified. It is the responsibility of the HM and the GM to ensure that the resident’s GP or the appropriate person on the resident’s health care team is notified.

• A Tier 2 responder will discuss with the resident:

a. Calvary staff cannot provide the resident with any support beyond usual care. If the resident wants support people present during the process, they will need to discuss this with family and friends;

b. If the Calvary home is the best place for them to undertake VAD or if there is somewhere else they feel more comfortable;

c. If the resident is planning to self-administer the VAD substance, a Tier 2 responder will request the contact details of the nominated ‘Contact Person’ as appointed by the resident under the relevant VAD Act. Calvary will take no responsibility for any unused substance or locked box, unless it poses an immediate danger to residents, visitors or staff. The contact person has a legal obligation to return any unused substance to the dispensing pharmacist (TASMANIA: See note below);

d. If the resident is planning to have the VAD substance administered intravenously by an administering practitioner, a Tier 2 responder will request the contact details of the administering practitioner.

• If the resident is in a shared room with other residents, it should be considered whether, for the privacy of the resident and respect for other residents, the resident ought to be moved into a separate room without any other residents.

• If other residents residing in the same room have already been informed by the resident of their VAD intention and these other residents express a desire not to be present, every effort should be made to respect that wish.

• The Tier 2 responder, working with the resident, other Tier 2 responders, HM, regional executive team and GM, will update a care plan and establish a risk management plan to include:

a. The timeframe in which the resident plans to ingest or have the VAD substance administered;

b. If the resident is planning to have the VAD substance administered by a practitioner, liaison with the

‘Administering Practitioner’ and VAD Navigator Service, where appropriate;

c. If the resident is planning to ingest the VAD substance, a record of contact details for the contact person, who will return any unused substance to the dispensing pharmacist;

d. Care of residents and staff in the immediate aftermath of the event and ongoing impact;

e. Reporting requirements following the death of a resident by VAD substance.

5.1.20 Responding to requests to be present or assist whilst person self-administers or is assisted to administer the lethal VAD substance – residential care services

• ALL STAFF: Calvary staff must NOT be present or assist whilst a person self- administers or is supported to administer the VAD substance.

• Calvary staff must respond to the resident’s request with respect and compassion, in a manner consistent with their capabilities, as described in Table 1 and in alignment with Appendix 1.

• Calvary staff must disclose the following:

a. That our staff are not permitted to facilitate or be present whilst a person is undertaking VAD;

b. That they can be referred to a health professional within our services who is qualified to engage in discussions about end of life care;

c. That the resident may wish to discuss their request with members of their own support network, their nominated ‘Contact Person’ as prescribed in the relevant VAD legislation or the VAD navigator service.

• Any request to be present whilst a person self-administers or is assisted to administer the VAD substance will activate a Tier 1 response generally within 24 hours.

• A Tier 1 responder will:

a. Ensure, as appropriate, that the HM and GM are notified. It is the responsibility of the HM and the GM to ensure that the resident’s GP or the appropriate person on the resident’s health care team is notified.

b. Document the request and management plan in the resident’s clinical record;

c. Respond to the resident’s request for VAD in a manner consistent with their capabilities, as described in Table 1.

d. Reassure the resident that we will continue to provide usual care to them and will also provide necessary care and bereavement support to those who may require support in this situation, including medical treatment decision makers, support persons, family and friends of the resident and staff.

5.1.21 Care of the resident following ingestion or intravenous administration of lethal ‘Voluntary Assisted Dying’ substance – residential care services

• ALL STAFF: Any instance involving the care of a resident following ingestion or intravenous administration of VAD substance will activate an immediate Tier 2 response if not already activated.

• ALL STAFF: If a resident under the care of any Calvary service has ingested or been administered the VAD substance and it has not caused death, Calvary staff shall continue to provide care to the person. Normal decision-making protocols relevant to the resident’s clinical condition and wishes and preferences regarding treatment will be followed.

• ALL STAFF: If a resident under the care of any Calvary service has ingested the VAD substance and it has caused death, Calvary staff will follow all normal decision making protocols relevant to deceased persons, including any specific reporting requirements related to VAD under the relevant VAD Act or as required by Calvary.

• Calvary staff should refer management of any unused substance or the locked box to the nominated ‘Contact Person’ as appointed by the resident under the relevant VAD legislation.

• Calvary staff will not assume responsibility for any unused substance or the locked box, unless it poses an immediate danger to residents, visitors or staff which will be immediately escalated to a Tier 2 responder.

• In each of these cases, Calvary will provide necessary care and bereavement support to those who may be distressed by the situation, including medical treatment decision makers, family and friends of the resident, other residents and staff. It may also be appropriate to referral people to their spiritual advisors for care.

• Staff involved in the care of a resident following ingestion or intravenous administration of VAD substance should be offered appropriate support and provided with the contact details for the Employee Assistance Program.

5.1.22 Evaluation of Outcomes – residential care services

Calvary services involved in responding to the VAD legislation will:

• Have in place data collection processes to record the quality and access to care with respect to the VAD legislation;

• Participate in reviews and reporting of the response to VAD legislation within organisational governance committees;

• Contribute to organisation wide review with regard to VAD response implementation.

Community Care Services

5.1.23 Not initiating discussions about ‘Voluntary Assisted Dying’ – community care services

Calvary staff must not initiate discussions about VAD with clients or clients’ families. This requirement is consistent with Calvary’s Position Statement on Voluntary Assisted Dying and the legal requirements in some jurisdictions.

5.1.24 Exceptions to 5.1.23

If staff become aware that a client has initiated a discussion about VAD, it is important that staff do not ignore this. This includes instances in which the client has initiated a VAD discussion with a health practitioner at an external/non-Calvary health service.

Calvary staff may discuss VAD with a client if they have confirmed that the client has previously initiated a discussion about VAD with a health practitioner. The health practitioner can be either from within Calvary or from an external/non-Calvary health service.

This may be confirmed by the client’s clinical record, the health practitioner with whom the client raised the issue of VAD or other processes in standard clinical practice, e.g. hospital discharge summaries or clinic letters. However, staff must not ask the client for confirmation, as this would be initiating a discussion about VAD, which is inconsistent with Calvary’s position and illegal in some jurisdictions.

5.1.25 Responding to ‘desire to die’ statements (DTDS) – community care services

It is not uncommon for clients who are approaching the end of their lives to make statements expressing a desire to die or to have their death hastened. Whilst such statements can be confronting for staff, it is important to acknowledge the statement and to not:

o ignore the statement; o dismiss the statement as transient; o monopolise the conversation; o focus solely on physical issues/concerns; o change the topic; o offer premature or false reassurance.

Refer to Appendix 5: ‘Desire to Die Statements’ (DTDS) Guideline for further guidance.

A DTDS may not constitute a request for VAD, and should not automatically be assumed to be a request or desire for VAD.

All DTDS expressed by a client will initiate a Tier 1 response.

NOTE FOR STAFF OF CALVARY SERVICES WHICH HAVE A SUICIDE RISK MANAGEMENT PROCEDURE IN PLACE

(e.g. CHCB): Where the DTDS is NOT an explicit request for access to VAD, staff should also refer to the relevant suicide risk management procedure and complete a risk assessment in response to the DTDS.

• ALL STAFF: Calvary staff who receive any expressed DTDS from a client will respond with respect and compassion and will initiate a Tier 1 response consistent with their local guideline and in alignment with Appendix 2.

• Tier 1 responders will: o be alert to their own responses;

o through active listening, be open in their manner of hearing the client’s concerns; o assess potential contributing factors;

o address potentially reversible issues and make appropriate referrals to other members of the treating team to support this;

o document the conversation and plan of management in the client’s clinical notes;

• If concerns regarding the client are unable to be satisfactorily addressed by the primary team and Tier 1 responders, these concerns will be escalated to a Tier 2 responder consistent with the local guideline.

5.1.26 Responding to requests for information about ‘Voluntary Assisted Dying’ – community care services  All requests for information about VAD must be received in a compassionate and respectful manner.

• If a client commits to accessing further information about or assessment for VAD through appropriate channels outside of our local services, Calvary staff will continue to accompany the client and provide all normal care to them.

• ALL STAFF: If a client requests information about VAD, Calvary staff will disclose the following: a. That our services do not provide VAD;

b. That they can be referred to a health professional within our services who is qualified to engage in discussions about their concerns and their end of life care;

c. That the relevant Department of Health provides information regarding VAD. At a client’s request, Calvary staff will provide available contact information for the relevant VAD navigator service.

• Clients who agree to engage in further discussions will be directed to a Tier 1 responder for further consultation.

• All requests for information about VAD and any further discussions will be recorded in the client’s clinical record.

5.1.27 Responding to requests for access to ‘Voluntary Assisted Dying’ – community care services

• ALL STAFF: Calvary staff must respond to the client’s request with respect and compassion, in a manner consistent with their capabilities, as described in Table 1 and in alignment with Appendix 1.

• Any request for VAD will activate a Tier 1 response, generally within 24 hours.

• A Tier 1 responder will:

a. Ensure, as appropriate, that the clinical manager has been notified;

b. Document the request in the client’s clinical record;

c. Respond to the client’s request for ‘Voluntary Assisted Dying’ in a manner consistent with their capabilities, as described in Table 1 and per the Tier 1 Initial Response Practice Guidance Appendix 2;

a. If, after discussion with a Tier 1 responder, the client still expresses a desire to further explore VAD, alternatives will be explored with clear communication that VAD is not provided by Calvary services. The client may choose to contact the VAD navigator service.

5.1.28 Responding to a client in possession of lethal VAD substance – community care services

• ALL STAFF: Where it is known that a client is in possession of the VAD substance within their home, Calvary staff will not assume any responsibility for the substance. This requirement is consistent with the legislation in all jurisdictions.

• Where it is known that a client is in possession of the VAD substance within their home, Calvary staff will request the contact details of the client’s nominated ‘Contact Person’ appointed under the relevant VAD legislation and document the contact details in the client’s clinical record.

• Where it is known that a client is in possession of the VAD substance, this information shall be immediately escalated to a Tier 2 responder and documented in the client’s clinical record.

• The Tier 2 responder will work with the client, the Calvary community team involved in the client’s care, other Tier 2 responders, the regional executive team and the GM, to ensure all parties are well supported. Where there are any concerns an acceptable and prudent resolution will be sought, taking into account the client’s preferences for care as well as clinical, ethical and legal advice as necessary. The decision-making process and outcome are to be documented.

5.1.29 Responding to requests to be present or assist whilst a client self-administers or is assisted to administer the lethal VAD substance – community care services

• ALL STAFF: Calvary staff must NOT be present or assist whilst a person self- administers or is supported to administer the VAD substance.

• Calvary staff must respond to the client’s request with respect and compassion, in a manner consistent with their capabilities, as described in Table 1 and in alignment with Appendix 1.

• Calvary staff must disclose the following:

a. That our staff are not permitted to facilitate or be present whilst a person is undertaking VAD;

b. That they can be referred to a health professional within our services who is qualified to engage in discussions about end of life care;

c. That the client may wish to discuss their request with members of their own support network or their nominated ‘Contact Person’ as prescribed in the relevant VAD legislation or the VAD navigator service.

• Any request to be present whilst a person self-administers or is administered the VAD substance will activate a Tier 1 response generally within 24 hours.

• A Tier 1 responder will:

a. Ensure, as appropriate, that the senior clinical leader is notified;

b. Document the request and management plan in the client’s clinical record;

c. Respond to the client’s request for VAD in a manner consistent with their capabilities, as described in

Table 1;

d. Reassure the client that we will continue to provide usual care to them and will also provide necessary care and bereavement support to those who may require support in this situation, including medical treatment decision makers, support persons, family and friends of the client and staff.

5.1.30 Care of the client following ingestion or intravenous administration of lethal VAD substance – community care services

• ALL STAFF: Any instance involving the care of a client following ingestion or intravenous administration of VAD substance will activate an immediate Tier 2 response if not already activated.

• ALL STAFF: If a client under the care of any Calvary service is found having ingested or been administered the VAD substance and it has not caused death, Calvary staff shall continue to provide care to the person. Normal decision-making protocols relevant to the client’s clinical condition and wishes and preferences regarding treatment will be followed.

• ALL STAFF: If a client under the care of any Calvary service has ingested the VAD substance and it has caused death, Calvary staff will follow all normal decision making protocols relevant to deceased persons, including any specific reporting requirements related to VAD under the relevant VAD Act or as required by Calvary.

• In each of these cases, at no point will Calvary staff assume responsibility for any unused substance or the locked box. Calvary staff should refer management of these to the nominated ‘Contact Person’ as appointed by the client under the relevant VAD legislation.

• In each of these cases, Calvary will provide necessary care and bereavement support to those who may be distressed by the situation, including medical treatment decision makers, family and friends of the client and staff. It may also be appropriate to referral people to their spiritual advisors for care.

• Staff involved in the care of a client following ingestion or intravenous administration of VAD substance should be offered appropriate support and provided with the contact details for the Employee Assistance Program.

5.1.31 Evaluation of Outcomes – community care services

Calvary services involved in responding to the VAD legislation will:

• Have in place data collection processes to record the quality and access to care with respect to the VAD legislation;

• Participate in reviews and reporting of the response to VAD legislation within organisational governance committees;

• Contribute to organisation wide review with regard to VAD response implementation.

6 Related Calvary Documents

• Calvary Position Statement on Voluntary Assisted Dying

• Calvary Responding to Requests for Access to Voluntary Assisted Dying Policy

7 Evidence Summary

The passing of the Voluntary Assisted Dying Act 2017 (Vic) led Catholic health, aged and community services in Victoria through Catholic Health Australia to form the “Voluntary Assisted Dying (VAD)” Act (2017) CHA Response Taskforce. In response to clinical governance issues arising from the introduction of the VAD Act and its impact on Catholic Mission and Identity, the Taskforce formed a working group to specifically address these issues through the development of an appropriate framework that could be adapted and adopted by Catholic providers in Victoria, within the context of their own governance frameworks.

The objectives of this work was to:

1. Recommend a structured competency approach governance system (referred to here as a tiered system) to respond to issues relating to VAD;

2. Provide clinical governance guidelines which reflect the ethics and legal advice consistent with our ethical principles;

3. Recommend policy provisions, guidelines, and education and training designed to support a consistent response.

The CHA Taskforce agreed to a common approach to clinical governance which will enact our ethic of care. This begins with each facility selecting a dedicated executive as the sponsor overseeing the VAD response process, with regular reporting to the NCEO and Board as relevant. It also includes a tiered escalation system for any issues which arise related to VAD, to ensure that appropriate care services and expertise are available to patients, residents and staff.

Following the subsequent passing of VAD legislation in Western Australia, South Australia, Tasmania,

Queensland and New South Wales, the Procedure for Responding to Requests for Access to Voluntary Assisted Dying in Calvary’s Victorian services was reviewed in detail by the Calvary Voluntary Assisted Dying Response Steering Committee and a national procedure was developed, following internal and external consultation.

7.1 Other key concepts underpinning this procedure

‘Voluntary Assisted Dying’ as an intervention is not condoned by the Code of Ethical Standard for Catholic Health and Aged Care Services in Australia (‘the Code’). Nonetheless, the Code includes a framework for assessing issues related to complicity in complex scenarios and provides guidance which underpins this procedure.

The Code uses the language of ‘cooperation’ to refer to issues of complicity. It distinguishes between formal and material cooperation.

Formal cooperation would occur in the context of ‘VAD’ if Calvary or its staff undertook actions which had as their purpose or intention the facilitation of someone accessing or undertaking VAD, such as referring a patient to a doctor who provides VAD with the intention of facilitating the VAD process.

Material cooperation would occur in the context of ‘VAD’ if Calvary or its staff undertook actions which in their purpose and intention are consistent with our ethical framework, but in some way contribute to a person’s accessing or undertaking VAD. For example, commitment to the safe transfer of a fragile patient to another facility in which they seek after ‘VAD’.

Whilst always prohibiting formal cooperation, the Code recognises that material cooperation is sometimes unavoidable, necessary, and therefore tolerable. It encourages healthcare organisations to think carefully about issues related to material cooperation, and such thinking is reflected in our procedure. In this regard, this procedure differentiates referrals from transfers and limits Calvary’s roles to providing the necessary information and linkage of services. Typically, issues related to cooperation will be escalated to Tier 1 or Tier 2 teams, who will have training to support them in their response.

8 Definitions

• Administering practitioner – the healthcare professional accredited to administer the VAD substance to patient. This is usually a medical practitioner, often the coordinating practitioner, but the role may be transferred to a nurse practitioner or registered nurse in some jurisdictions.

• All Staff for the purposes of this policy refers to:

- Every Calvary employee;

- Contractors/sub-contractors and any of their employees whilst engaged on work for Calvary; - Visiting Medical Officers;

- Volunteers and unpaid employees;

- Students on placement;

- Researchers;

- Consultants or consultants’ employees whilst on Calvary work; and - Agents who are acting on behalf of Calvary.

• Calvary refers to the Little Company of Mary Health Care and all of its employing entities.

• Consulting practitioner – the medical practitioner who accepts a referral from the coordinating practitioner to determine whether a person is eligible to access VAD.

• Contact person – the person nominated by the patient/resident/client to return any remaining or unused VAD substance to an authorised disposer, usually the dispensing pharmacist, after the patient/resident/client’s death. In some jurisdictions, the contact person is also authorised to receive the VAD substance from the authorised supplier, usually the dispensing pharmacist, and supply it to the patient/resident/client.

• Coordinating practitioner – the medical practitioner who coordinates a person’s VAD pathway, by accepting a person’s first request for access to VAD and assessing their eligibility for VAD. The coordinating practitioner may also be the administering practitioner and the patient’s nominated contact person.

• ‘Desire to Die’ statement - These statements are described by a variety of terms, such as ‘death talk’ or ‘suicide talk’, and are referred to in the literature as ‘desire to die statements’ (DTDSs). ‘Desire to die’ statements are sometimes thought to underlie suicidal ideation; however, not all DTDSs fall into this category, they may have other foundations not necessarily associated with a specific desire to expedite the dying process.^{^[3]}

• End of life¹ refers to the period when a patient is living with, and impaired by, a fatal condition even if the trajectory is ambiguous or unknown. This period may be years in the case of patients with chronic or malignant disease or very brief in the case of patients who suffer acute and unexpected illness or events such as sepsis, stroke or trauma.

• End of Life Care^{^[4]} includes physical, spiritual and psychosocial assessment, and care and treatment delivered by health professionals and ancillary staff. It also includes support of families and carers, and care of the person’s body after their death.

People are ‘approaching the end-of-life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:

o advanced, progressive, incurable conditions;

o general frailty and co-existing conditions that mean that they are expected to die within 12 months;

o existing conditions, if they are at risk of dying from a sudden acute crisis in their condition; o life-threatening acute conditions caused by sudden catastrophic events.

• Facilitation (or facilitate) - means to take measures to enable a person to access a service (in this case, ‘Voluntary Assisted Dying’), with the intention of supporting their access to this. In the Code of Ethical

Standards this is referred to as formal cooperation. This is to be distinguished from acceptable material cooperation^{^[5]}. The provision of accurate information regarding end of life care options is not considered facilitation of VAD.

• Health practitioner: a health professional eligible for registration with a national board as well as selfregulated practitioners eligible for registration with their national bodies and associations, including speech pathology, social work, exercise physiologists, audiologists and dieticians.

• Palliative Care^{^[6]} an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:

o aims to enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications;

o provides relief from pain and other distressing symptoms; o affirms life and regards dying as a normal process;

o neither hastens nor postpones death;

o integrates the psychological and spiritual aspects of patient care;

o offers a support system to help patients live as actively as possible until death;

o offers a support system to help the family cope during the patients’ illness and in their own bereavement; and

o uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated.

• Refer - means to provide a formal medical referral to another provider with the intention of providing access to a specific treatment or investigation.

• Relevant Voluntary Assisted Dying Legislation – means the Voluntary Assisted Dying Act which is applicable to the jurisdiction in which a particular Calvary facility or Calvary service operates.

o Voluntary Assisted Dying Act 2021 (Qld) o Voluntary Assisted Dying Act 2021 (NSW) o Voluntary Assisted Dying Act 2017 (Vic) o Voluntary Assisted Dying Act 2021 (SA)

o End of Life Choices (Voluntary Assisted Dying) Act (Tas)

• Requests for access to Voluntary Assisted Dying – This refers to when a patient/resident/client makes a formal first request for access to Voluntary Assisted Dying, as described in the relevant VAD legislation.

• Specialist Palliative Care^¹ - Services provided by clinicians who have advanced training in palliative care. The role of specialist palliative care services includes providing direct care to patients with complex palliative needs and providing consultation services to support, advise and educate non- specialist clinicians who are providing palliative care.

• Tier 1 - Responses at this level can be fulfilled by various clinical staff, from specialist doctors to appropriately trained nurses, other allied health personnel, the patient/resident/client GP. Tier 1 responses will be different across our services influenced by existing internal capability and access to professional expertise where it is not internally available. A Tier 1 response may include: referral to specialist palliative care services, up-skilling existing staff to the required level of competency to provide a Tier 1 response, referral to the patient/resident/client GP.

• Tier 2 - Responses at this level are concerned with decision-making in complex scenarios. The Tier 2 team is comprised of senior staff who have decision-making authority, prepare risk mitigation plans, seek advice (such as ethical or legal advice) where needed and provide support for the governance of the system.

• Transfer - means to support the safe and clinically appropriate movement of a patient/resident/consumer from one facility to another, including all relevant communication with the receiving provider and transport arrangements.

• Voluntary Assisted Dying - the term used to describe euthanasia and assisted suicide in the relevant VAD legislation in all jurisdictions.

• Voluntary Assisted Dying Commission/Board/Review Board – the independent body established under the relevant legislation to provide oversight and monitor compliance.

o Voluntary Assisted Dying Review Board (QLD) o Voluntary Assisted Dying Board (NSW) o Voluntary Assisted Dying Review Board (VIC) o Voluntary Assisted Dying Review Board (SA) o Voluntary Assisted Dying Commission (TAS)

• Voluntary Assisted Dying Navigator Service – means the government service established to be a point of contact for people seeking information and assistance with VAD and to provide information about VAD to health practitioner and health care providers.

o Queensland Voluntary Assisted Dying Support Service (QVAD -Support) o Voluntary Assisted Dying Care Navigator Service (NSW) o Statewide VAD Care Navigator Service (VIC) o Voluntary Assisted Dying Care Navigator Service (SA) o Voluntary Assisted Dying Navigation Service (TAS)

• Voluntary Assisted Dying Substance – means a poison or controlled substance or a drug of dependence specified in a voluntary assisted dying permit for the purpose of causing a person’s death under the relevant Voluntary Assisted Dying Act.

9 References

1. Voluntary Assisted Dying Act 2021 (Qld) Voluntary Assisted Dying Act 2021 (NSW)

Voluntary Assisted Dying Act 2017 (Vic)

Voluntary Assisted Dying Act 2021 (SA)

End of Life Choices (Voluntary Assisted Dying) Act (Tas)

2. Catholic Health Australia, Code of Ethical Standards for Catholic Health and Aged Care Services in Australia (Deakin West: Catholic Health Australia, 2001), Part 2, no. 1.13; 1.14; 1.15; 1.16; 5.21, Sec 8.

3. Catholic Health Australia, Excellence in end-of-life care: A Restatement of Core Principles Revision Oct 18

4. Code of Ethical Standards, Part 2, no. 1.13; 1.14; 1.15; 1.16; 5.21.

5. World Health Organization, definition of palliative care, 2004 and WHO fact sheet 2015.

6. National Palliative Care Strategy Draft 2.1, Commonwealth Dept. of Health, October 2017.

7. Apostolic Exhortation Evangelii Gaudium of the Holy Father Francis to the Bishops, Clergy, Consecrated Persons and the Lay Faithful Chapter 3, N.169-173, Personal accompaniment in process of growthⁱ

8. Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe high quality end of life care. 2015.

9. Radbruch L, Leget C, Bahr P, Müller-Busch C, Ellershaw J, de Conno F, et al. Euthanasia and physicianassisted suicide: A white paper from the European Association for Palliative Care. Palliat Med. 2016 Feb;30(2):104–16.

10. Hudson PL, Schofield P, Kelly B, Hudson R, O'Connor M, Kristjanson LJ, Ashby M, Aranda S., Responding to desire to die statements from patients with advanced disease: recommendations for health Professionals; Palliative Medicine 2006 Oct;20(7):703-10.

10
Appendices

10.1 Appendix 1

ALL STAFF ‘CARE(R)’ Response Guideline

What do I do if I am asked a difficult question?

When considering your response to a difficult question, it can be hard to think of the right things to say in that moment. One easy way to do this is to use the CARE(R) approach:

C (Clarify)

A (Acknowledge)

ALL STAFF

R (Respond)

E (Escalate)

R (Resources) Clinical Staff

CARE(R)

C- Clarify

Clarifying questions:

• Ensure we have understood the person correctly;

• Assists us to obtain essential information; and

• Are simple to ensure we have the correct information.

Examples of clarifying questions:

• Did I hear you say….?

• Did I understand correctly when you said….?

• What did you mean when you said….?

CARE(R)

A- Acknowledge

It is important to acknowledge the concern/statement the patient has raised and not to ignore it because it is too hard.

By acknowledging their concern/statement we are showing that we care.

Some examples of statement you can use that show you are acknowledging the patients include:

• “That must be really hard for you”.

• “I am sorry that you are going through this”.

• “That sounds really challenging”.

• “This must be hard to talk about, thank you for opening up to me”.

CARE(R)

R- Respond

By understanding what the patient is telling us and acknowledging what they are experiencing, we need to ensure they know we are going to take action.

It is important to tell them how you will respond to what they have told you.

Some examples of ways you can respond include:

• “I can see this is upsetting for you, so I would like to speak to [a colleague] who will be able to talk through ways we can help you. Is this ok with you?”

• “We have a team that can support you and discuss this further. Could I organise for someone from the team to come and see you?”

• “Let’s see if we can get on top of the [symptom] that you are experiencing now, then I think it would be helpful for you to talk to one of our specialists in this area who can provide you with more support and advice.”

CARE(R)

E- Escalate

It is important you do what you have said you are going to do. You must escalate to the appropriate person, whether this is your manager or an identified Tier 1 or Tier 2 responder that are available to help you.

If you are responsible for documenting, ensure you have documented all the information in the patient notes. If not ensure you have provided as much information to your manager/specialist team, so they can document appropriately.

Remember: Documentation into patient notes must be objective. You must only document the facts, not your opinion on the situation with which you were presented.

⁷ St John of God Health Care Group Learning and Development – ALL STAFF Training Module

CARE(R)

R –Resources

If you are a health professional and feel comfortable to do so, you may want to provide resources on palliative/supportive care or symptom management you have available.

10.2 Appendix 2

TIER 1 Initial Response Practice Guidance

When first making contact with a patient/resident/client following an escalation for follow-up form an ‘All Staff’ responder it is important that the Tier 1 responder utilises the CARE(R) approach, and during their interaction with the patient/resident/client uses open ended questions that enable the person to describe what further support or information they require in their own words.

Consider the following scenario and question that arises:

- A person raises VAD with an ‘all staff’ responder

- ‘All staff’ responder escalates to ‘Tier 1’

- Tier 1 contacts in person or phone (with preference for in person) the patient/resident/client to discuss further – can a Tier 1 responder directly bring up VAD, or must they wait for patient to raise it?

The following advice is provided to assist Tier 1 staff responding to such a request:

- The best approach to the above scenario would be for the Tier 1 responder to meet with/speak with the patient/resident/client and let them know they are making contact with them following their previous conversation with [name ‘all staff’ responder] and then to ask an open ended question that enables the person to state in their own words what they would like to discuss. As an example, “Can you tell me more about the issues you raised with ‘x’?” Or “When you were speaking with ‘x’, you raised some questions about your end of life care, can you tell me a bit more about what is concerning you or information you are seeking?”

- The person may then not raise VAD, however, this is ok and would not be considered a failure to answer their initial request. It could be a situation where there had been an incorrect interpretation by the ‘all staff’ responder that VAD was what they were asking about. Or it could be that an appropriate initial response was provided which alleviated some of the persons concerns.

- If the Tier 1 responder is concerned that the person may have more they wish to discuss, or feels that it would be beneficial to the patient/resident/client, they may also organise a further meeting with them as part of the Tier 1 conversation if they didn’t raise VAD, but you think they might want to discuss it.

- The Tier 1 responder may also speak to the ‘All Staff’ responder who escalated the discussion to clarify and discuss with the broader team if concerns remain.

- If there are any concerns from the Tier 1 responder or the broader care team, the matter should be escalated to a Tier 2 responder for further advice.

10.3 Appendix 3

Tiered Response Guideline: hospitals, health service establishment based and inpatient services

Calvary has adopted a tiered governance and escalation system to ensure a consistent, ethical and compassionate approach when responding to patients, residents or clients who express a desire for information or access to Voluntary Assisted Dying; and to ensure all staff have the appropriate level of competency and support to respond to such requests.

The tiered system is comprised of the following levels of response, with escalation pathways between each tier articulated in the Responding to Requests for Access to Voluntary Assisted Dying Procedure.

At all Calvary services:

• All Staff

• Tier 1

• Tier 2

All Staff; including contractors, volunteers, visiting medical officers, students will:

• Be aware of the organisation’s position on Voluntary Assisted Dying;

• Perform their duties in a manner consistent with the requirements of the Calvary Responding to Requests for Access to Voluntary Assisted Dying Policy and Procedure

• Be aware of how to escalate to Tier 1 or Tier 2 response where required through the following roles.

Tier 1 – Staff with Professional Expertise:

Tier 1 responders have capability which enables them to provide relevant professional expertise for discussions about options for patient/resident/client end of life care. All Tier 1 responders will undertake VAD training relevant to Tier 1. Tier 1 responders are expected to discuss VAD scenarios with other Tier 1 responders to ensure peer support and robust decision making.

Roles which may include Tier 1 responsibilities include Nursing Coordinator, NDIS Coordinator and within the inpatient setting:

• NUM, ANUM, CNC

• Allied Health Grade 3/senior roles within the specific discipline  Medical consultants

Tier 2 – Senior clinicians, Executives and Managers with Decision Making Authority and Competency: Tier 2 responders have capability which enables them to take responsibility for decision-making in complex scenarios, will undertake training relevant to Tier 2 and are responsible for:

• Having decision-making capability and authority in complex cases;

• Informing relevant stakeholders (internal and external);

• Preparing risk mitigation plans;

• Seeking advice (such as ethical or legal advice) where needed;

• Taking the overall responsibility in both responding to complex cases and providing support for the governance of the system;

• Discussing complex scenarios with other Tier 2 responders to ensure the best decision-making in complex scenarios.

Where appropriate, inpatient services will work in liaison with Calvary aged care and community services to provide a collaborative response and to assist organisational learning in responding to VAD issues.

10.4 Appendix 4

Tiered Response Guideline: Residential and Community Care Based Services

Calvary has adopted a tiered governance and escalation system to ensure a consistent, ethical and compassionate approach when responding to patients, residents or clients who express a desire for information or access to Voluntary Assisted Dying; and to ensure all staff have the appropriate level of competency and support to respond to such requests.

In Calvary aged care and community care services, All Staff including contractors, volunteers, visiting medical officers, students will:

• Be aware of the organisation’s position on Voluntary Assisted Dying;

• Perform their duties in a manner consistent with the requirements of the Calvary Responding to Requests for Access to Voluntary Assisted Dying Policy and Procedure;

• Be aware of how to escalate to Tier 1 or Tier 2 response where required.

Tier 1 – Staff with Professional Expertise

Tier 1 responders have capability which enables them to provide relevant professional expertise for discussions about options for patient/resident/client end of life care. In Calvary aged care and community care services, all Tier 1 responders will undertake VAD training relevant to Tier 1.

In community care services, roles with Tier 1 responsibilities include:

• Case Managers

• Service Coordinators

In aged care services, roles with Tier 1 responsibilities include:

• Home Managers

• Clinical Care Mangers

• General Managers

Tier 2 – Senior clinicians, Executives and Managers with Decision Making Authority and Competency: Tier 2 responders have capability which enables them to take responsibility for decision-making in complex scenarios, will undertake training relevant to Tier 2 and are responsible for:

• Having decision-making capability and authority in complex cases;

• Informing relevant stakeholders (internal and external);

• Preparing risk mitigation plans;

• Seeking advice (such as ethical or legal advice) where needed

• Taking the overall responsibility in both responding to complex cases and providing support for the governance of the system;

• Discussing complex scenarios with other Tier 2 responders to ensure the best decision-making in complex scenarios.

Where appropriate, inpatient services will work in liaison with Calvary aged and community care services to provide a collaborative response and to assist organisational learning in responding to VAD issues.

10.5 Appendix 5

‘Desire to Die Statements’ (DTDS) Guideline

A DTDS may not constitute a request for VAD, and should not automatically be assumed to be a request or desire for VAD.

DTDS may include, but not be limited to, statements such as:

• “I’m ready to die”

• “I just want this to be over”

• “I’ve had enough”

• “I’ve heard that I can now get access to a substance to help me end this, is that something you can help me with?”

The first 3 statements would not constitute a persons expressed wish for access to VAD, and should be responded to according 5.1.2 of this procedure. The last statement would constitute an acceptable request for information regarding VAD and should be responded to according to 5.1.3 of this procedure and staff should also refer to the relevant suicide risk management procedure and consider completion of a risk assessment in response to the DTDS.

‘Responding to emotional cues: general recommended principles’^{^[7]}

1. Be alert to your own responses

- Adopt an open posture; be aware of your own emotional response at each stage of the conversation

- Be aware that your response can shape the communication; e.g. if you convey a sense of shock or bewilderment, impatience or your own feelings of futility, this may have a negative effect or it may limit the conversation to follow

- Monitor your attitudes and responses to DTDSs; seek help from colleagues or a supervisor if necessary - Show regard for the person by your verbal and non-verbal behaviour

2. Be open to hearing concerns

- Ask questions that gently probe emotional concerns

- Be alert to verbal and non-verbal signs of psychological distress

- Encourage the person, by sensitive prompting where necessary, to express their feelings

- Listen actively without interrupting, seek clarification of feelings and concerns

- Acknowledge the feeling/s being expressed without needing to actively support the desire to die: try to match the words you use with the level of emotion the person is experiencing

- Use silence appropriately; do not rush to fill gaps in the conversation

- Sit quietly through tears

- Express empathy, both by your verbal and non-verbal responses

- Acknowledge there are individual differences in patients’ emotional responses to the impact of lifethreatening illness

3. Assessing the potential contributing factors

- Assess whether the person has appropriate social support

- Assess type and level of formal assistance and/or referral/s that may be required (e.g., psychological, informational resources)

- Assess for psychological distress (e.g., depression/anxiety) and/or existential distress

- Assess for delirium, cognitive change and competence

- Assess level of understanding regarding goals of care and treatment options

- Assess for unrelieved physical symptoms

- Assess for interpersonal factors (e.g. family conflict, conflict with clinical staff)

4. Responding to specific issue/s

- Address potentially reversible causes (as discerned from assessment) and develop plan of management

- Commence planning strategies (e.g. referral, another meeting) for issues that cannot readily be resolved

5. Concluding the discussion

- Summarize main points of discussion; checking your perceptions with the patient’s perceptions

- Ask if there is anything else the patient wants to discuss or if they have any other questions to raise

- Offer assistance to discuss the patient’s situation with others, e.g. in a family meeting

- Indicate your availability for contact to address any questions or concerns and arrange for further appointment to review situation

- Explain that it is important for you to let the other members of the treatment team know about this discussion and reassure them that it will be treated in the strictest confidence within the team

6. After discussion

- Document discussion in medical records

- Advise other members of the treatment team, so they know your perceptions of the person’s emotional state and can assist with follow up and/or referrals

Below are example phrases that could be used when responding to a patient/resident/client who has expressed a DTDS that is not an expressed wish to explore or access VAD. The phrases and questions serve to assist the clinician in attempting to ascertain the nature of the DTDS, and to illicit factors that that may be contributing to the expressed DTDS.^{^[8]}

Phrases/questions to assist in assessing the nature of the DTDS

Questions to consider in assessing factors that may be contributing to the DTDS and initial interventions

‘‘Sometimes people feel so overwhelmed by things that they feel everything is ‘just too much’, would you say that you have felt like that lately?’’ “Do you feel that things will get any better than they are now?’’

‘‘Can you tell me about the things that frighten or concern you the most at the moment?’’ “What are the hardest things at the moment, or things that cause you the greatest worry?”

What have you been able to get interested in lately? What do you find that you can get involved in that interests you or you can enjoy?

Do you feel this (desire to die) more so at any particular time of the day or night, e.g., when your visitors have left

Is the patient fully informed about their disease and prognosis?

Is the patient competent? (Make appropriate referral if patient consents) Is the patient aware of available resources, e.g., referral to another member of the multidisciplinary team?

Is the patient aware of the care options available to them?

Suggest the patient may like to write down their concerns (with assistance if necessary) so the team can focus more clearly on the patient’s feelings at this time.

If feelings of distress have been identified, acknowledge these feelings and gently ask the patient whether they

or in the early hours of the morning or when you first wake up?’’

‘‘Is this feeling there all the time or does it ‘come and go’?’’

“What do you feel could be improved in your care and treatment?”

“Sometimes, going through such times, some people feel disappointed in: their beliefs or faith or feel like people important to them don’t understand. Have you felt this way?

“Could you tell me the things that you most want to do at this point in your life, the things that you value most?

want to talk about it further. Consider referral to another member of the team.

Discuss with the patient and family the possibility of adjusting visiting times to cover the more intense periods of loneliness and isolation.

Recognition of religious/spiritual coping strategies relevant to the patient’s experience and beliefs.

A DTDS may reflect the person’s perception of losing control. If so, what would assist them to maintain control over this final phase of their life?

[1] CHA VAD Response Taskforce Clinical Governance Framework

[2] Until such a maturity level is reached such that Tier 2 responders are confident that the regional executive team and GM no longer need to be habitually involved.

[3] Hudson PL, Schofield P, Kelly B, Hudson R, O'Connor M, Kristjanson LJ, Ashby M, Aranda S., Responding to desire to die statements from patients with advanced disease: recommendations for health Professionals; Palliative Medicine 2006 Oct;20(7):703-10.

[4] Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe high quality end of life care. 2015.

[5] Catholic Health Australia, Code of Ethical Standards for Catholic Health and Aged Care Services in Australia (Deakin West:

Catholic Health Australia, 2001), Part 2, section 8.

[6] World Health Organization, definition of palliative care, 2004 and WHO fact sheet 2015.

[7] Hudson PL, Schofield P, Kelly B, Hudson R, O'Connor M, Kristjanson LJ, Ashby M, Aranda S., Responding to desire to die statements from patients with advanced disease: recommendations for health Professionals; Palliative Medicine 2006 Oct;20(7):703-10.

[8] These phrases and questions have been derived from Hudson PL, Schofield P, Kelly B, Hudson R, O'Connor M, Kristjanson LJ, Ashby M, Aranda S., Responding to desire to die statements from patients with advanced disease: recommendations for health Professionals; Palliative Medicine 2006 Oct; 20(7): 703-10.

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Responding to Requests for Access to

Voluntary Assisted Dying

1 Applies to

This Policy applies to:

 All Calvary employees, Visiting Medical Officers (VMO), students, volunteers, contractors and to any other persons acting on behalf of Calvary Health Care.

2 Purpose

Consistent with Calvary’s Position Statement on Voluntary Assisted Dying , Code of Ethical Standards for Catholic Health and Aged Care Services and our values of hospitality, healing, stewardship and respect, Calvary is committed to providing a consistent, ethical and compassionate approach when responding to patients, residents or clients who express a desire for information or access to Voluntary Assisted Dying (VAD).

3 Responsibilities

LCMHC Board, National CEO, National Executive and Managers

• The Board and senior management of Calvary are responsible for the governance of the organisation.

• The principles and requirements of the National Responding to Requests for Access to Voluntary Assisted Dying Policy and National Responding to Requests for Access to Voluntary Assisted Dying Procedure are applied, achieved and sustained.

Regional CEO, Local Executive, Managers and Supervisors

• The principles and requirements of the Calvary Responding to Requests for Access to Voluntary Assisted Dying Policy and Calvary Responding to Requests for Access to Voluntary Assisted Dying Procedure are applied, achieved and sustained within their services and departments and compliance with these requirements are reported through the required governance reporting mechanisms.

• Will establish and maintain a system within their services to ensure patients, clients and/or residents have timely access to a Tier 1 response.

• Will establish and maintain a Tier 2 response capability within the Executive and Management Team which is designed to take on responsibility for decision-making in complex scenarios.

• Will appropriately monitor, record and report Tier 1 and Tier 2 responses and interventions in order that statistical and qualitative data may inform policy, equip decision makers and demonstrate accountability to those who govern the organisation.

All employees, volunteers, students, VMO’s, Contractors

 Are compliant with this policy in all actions and interactions whilst undertaking their role within or on behalf of Calvary Health Care and across all service settings.

4 Policy

Calvary Health Care does not support euthanasia, assisted suicide or voluntary assisted dying, nor do we recognise these interventions as medical treatments.

Aligned with Our Enduring Commitment to End of Life Care (Catholic Health and Aged Care Services) and Calvary’s position statement , those working within and for our services:

• Will empower patients, residents and clients to actively participate in decision making regarding their care and honour their self-determination through the use of advance care planning; and will recognise the role of substitute decision makers/medical treatment decision makers/agents acting on behalf of the patient, resident or client.

• Will provide holistic, comprehensive end of life care; addressing the physical, spiritual, psychological and social needs of patients, residents, clients and their families, including existential distress with the goal of reducing suffering.

• Aligned to the World Health Organisation definition of palliative care, will neither hasten nor prolong death.

• Will, in alignment with the principles set out in the Spirit of Calvary , respond openly and sensitively to anyone within our care who seeks information about or expresses a wish to consider voluntary assisted dying, or has informed us of their engagement in the VAD assessment process or who has been granted a VAD permit.

• Will actively listen to and accompany any patient, resident or client who is nearing end of life, and will not abandon a person who is in need of care. Any expressed wish to access or explore voluntary assisted dying will be acknowledged with respect and without discrimination; while being clear that our services will not participate in or provide these interventions and that we will continue to provide our usual care.

• Will not facilitate or participate in referrals to nor assessments undertaken for the purpose of a patient, resident or client having access to or making use of the interventions allowed under Voluntary Assisted Dying legislation in any jurisdiction, nor will we provide (or facilitate the provision of) a substance for the same purpose. If a patient or resident wishes to undergo assessment of eligibility for VAD, we will we will follow normal protocols for leave from care, referral outside the service for specialist care and/or transfer to a facility of that person’s choice.

Calvary has adopted a tiered system to ensure a consistent, ethical and compassionate approach when responding to patients, residents or clients who express a desire for information or access to Voluntary Assisted Dying; and to ensure all staff have the appropriate level of competency and support to respond to such requests.

All Staff will be:

• Aware of the organisation’s position on Voluntary Assisted Dying ;

• Aware that they must not initiate discussions about or recommend ‘Voluntary Assisted Dying’;

• Aware that, if they are asked about ‘Voluntary Assisted Dying’, that they need to disclose specific information to the person asking (OR seek out an alternative staff member who can disclose this information) in a timely manner, namely:

1. That their service does not provide VAD nor information about VAD nor refer to VAD services nor facilitate VAD;

2. That there are palliative and care options that their service is able to connect them to, and that they can offer information on those or connect the person in their care to these options if they would like to seek this out; and

3. Are readily able to access written information for patients, clients and/or residents which communicates the available care options;

• Aware of how to document any interactions related to VAD;

• Aware of how to escalate to Tier 1 or Tier 2 response where required.

Tier 1 – Staff with Professional Expertise

All Calvary services will have access to a Tier 1 response capability which is designed to include relevant professional expertise for discussions about options for patient/resident/client end of life care.

A Tier 1 response will:

• Engage in open and sensitive discussion with a patient, resident or client about their end of life concerns;

• Provide advice to patients, residents or clients on end of life care options;

• Provide advice to caregivers on end of life care options;

• Connect patients, residents or clients to end of life care options.

Tier 2 – Executive and Managers with Decision Making Authority and Competency

All Calvary service Executive and Management teams will establish and maintain a Tier 2 response capability which is designed to take responsibility for decision-making in complex scenarios. The Tier 2 team will be comprised of senior staff who have decision-making authority in the services for which they are responsible.

A Tier 2 response will:

• Have decision-making capability and authority in complex cases;

• Inform relevant stakeholders (internal and external);

• Prepare risk mitigation plans;

• Seek advice (such as ethical or legal advice) where needed;

• Take the overall responsibility in both responding to complex cases and providing support for the governance of the system.

Monitoring and Reporting

All Calvary service Executive and Management teams will establish mechanisms to appropriately monitor, record and report Tier 1 and Tier 2 responses and interventions in order that statistical and qualitative data may inform policy, equip decision makers and demonstrate accountability to those who govern the organisation.

5 Related Calvary Documents

• Calvary Position Statement on Voluntary Assisted Dying

• Calvary Responding to Requests for Access to Voluntary Assisted Dying Procedure

6 Definitions

 All Staff for the purposes of this policy refers to:

- Every Calvary employee;

- Contractors/sub-contractors and any of their employees whilst engaged on work for Calvary; - Visiting Medical Officers;

- Volunteers and unpaid employees;

- Students on placement;

- Researchers;

- Consultants or consultants’ employees whilst on Calvary work; and - Agents who are acting on behalf of Calvary.

• Calvary refers to the Little Company of Mary Health Care and all of its employing entities.

• End of life period¹ refers to the period when a person is living with, and impaired by, a life limiting condition even if the trajectory is ambiguous or unknown. This period may be years in the case of people living with chronic or malignant disease or very brief in the case of people who suffer acute and unexpected illness or events such as sepsis, stroke or trauma.

• End of Life Care^{^[1]} includes physical, spiritual and psychosocial assessment, and care and treatment delivered by health professionals and ancillary staff. It also includes support of families and carers, and care of the person’s body after their death.

People are ‘approaching the end-of-life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with: o advanced, progressive, incurable conditions;

o general frailty and co-existing conditions that mean that they are expected to die within 12 months;

o existing conditions, if they are at risk of dying from a sudden acute crisis in their condition; o life-threatening acute conditions caused by sudden catastrophic events.

• Euthanasia - the intentional bringing about of the death of a person in order to relieve suffering. It can be either voluntary or non-voluntary.

• Palliative Care^{^[2]} an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:

o provides relief from pain and other distressing symptoms; o affirms life and regards dying as a normal process;

o neither hastens nor postpones death;

o integrates the psychological and spiritual aspects of patient care;

o offers a support system to help patients live as actively as possible until death;

o offers a support system to help the family cope during the patients’ illness and in their own bereavement; and

o uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated.

• Physician Assisted Suicide - the intentional giving of assistance, by a doctor, to someone to commit suicide.

palliative needs and providing consultation services to support, advise and educate non- specialist clinicians who are providing palliative care.

• Tier 1 - Responses at this level can be fulfilled by various clinical staff, from specialist doctors to appropriately trained nurses, other allied health personnel, the patient/client/resident GP. Tier 1 responses will be different across our services influenced by existing internal capability and access to professional expertise where it is not internally available. A Tier 1 response may include: referral to specialist palliative care services, up-skilling existing staff to the required level of competency to provide a Tier 1 response, referral to the patient/client/resident GP.

• Voluntary Assisted Dying - the term used to describe physician-assisted suicide and euthanasia in Voluntary Assisted Dying legislation in Australia.

7 References

• Voluntary Assisted Dying Act 2017 (Vic) and other similar Acts in Australian jurisdictions.

• Catholic Health Australia, Code of Ethical Standards for Catholic Health and Aged Care Services in Australia (Deakin West: Catholic Health Australia, 2001), Part 2, no. 1.13; 1.14; 1.15; 1.16; 5.21.

• Catholic Health Australia, Excellence in end-of-life care: A Restatement of Core Principles Revision 10-18

• Code of Ethical Standards, Part 2, no. 1.13; 1.14; 1.15; 1.16; 5.21.

• World Health Organization, definition of palliative care, 2004 and WHO fact sheet 2015.

• National Palliative Care Strategy Draft 2.1, Commonwealth Dept. of Health, October

• Apostolic Exhortation Evangelii Gaudium of the Holy Father Francis to the Bishops, Clergy, Consecrated

Persons and the Lay Faithful Chapter 3, N.169-173, Personal accompaniment in process of growthⁱ

• Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe high quality end of life care. 2015.

• Radbruch L, Leget C, Bahr P, Müller-Busch C, Ellershaw J, de Conno F, et al. Euthanasia and physician assisted suicide: A white paper from the European Association for Palliative Care. Palliat Med. 2016 Feb;30(2):104–16.

of 5-

2017.

Approved by: National Director of Mission

Approved Date: 23/11/2021

UNCONTROLLED WHEN PRINTED

Review Date: 23/11/2023

[1] Adapted from the Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe high quality end of life care. 2015.

[2] World Health Organization, definition of palliative care, 2004 and WHO fact sheet 2015.

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Program: Calvary’s Response to Voluntary Assisted Dying

Calvary’s Response to Voluntary Assisted Dying

Preamble

Calvary Health Care

Definitions

ALL STAFF

5.1.1 Not initiating discussions about ‘Voluntary Assisted Dying’ – in hospitals, health service establishment based and inpatient services

5.1.2 Exceptions to 5.1.1

5.1.3 Responding to ‘desire to die’ statements (DTDS) – in hospitals, health service establishment based and inpatient services

5.1.4 Responding to requests for information about ‘Voluntary Assisted Dying’ – in hospitals, health service establishment based and inpatient services

5.1.5 Responding to formal and informal requests for access to ‘Voluntary Assisted Dying’ – in hospitals, health service establishment based and inpatient services

5.1.6 Responding to requests for transfers, discharge and leave from care for the purpose of accessing ‘Voluntary Assisted Dying’ – hospitals, health service establishment based and inpatient services

5.1.7 Responding to a patient in possession of lethal VAD substance – hospitals, health service establishment based and inpatient services

5.1.8 Responding to requests to be present or assist whilst person self-administers or is assisted to administer the lethal VAD substance – hospitals, health service establishment based and inpatient services

5.1.9 Care of the patient following ingestion or intravenous administration of lethal VAD substance – hospitals, health service establishment based and inpatient services

5.1.10 Responding to requests for specialist opinion by the VAD ‘Consulting Practitioner’ – hospitals, health service establishment based and inpatient services

5.1.12 Not initiating discussions about ‘Voluntary Assisted Dying’ – residential care services

5.1.13 Exceptions to 5.1.12

5.1.14 Responding to ‘desire to die’ statements (DTDS) – residential care services

5.1.15 Responding to requests for information about ‘Voluntary Assisted Dying’

5.1.16 Responding to formal and informal requests for access to ‘Voluntary Assisted Dying’ – residential care services

5.1.17 Responding to requests for transfer or leave from care – residential care services

5.1.18 Responding to a resident in possession of lethal ‘Voluntary Assisted Dying’ substance – residential care services

5.1.19 Responding to a resident planning to ingest lethal ‘Voluntary Assisted Dying’ substance or have the substance administered intravenously – residential care services

5.1.20 Responding to requests to be present or assist whilst person self-administers or is assisted to administer the lethal VAD substance – residential care services

5.1.21 Care of the resident following ingestion or intravenous administration of lethal ‘Voluntary Assisted Dying’ substance – residential care services

5.1.22 Evaluation of Outcomes – residential care services

5.1.23 Not initiating discussions about ‘Voluntary Assisted Dying’ – community care services

5.1.24 Exceptions to 5.1.23

5.1.25 Responding to ‘desire to die’ statements (DTDS) – community care services

5.1.27 Responding to requests for access to ‘Voluntary Assisted Dying’ – community care services

5.1.28 Responding to a client in possession of lethal VAD substance – community care services

5.1.29 Responding to requests to be present or assist whilst a client self-administers or is assisted to administer the lethal VAD substance – community care services

5.1.30 Care of the client following ingestion or intravenous administration of lethal VAD substance – community care services

5.1.31 Evaluation of Outcomes – community care services

6 Related Calvary Documents

7 Evidence Summary

8 Definitions

9 References

1 Applies to

2 Purpose

3 Responsibilities

LCMHC Board, National CEO, National Executive and Managers

Regional CEO, Local Executive, Managers and Supervisors

All employees, volunteers, students, VMO’s, Contractors

4 Policy

Tier 1 – Staff with Professional Expertise

Tier 2 – Executive and Managers with Decision Making Authority and Competency

Monitoring and Reporting

5 Related Calvary Documents

6 Definitions

7 References

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