Dr Joanne Wright is an old-age psychiatrist practicing in Sydney. The Catholic Weekly sought her views via email on the push for telehealth to assess patients for voluntary assisted dying (VAD).
What accounts for the push for telehealth VAD?
Few healthcare practitioners want to be involved in the process of VAD assessment and administration. That’s one reason why it’s hard to access VAD in rural areas.
Efforts have been made to swell the numbers of VAD practitioners by allowing registered nurses or nurse practitioners to administer the medication (in some jurisdictions).
Adding telehealth assessments is an attempt to increase access to city-based assessors.
And by the way, to be clear, VAD should not be confused with the withdrawal of futile treatment and palliation of symptoms. This is ethical medical practice.
VAD is the deliberate administration of a poison in order to end a patient’s life.
What’s wrong with telehealth for VAD?
Telehealth for a topic as sensitive as VAD assessments is a blunt instrument and inappropriate.
VAD assessors are not usually the patient’s regular GP or other clinician. They don’t have close familiarity with the patient, their family dynamics, the way they think, their mental health history.
Palliative care and other clinicians know that a patient’s fears often exceed the reality of their medical situation. With accompaniment and good communication, these fears can be allayed. In the palliative care situation, the interpersonal relationship between the patient and healthcare professional is pivotal.
Telehealth puts a physical distance between the patient and clinician, potentially impeding rapport and trust. It may be more difficult to identify emotional cues. Lack of physical touch can negatively affect the relationship and the comfort given to the patient. There can be limitations in detecting non-verbal or even subtle auditory cues and more difficulty in soothing or reassuring patients if they become acutely distressed.
There is a distinct difference between using telehealth to enhance health and quality of life and using it for the purposes of ending a patient’s life. Retaining face-to-face assessments is pivotal as a safeguard.
What gets left out of a telehealth assessment?
Assessing the mental state of medically unwell patients is nuanced. In this population there are high rates of mental disorders such as mood and anxiety disorders, adjustment disorders and cognitive disorders, especially delirium.
These can all be subtle and my clinical experience is that many healthcare professionals miss them when assessing face to face, let alone if the assessment were to be done via telehealth.
The literature also states that mental disorders are under-diagnosed in medically ill patients. Subacute delirium for example can be difficult to detect. This can lead to errors in assessments which represent a safety risk. Such mental disorders distort the judgement of the patient.
How can a psychiatrist help in a VAD assessment?
In my experience, patients often express the wish to die when they are in crisis, frightened, and have a sense of hopelessness. How the doctor responds to them can profoundly shape their ongoing responses.
An excellent study by Prof Brian Kelly, of the University of Newcastle, showed that the patients of doctors with greater training in psychological therapies and who have a more positive outlook are less likely to want assisted suicide.
In other words, a VAD doctor, or any doctor’s attitude, even if subtly conveyed, can influence whether the patient wants assisted suicide.
A patient who asks for VAD is often expressing suicidal ideas. I have heard repeatedly elderly men say: “I’m sick of living, give me a gun”.
Obviously, I have never handed my patient a gun. Instead, I explored why they are saying this.
They often are repeating cliches about how elderly males react to what they perceive to be hopeless situations. Asking for VAD can be another of these clichés – it is an expression of distress and suicidal thinking – which requires exploration and assistance.
We have to ask what are the problems – medical , social or otherwise – that have led to this situation. It is not my job to buy into the patient’s sense of hopelessness and distress but to help with solutions and comfort.
Would telehealth assessments detect coercion?
As an old-age psychiatrist I frequently see varying degrees of coercion occurring. Often this is when finances are involved. Inheritance impatience is a known phenomenon.
Asking the patient “are you being coerced” is clearly a very blunt instrument and likely to miss coercion and situations of emotional and financial abuse. We know that such abuse is common in the Australian population. VAD practitioners must be highly confident that their assessments are infallible.
The data about coercion amongst the elderly is based on survey instruments which are incident-based, so they are unable to capture the ongoing nature and more subtle forms of coercive control in everyday life.
Further, given the way coercive control can restrict a person’s autonomy and deny their personhood, self-reports of controlling behaviour are likely to underestimate true prevalence.
But telehealth worked with COVID, didn’t it?
In the post-COVID medical literature there have been a lot of articles trumpeting how great telehealth is. This seems to have been mainly reported on in terms of its acceptability to patients and clinicians.
Little attention has been paid to limitations or adverse outcomes. In fact, this would be difficult to research – especially in the VAD space where the person in question is dead.
