Since the End of Life Choice Act became law, Dr Kees Lodder has been involved in assisted dying requests. Here, he explains to Alex Casey what the process entails, and what he has learned along the way.
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People always assume it must be depressing to work in death and dying, but I’ve found it to be the most rewarding aspect of medicine to work in. You can alleviate so much suffering for someone, not just physically but also emotionally and spiritually.
I worked for over two decades as a GP before moving into palliative care in both hospitals and hospices. More recently, I’ve been assessing assisted dying requests. I’m very interested in helping people have a good death, and find it fascinating that it remains one of the biggest taboos out there.
When the End of Life Choice Act became law in 2021, I immediately went through the training programme to assess requests. Between 1 April 2022 and 31 March 2023, 328 people completed the process to have an assisted death.
Very few people know what the process actually entails. To begin, any patient can ring the Ministry of Health number (0800 223 852) and speak to one of three excellent and friendly nurses. They will collect all the information, and send it on for a first opinion assessment. The first doctor is called an attending medical practitioner (AMP), who will then contact the patient and write an extensive report on whether they’re eligible or not eligible.
The eligibility criteria is very strict. You need to be 18 or older in New Zealand. You need to be a New Zealand citizen, or a permanent resident. You need to be in an advanced state of irreversible decline in your physical capacity, with less than six months to live. You need to be experiencing unbearable suffering that cannot be released in a tolerable manner, and you need to express your wishes to die free of pressure from anybody else. It’s also crucial that you are able to process all the information and be of sound mind to make the decision.
If the first doctor has decided that you are eligible to continue through the process, you will then see the second doctor. They are referred to as an IMP, or independent medical practitioner, which is what I do. We will talk to your specialists, your GP and hospice staff, and look through all your files to ascertain that you have less than six months to live. It is a very thorough and rigorous process – of those who have applied so far, 16% were deemed ineligible with the first opinion, and a further 3.5% by the second opinion.
I always meet with patients face-to-face, ideally with as much of their whānau present as possible. After I introduce myself and tell them a bit about my background, I always ask them the same, simple, open question: “How are you coping right now?”
From there, it becomes really easy to have an open conversation. I’m always fascinated by what people think will happen when they die. People who say they are not religious at all will come back with the most detailed images of what they think the afterlife looks like. A number of people have told about their vivid and reassuring near-death experiences. We talk about who they want to be there when they die, who they want to remove their body and after how long, and what they want for their funeral. There’s often even room for a few jokes.
After the two assessments are done, your case goes to the registrar to be signed off, at which point you set up an appointment for your assisted death within the next six months. We tell the patients that the whole assessment process could take up to six weeks but it can be done faster depending on the availability of the AMP and IMP. The specific medication can only be dispensed from two pharmacies in the country, and consists of three steps. The first drug is to make you go to sleep, the second is a body relaxant, and then the third stops your heart. I always emphasise that it is a very peaceful process that only takes a few minutes.
What I really find interesting is that those who are seeking out an assisted death often have very little fear of dying. The difference in attitude between people that have come to terms with the fact that they’re dying, compared to people who haven’t ever thought about their own death before, is huge. Research also shows that those who have supported their loved one in the decision to have an assisted death experience a less complex grief process, which makes sense given how much conversation, planning and support there is.
There is definitely a cultural change happening when it comes to death, but there is still a lot more educating to be done. A lot of people don’t know what the process entails, or that they can start it without their GP or specialist. There are still many conscientious objectors in medicine that are opposed to assisted dying, including Hospice New Zealand, certain aged care facilities and individual GPs. My hope is that, one day, all our residential care facilities will accept assisted dying to take place in their premises, since this is the place that so many people call their home.
Even if assisted dying isn’t for you, there is a huge advantage in preparing better for our own deaths and the deaths of our nearest and dearest. We will all lose loved ones, friends and whānau. So by being able to talk about it and having an increased awareness about it, we can be much more accepting of it. I’ve always said that having a plan around your death is the best gift you can give to your family. It’s something we’re all going to face, so why keep your head in the sand until it’s too late?
As told to Alex Casey