Palliative Care and Voluntary Assisted Dying: A Case Study Analysis

This case study examines Melissa, a 37-year-old woman diagnosed with stage 4 colorectal cancer with liver metastases. It explores her palliative care options, including advanced care planning and the potential for voluntary assisted dying, considering the legal changes in Victoria. The study delves into the disease's progression, treatment options, and the emotional, physical, and psychosocial needs of Melissa and her family. It addresses the ethical considerations surrounding end-of-life decisions, the role of palliative care in improving quality of life, and the importance of communication and support for both the patient and her children. The case study also discusses the legal framework for voluntary assisted dying in Australia and the process involved. It also analyzes the implications of the patient's condition and prognosis on her ability to make decisions about her end-of-life care, including the right to determine the time and place of her death. The case study highlights the importance of advanced care planning, including the need for communication among family members and healthcare providers to ensure the patient's wishes are respected.

Palliative care for Stage Four Colorectal
Metastatic Cancer and role of Passive
Euthanasia in Dying with Dignity
The right to determine the time and place to die

Introduction
Melissa is a divorced woman in late thirties, with two children in pre-teens and teens, living
and working alone in Victoria. She has been diagnosed with colorectal cancer stage-4 12
months ago, has undergone a surgery along with Ileostomy and developed metastatic liver,
with poor chances of living maximum for 6 months. Her husband only leverages in financial
shared care over their children; and she is planning for advanced care planning with her
family, concerned about future childcare options for her children. She is opting for palliative
care, as other means of treatment are not working, and through palliative care, she wants to
have the right to determine her place and time of death, corresponding to the recently passed
bill of legalising passive voluntary euthanasia in Victoria in June 2019.
The essay deals with the emerging issue of voluntary euthanasia in Australia, in lieu for
terminally ill patients for bringing good death through compassionate means, by preserving
the dignity and rights of a terminally ill adult patient. Palliative care options, advanced care
planning, childhood care options have also been discussed to throw light on options available
for terminally ill patients and family members in Australia in relation to recently passed bill
of passive euthanasia.
Stage-4 colorectal cancer and treatment options
A stage 4 colorectal bowel cancer involves cancer spreading from colon tissues to liver and
abdominal civility, lungs or lymph nodes. The treatment options vary from surgery by
Ileostomy, chemotherapy, radiation therapy, hepatic artery infusion, Embolization and non-
invasive treatments (Junttila et al., 2015). In case the above-mentioned treatment options are
not successful, a patient prognosis with Stage-4 colorectal cancer opts for palliative care. In
such cases, as invasive treatments cannot improve life span of patients, treatment which eases
discomfort, pain, to make their living conditions better and stress-free. Managing the pain and
reduction of symptoms improves the living conditions of such terminally ill patients. End-of-
life-care options include psychosocial, physical and spiritual assessment and treatment
provided to terminally ill patients meeting their choices of death and last needs of life
(Blaschke, Schofield, Taylor & Ugalde, 2019). Coordinating care, providing advices, nursing,
care-giving, emotional support, respite, and support services involving family, homes and
hospitals to give meaningful addition during time of death.

Palliative treatment and advanced care planning ACP options in Victoria
In may 2019, the Victorian Budget improved better access facilities to palliative care for the
next 4 years, implicating better palliative care options for terminally-ill patients like Melissa
("More than 10,500 Victorians Set to Benefit from Palliative Care Budget Boost - Palliative
Care Victoria", 2019). Palliative Care Victoria is a strategic body contributing widely to
policies on Palliative care in Victoria, envisages in providing palliative care through
collaboration, advocacy and capacity building of caregivers in end-of-life and palliative care
for chronically ill patients. Palliative care does not only include the patients, but involves
families and primary carers in homes, for better accessibility and empowerment of caregivers.
For cancer patients within last-stage in cancer, emotional, physical, practical and spiritual
needs are encompassed by palliative care for providing the highest quality and comfortable
living until death (Fletcher, Hughes, Pickstock & Auret, 2018).
The main aim of palliative care is to integrate feelings of patients, family-members in a
common ground and provide better dying options with comfort for the patient, through
acceptance and endurance (De Lima et al., 2017). In case of Melissa, her estrangement with
her husband and in-laws has led problems for sharing care for her children. Her own parents
are critically ill, which has limited options for future childcare for her teenager children,
increasing problems for Melissa. Through palliative care integration with healthcare systems,
a common point of understanding with her husband and parents can be brought for improving
childcare after her death. Along with this advanced-care options and end-of-life-care options
are also envisaged within ambit of palliative care. Palliative care-includes easing pain, special
aids in homes, assisting in taking with family over sensitive issues, supporting cultural
obligations, counselling, emotional support and respite care provisions (Rosenwax, Spilsbury,
McNamara & Semmens, 2016). Throughout advanced cancer, palliative and end-of-life care
enables in providing comfortable life. However, including voluntary assisted dying is yet
another addition to palliative care, which improves condition of life before death for patients
like Melissa.
Patients through advanced care planning generate decisions along with their family members
so that they can provide their views, lest they become incapable to do so in future. Through
cumulative conversations, communication among healthcare providers, terminally-ill patient
and families, the process is made after proper review of patient needs and preferences
(Johnson, Butow, Kerridge & Tattersall, 2017). In case of Melissa living with Stage-4

colorectal cancer, advanced care plans are made in order to express her views of death and
for protecting her children in the future. Colorectal cancer symptoms are mostly involved
with huge physical pain, blood in passing stools and abdominal pains (Ye, 2016). Advanced
care planning is done so that her husband, parents and in-laws get to know about her
preference of death and for caring for her teenage children.
After talking with the healthcare team, oncologist and specialists, Melissa is sure that she
might have few months to live; Melissa accepts initiating discussions with family members,
through advanced care planning guidelines. For the process to be fruitful, her two children
must be aware of her condition, so that their emotions do not turn into negative attitude.
Moreover, the children should be open to the idea of death of their sole caregiver mother,
with possibility of moving-in with their father after their mother’s death. More time should be
spent with mother for creating better memories, and realistic hope for future should be
provided to the children (Janin, Ellis, Wakefield & Fardell, 2018). For coping with situation,
getting help from social workers, child psychologists, school counsellors are needed, to
enable them to accept their mother’s death. Moreover, Melissa’s latest developments should
be provided to her husband, and his role as the primary care-taker of his children, should be
intimated.
The main role of advanced care planning is to oversee communication among family
members, and enable better connection with husband-wife for upbringing their children.
Melissa needs the advanced care planning, as it will assure her about her children’s prospects
in the future with their father’s help. In addition, ACP will enable learning about palliative
care, provide options of the means of death as preferred by Melissa, and dealing with her
final wishes before death. ACP is generated taking into consideration Fitch’s model of
supportive care and providing interventions at different tiers of critical point for patient’s
support need (Sussman et al., 2017).

Figure: Fitch’s Model of Supportive care
Source: (Sussman et al., 2017)
Overall advanced care plans helps in making preferences for future care, creating a platform
for conversation, preferences towards advanced care directives, taking control in planning
medical treatment decisions, and improving the conditions for children’s development in
future, as time of death draws close. In Melissa’s case, her need for advanced care planning is
to achieve ongoing care decisions for her teenage children by their father and grandparents.
Under the ‘parental right doctrine’, upon death of a parent, and presence of their biological
parent, their custody will automatically shift to the alive biological parent (Rathus, 2016).
Advanced care planning will enable to take all these decisions through communication, to
ease the mental tension of Melissa as part of palliative care.
The right to determine the time and place to die
Even after getting best palliative care and end-of-life care assistance from healthcare services,
many terminally ill patients during their death is not able to accept the physical and mental
agony, which adds to their death experience. Hence, some of these people want assistance to
die through voluntary assisted means of death. After voluntary assisted dying bill was passed
in 2017 in Australia, the law started functioning in Victoria from 19th June 2019 ("Parliament
of Victoria - Voluntary Assisted Dying Bill 2017", 2019). Within the first year of

functionality, the doctors expect more than dozen patients likely to take up this mean of
death, with figures increasing more than 150 for subsequent years.
The method of voluntary assisted death means that a doctor will assist terminally ill patient
suffering from life-long diseases, to die in comfortable means, through compassion and
keeping dignity of patient even during death ("At a time and place of their choosing':
Victoria's voluntary euthanasia laws begin this week", 2019). The whole process has three
characteristic features namely it is voluntary, it is consistent will using their requests on
death, and patient upon being fully informed about their condition and undergoing palliative
care makes the decision. If the suffering cause by the terminal illness cannot be managed
through medications, or otherwise deteriorates the mental and physical conditions of the
patients further through tolerable means, the patient can control their time of death and place
of death. The place suggests, whether the patient wants to die in hospital or in their own
home in front of loved ones (Blaschke, Schofield, Taylor & Ugalde, 2019). This is possible
through means of self-administration through a lethal medication, or even done by
practitioners in a manner suitable for the patient in ending their lives, due to inability of
tolerating the burden of the disease implications.
Melissa’s case can be covered under the ambit of voluntary assisted death, as she is more
than 18 years old, is an Australian citizen living in Victoria, having own decision making
capacity, and is suffering from a terminal illness, incurable and progressive. Moreover, the
implications and symptoms are intolerable for patients, as Stage-4 colorectal cancer is very
painful, and has co morbidities attached (Beardsley, Brown & Sandroussi, 2018). Moreover,
her prognosis is poor and if her death is estimated within 6 months, she can consider
voluntary assisted death as her means of dying in a dignified manner. Through a series of
steps of requiring appropriate permissions from doctors and state authorities, the voluntary
assisted death process can be started. The whole process of self-administration is maintained
along with various safeguards so that patients are not coerced or pressured into taking the
decision of voluntary death, and should be upon one’s own capability (Beardsley, Brown &
Sandroussi, 2018).
A kit containing a lethal dose of substance along with two more liquids are delivered to the
terminally ill patient’s home and the whole process is intimated to the patient. The patient is
provided a key to the safe box wherein the lethal dose is kept and they have to mix the liquids
themselves, for taking the lethal dose as directed without external assistance. The process of

death in the voluntary assisted death process is stress and pain free. Upon taking the
medication, the patient is most likely to feel sleepy and drowsy, and will become unconscious
within some time (Gilbert & Boag, 2018). The time of death can also be administered within
an hour or more. Hence, the right of choosing own place of death, means of death and time of
death are within the jurisprudence of the terminally ill patient. The main aim for the law is to
bring relief from suffering for the patient and their family members, upon uncontrolled
acceptance of the pain endured from the illness. Moreover, the wider implication of using
medications for voluntary assisted death is to have a feeling of control over one’s death,
which decreases feelings of unsurely and enable patients to have a better relieved time with
family members and loved ones (Karapetis et al., 2018).
In case of Melissa, as she is suffering from stage4 colorectal cancer with Ileostomy
procedure, with cancer spreading to liver, her condition will decrease progressively. She has
also had frank talks with her healthcare practitioner who has told about her poor prognosis. In
such a situation, when the pain and exertion from the cancer becomes too much for them to
endure, patient can opt for going to voluntary assisted death, and decide their place and time
of death on their own (Karapetis et al., 2018). However, as she is also tensed about the future
prospects of her children, only after proper advanced care planning and knowing about her
children’s future, Melissa will want to opt for this means of death. However, this means of
death is not yet universal but based on certain safeguards and upon sole discretion of medical
practitioner and the state health services.
Conclusion
The concept of voluntary assisted death even though new, has been widespread globally in
Belgium, Netherlands, Canada, Luxembourg, and different states in USA. In case of
terminally ill patients suffering from cancer and having life expectancy of 6 months or less,
this concept enables them to choose place and time of their death, for imbibing dignity upon
the death process. Palliative care, end-of-life care along with advanced care planning is some
added care services for such patients, for making their transition to death comfortable. Taking
the case study as precedent the concepts have been analysed, for practical implementation of
passive euthanasia for terminally ill patients.

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