For the last year, Angela Cooney has been doing the opposite of what doctors are normally trained to do – she has been helping people end their lives.
Dr Cooney is often their first step in accessing Western Australia's voluntary assisted dying scheme, and in many instances, also the last.
For some of the more than 171 West Australians who have used the scheme since it came into effect exactly a year ago, she has been there to help them, and their families, in their final moments.
"This is absolutely anathema to a lot of doctors," she said.
"It's not easy, and I lie awake at night rehearsing in my mind the scenario, how it's going to go, to make sure I do it right. And I live in fear of getting it wrong so that that person might suffer more."
But Dr Cooney said the value of the service far outweighed the personal toll of administering it.
Take-up bigger than expected
Based on the most recent data, 682 people took the first step in the initial 12 months of WA's voluntary assisted dying (VAD) laws, with about a quarter ultimately using the scheme to end their lives.
That is between three and four times greater than what was expected, according to Scott Blackwell, who chairs the board overseeing voluntary assisted dying in WA.
"There's been such a lot of demand and we wondered whether that would slow down, but now more people are finding out about it and it's not slowing down at all," he said.
That unexpected demand also caught the government off guard and meant it chipping in an extra $1.6 million for the scheme to keep pace.
Two-thirds of cases cancer-related
People who accessed the scheme had an average age of 73, with slightly more men than women following it through to the end.
Of those, 65 per cent had been diagnosed with cancer-related conditions, 15 per cent were neurological-related and 8 per cent had respiratory issues.
The vast majority, 79 per cent, were in the metropolitan area, with the remaining 21 per cent spread across the rest of WA.
Those figures are roughly in line with how WA's population is divided between the city and the country.
From opponent to advocate
About 20 years ago, Simon Towler was the state president of the Australian Medical Association, arguing on radio against euthanasia campaigner Philip Nitschke.
Now he is one of the state's leading VAD providers, having seen both the public's demand for voluntary euthanasia but also the distress of families who were left without a choice at the end of loved one's life.
"There was a lot of conversation around VAD — that it's going to be wealthy, western suburbs, ageing males who will access VAD," he said.
"That has not been the experience in this state.
"We've had everything from very wealthy people through to very poor people, we've even had Aboriginal people who've accessed VAD when there were comments [saying] that would not happen."
And while he admitted it could be "terrifying" to be involved in, he described the "absolute privilege" to be part of the process.
Both Dr Cooney and Dr Towler said the value of the scheme often came in providing people with a sense of control, when much of their situation was out of their hands.
"Much of the suffering of this is more existential," Dr Cooney explained.
"It can be about the fear of pain or the fear of being breathless, of drowning in your own secretions in those last few days, of powerlessness."
That is on top of people being unable to do the things that used to bring them joy or worrying about their family seeing them suffer.
'Part of the fabric of end-of-life care': Minister
Health Minister Amber-Jade Sanderson, who was a key player in wrestling WA's euthanasia legislation through parliament, explained the significance of the laws in a similar way.
"Palliative care is a fantastic medicine and it can actually support most people at the end of life, but there are those diseases that cannot be relieved by palliative care," she said.
"It's an important part of their journey at end of life in providing comfort and assurance that they will have a gentle end.
"We don't see a lot of media, we don't see a lot of attention given to it, and that frankly is as it should be.
"It is just part of the fabric of end-of-life care, and it also came with significant investment in palliative care in WA so that people had a genuine choice."
Law changed after intense political wrangling
WA's voluntary euthanasia laws came after a drawn-out debate, both in and outside of Parliament, with one sitting of the lower house lasting almost 21 hours.
It ended with legislation containing more than 100 safeguards, including that the person accessing the scheme be:
- 18 years or older
- terminally ill with a condition causing intolerable suffering
- likely to die within six months, or 12 months for neurodegenerative conditions.
They must make three requests to die – two verbal and one written – with two independent doctors overseeing the process.
Once the requirements have been met, a person can choose to either administer the VAD substance themselves, or have it done by a qualified doctor or nurse.
Not everyone able to follow through
Dr Towler said even once that process had been completed, about one-third of people who received the oral medicine would never take it.
Throughout the process, a person must have the ability to make decisions for themselves, which can be challenging for some.
"This has happened to us, that every time you go in, [people say] 'yes, yes, I really want to do this, please help me, thank you very much'," Dr Cooney said.
"And you go in on the last day with the medicine and you say to the person, 'so why am I here?'. And they're looking out the window and they have no idea who you are or why you're there.
"All bets are off. You can't do anything for that person. There's no provision for advanced consent, and that's just how it is at the moment. Maybe it will change in future."
'Quality' doctors rise to the occasion
Even after a year, there are only 66 doctors in WA who have completed the training required to take part in the scheme.
They are assisted by a group of "care navigators" who support people through the VAD process.
"I must admit during the implementation, we weren't certain who might step up to do this work, but it has been really impressive to see the quality of person who stepped up to do this work," Dr Blackwell said.
"I think that's really the glue that holds it together."
The scheme has also been set up to make sure geography is not a barrier, which in some cases can involve the government paying people like Dr Cooney to travel across the state.
"That's wonderful … when we first started doing this in WA, not all the states had come to the party. So Medicare had nothing to say about it [and] there is no provision for this service in Medicare," she said.
It means doctors are often left to foot the bill for some of their services, something Dr Towler described as "unsustainable" in the long term.
It is something doctors are keen to see changed, with some hoping it may come soon, given all states have now passed laws to enable VAD.
The territories remain barred from doing the same because of a federal law passed in 1997.
Ms Sanderson said that would be the next step for the federal government, to give all Australians a choice in how they end their lives.
