Dr. Cameron McLaren:

This is a very important question because if people look this up on the Victoria department of health website, they will see a very over-simplified, flow diagram of a patient's journey but it is far more complex than that. I will touch on each step briefly. Initially a person becomes aware of this and that can be through general knowledge or a discussion with a family member or previous experiences, as we are seeing now with people who have had a brother-in-law or someone how has gone through voluntary assisted dying. Now they are facing the same situation themselves and the decision to chase that themselves. That is a huge part and we are not capturing that part of the journey because we capture them as soon as they make contact. Often at that stage they might make an inquiry with their GP and they will find our state-wide voluntary assisted dying care navigator. All GPs are not specifically trained in voluntary assisted dying and they are encouraged to refer to the voluntary assisted dying care navigator for the state which can help them through that process. The care navigator will find a doctor, who suits the person's needs. Many of these patients need a home visit because they cannot attend a clinic, as Dr. Allcroft mentioned. Most, if not all, of our assessments have to be done face to face. We need two doctors who can do home visits. In Victoria, we actually need one of those two doctors to be a specialist in the condition that the patient has. I would not recommend that as a model for Ireland to look at, otherwise there will be very busy oncologists trying to see all of these patients. Myself excluded, oncologists do not often do home visits.

Once the people see one doctor, they will be referred on. If they are found to be ineligible the process stops. If they are found to be eligible they will then be referred on to a consulting doctor who has to perform an independent assessment of their eligibility against a set of criteria. As part of the assessment, we promote that it is VAD care provision, so it is not just assessments of eligibility. We ensure that the patients are linked in with palliative care and we promote symptom control during those conversations as well. Those conversations have often been a gateway to actually get patients who have previously refused palliative care involvement to involve themselves while undergoing the process.

If they are eligible under those assessments, they will return to the first doctor, the co-ordinating medical practitioner, who then sits with them to do a written declaration of their wish to undergo voluntary assisted dying.

This is a written application which is pre-worded for them. Then a patient must verbally request, one more time, that they wish to proceed with voluntary assisted dying and then a contact person can be appointed. This contact person is responsible for the medication. If the patient receives it and does not use it - I always tell them that we cannot have that circulating in the community - the contact person becomes legally responsible for the return of the medication. Once that is all done, in Victoria we have to apply for a special permit to prescribe the individual medication to the individual each time and that can take a few days to turn around. Then we can prescribe the medication. Once that is with the single pharmacy in the state that does this, it is up to the patient and their contact person to contact the pharmacy and organise delivery and dispensing. This is a long process and is not just a drop off. It can take about two hours for the pharmacy to go through the steps. The pharmacy does its own capacity assessments. They look at all the medications that the patients are taking. They make sure that they can ingest 30 ml of liquid in three minutes, which is the recommendation. If at the end of that they are eligible to receive the medication, the pharmacy will then ask them if they would like the medication that day or on a different day. Some patients do not like the medication being stored in their house.

If the patient is unable to ingest or absorb the medication, we have to apply for a different permit which is called an intravenous permit. This is for situations where we might have a patient with a bowel obstruction or difficulty swallowing. One of the problems we have had is that those permits are separate. If someone receives oral medication and then loses their ability to swallow we have to return that medication, apply for a new permit, get the new prescription done and get the new medication kit delivered. Regarding some of the issues that we need to evolve in Victoria, these are some of the issues that patients are facing. If an end-stage cancer patient suddenly develops a bowel obstruction, they do not have that many days of not being able to eat or drink for us to get the medication process sorted and get the intravenous medication to them.

We finally get to the stage where they have either got the oral or intravenous medication and then it is completely up to the patient when they take it. It depends on who is available at the time. For oral administration, I offer to be present for all patients at their home or in the hospital when they choose to take the medication. I find that useful because I can talk the family through the process and explain to them what is going on at each step.