Interviewer: Torrin Wilkins

Interviewee: Dr Nancy Burge

Torrin Wilkins: My name is Torrin Wilkins, the Director of Centre Think Tank, and I am joined by Nancy Burge. We will be discussing the system of assisted dying used in Western Australia. Nancy graduated from University College London in 1982. She then worked as a general practitioner in Brighton and then the Isle of Skye before moving to Perth in Western Australia in 2015.

She was among the first doctors to undergo training when Western Australia legalised assisted dying. So thank you so much for joining me today, Nancy.

Dr Nancy Burge: You are welcome.

Torrin Wilkins: So, for my first question, any system that provides assisted dying also needs to detect any cases of coercion that might exist within that system. So, what measures are used within your system to do this?

Dr Nancy Burge: Well, this is quite an interesting question. When assisted dying became practical in Australia, all doctors had to do some quite difficult training. We had to pass several modules to make sure that we understood the systems. And one of the issues was, how do you detect coercion?

There are not actually any tools for detecting coercion, and that was one of the things that was specified in the training, that there are no particular tools. But there are things that many of the VAD doctors, GPs, certainly in Western Australia—maybe not in other States—but I think we generally are good judges of character.

I have not come across any instances of people being coerced. In some ways, it is the opposite in that you might get a couple coming in, and one person wants to know or access assisted dying. So they are asking all these questions, and the other person actually does not want them to access it because they do not want to lose their loved one. I think that if we had any concerns about this, we would actually try and speak to the person on their own. We would ask them if we could ask their spouse or family member or whatever, if we could speak to them alone and just try and suss out the situation and what was going on.

The interviews that we do for assisted dying tend to be quite long because there is a lot to cover, and people want to ask questions. So I think you do get a sense of really what is going on there. I have not had any cases where I have been concerned about coercion.

I had a couple of patients who were both lawyers, and they came in and sat down, and the first thing that the wife said was, “Shall I go out? Because I understand you need to see my husband on his own.” And I said, “Well, yes, I do not need to, but I can ask if I have concerns.” There was clearly no coercion going on there.

I think, as experienced doctors, you can have a sense of what is going on. And if there was coercion, we would have that sense that something was not right and would delve further.

Torrin Wilkins: So in terms of the past cases that you talked about, when people are worried about a loved one who would like to use the assisted dying system and maybe do not particularly want them to, would you say that that was coercion or more just that they had quite large concerns about them doing that?

Dr Nancy Burge: Well, they are not coercing them not to have it. Usually, they will say, “I do support them, but I do not want them to do it.” I have had a case where somebody did not want their spouse to know that they were accessing it, and that was very difficult to work within those parameters.

I think it has usually been a religious objection. It has been a Catholic who has not wanted their spouse to use voluntary assisted dying because they have regarded it as suicide. And that is an ethical thing, and you can talk about it, and the statewide care navigators are often very good at talking people through and giving support to family members who are not keen on the idea.

But at the end of the day, it is the individuals choice; their spouse does not have the right to say no.

Torrin Wilkins: And in terms of the spouse knowing about the process, as you mentioned, there was a case where someone did not want their spouse to know. Is that a possibility? Are they able to do it without a relative knowing?

Dr Nancy Burge: Well, I ended up passing this case on to someone else because I did not have the time to go into it in the depth that was going to be needed, but it would be very difficult. I think in the end, the person thought that they might end up going into a hospice and would be able to access the whole process at that point. But it depends on how fast their deterioration progresses. But it is very difficult, and nobody wants to be involved in subterfuge.

But, at the end of the day, I think you would try and do everything you could to facilitate that persons wishes, but they would have to accept that there were certain constraints and it might not be possible.

Torrin Wilkins: So, how do you pass on a report? Is it something where you would pass on a report where you had concerns about someone? In the situation that you did have serious concerns, would it be something you have dealt with yourself?

Dr Nancy Burge: Well, in part, in the process, if I took on a patient and I was their coordinating practitioner and I was doing the first assessment, you are looking at age, eligibility on residence grounds, and then capacity and so on. So you go through all those things. If you had concerns about coercion, I would probably not want to just complete the first assessment there. And then I would say, “Look, I am really not happy about this; I need to talk to you further.” And then, as the first, in the first assessment, I would have to decide if they thought they were eligible or not on coercion grounds. And if I said no, the process ends there.

I mean, the other thing that I could do is hold fire, say, “Right, I am not going to make a decision now. I need to think about this. I need to think about what else I could do. We will have another appointment in a week, say, and then I could consult with colleagues. I could consult with the VAD board. I could consult with the statewide care navigators. I could try and get a consensus of thoughts about how to proceed because it has been going on since 2021, but there are still new situations arising that we have not necessarily come across. And sharing that burden of uncertainty with other people can be really helpful.

Torrin Wilkins: So, in your experience of the service, how helpful are the statewide care navigator service and the statewide pharmacy service to both patients and providers?

Dr Nancy Burge: They are the backbone of the service. I made some notes and then I rang them up today to talk through all the things that they did. And there are things that they are doing in the background that I did not even know about. So we will start with the statewide care navigators.

They may be the first port of call for any patient who wants to find out about voluntary assisted dying. Not all GPs or consultants, or specialists are on board with this, and everybody obviously has the right to refuse. So they may just not want to discuss it. So the statewide care navigators, or the NAVs as we tend to call them, know who all the VAD doctors are in all the various areas, the various suburbs and places in Perth.

They cover Western Australia, which is huge. It is about a million square miles. Obviously, most people are centred in Perth, but there are some very, very rural, far-flung places. So they will support people and find them a practitioner. As you go down the process, they will also find a consulting practitioner, who is another independent practitioner, as part of the process.

If there is somebody in a very rural or remote place, they run something called the Regional Access Scheme. So there is funding available to either fly a doctor to that patient in the back of beyond or to fly the patient down to where there is a doctor. So there is funding for that. The idea is that everybody in Western Australia should be able to access the same services for VAD. Most practitioners are based in Perth or some of the smaller towns. But there are requirements for people all over the state.

They provide tremendous support to the family, provide education to the family, and to any of the relatives who may want to ask. They provide tremendous support to us as VAD practitioners. I mean, when we started, we were all fumbling our way through this new system, and they are incredibly supportive. They are really very wonderful people. I cannot say that enough.

For rural people or people who cannot travel easily to have a face-to-face visit, they will visit that patient and set up a video link. Not all consultations during the process can be done through video links. Some have to be done face-to-face because of the particular part of the criminal code, which means that you cannot discuss the actual substances and access them through video. It has to be face-to-face. But for some of the consultations, they can set up the video links.

The other thing is they provide education all over the place, from GP surgeries to nursing homes to hospitals. They link patients to other services. So if they have not got access to palliative care, they can link them into Silverchain, mental health, or aged care assessments.

The other thing that they do for me, which I find useful, is that sometimes they will access medical evidence. So, if I am seeing a patient and I am not sure whether they are eligible on medical grounds because of their prognosis, I will sometimes reach out to their specialist and get notes. Obviously, the specialist has to agree to get notes, recent letters from the hospital, and so on. That can be really useful as well. So they do an awful lot in the background.

They are a bunch of amazing people. They are physiotherapists, nurses, and social workers. The other thing that they can do is they can assist if someone wants to take the oral medication themselves, and they want someone to be there; then they will do that. Some of them who are nurses can pronounce life extinct, which can be really useful as well. They do an awful lot of different things that can be really useful.

They also provide bereavement advice after the person has died, which is hugely important.

And then the statewide pharmacists are a hugely important part of the service. I mean, you would think they just sit there in their dispensary and dispense the stuff, but they give help to us for writing the prescriptions, which are very specific. They have to be handwritten, absolutely 100% perfect. If it is logistically difficult, they will often pick up the scripts from our surgeries. They obviously deliver all the medication.

Yeah, so not only did they dispense it, but they also support practitioners. They debrief afterwards. They give training and education. They set up cannulation workshops so that people who are not sure about doing the injection part of the practitioner administration can practise that.

They also provide an on-call service so they can deliver medication; the logistics at different times, they will deliver the medication all over the state. So that could involve two of them visiting someone in most of the far-flung corners of the state.

And the other thing that I found that was quite really helpful and beautiful is that they know that they are often going to be the last health professional that that person sees before they take their substance. So if somebody is going to access the oral substance and take the drink at home, they will deliver it to them and they will have a run-through about how it is made because you have to mix it, shake the substance up, and then drink it as 30 mls of a certain liquid. So they will go through that so the patient knows how to unscrew the bottles, knows exactly how they are going to do it. They will go through the actual protocol of the timing because the person has to have an empty stomach, so as not to have eaten for so many hours beforehand. There are also adjunct medications that they take to make sure their stomach empties properly, and there are some calming medications and some anti-nausea medications. So they go through all that.

But apart from the medical side, they also make sure that the person and their spouse know who is going to pronounce life extinct so that the funeral service can come, know who they are going to ask to do the medical certificate, who the funeral home is, have they thought about how they are going to do this. Are they going to have music? Who is going to be there? So it is a huge thing that they do when they visit. It is not a quick in and out. They can be there for a long time.

And if the person needs a rerun six months down the track because they have not accessed their medication, they will go back and do the same thing. So both of them are an absolute backbone to the service. It would be nice to think that we doctors would have all the time to do this stuff, but we do not. So they are a really important part of the service.

Torrin Wilkins: So I was interested in the pharmacy service specifically. In one of the first interviews I did on this, I was speaking to someone who was a rural doctor, and they were describing it as a relatively invisible service. The actual pharmacy service did a lot of the behind-the-scenes work, but they did not have a huge amount of actual interaction with them. Did you find the same thing, that it is amazing at helping those going through the process, but do you see a lot of them in that process?

Dr Nancy Burge: I have talked to them. Yeah. I mean, we always think that VAD is not going to be an emergency, but sometimes it is because somebody who is going through the process suddenly deteriorates, and then they want to speed things up. And as a GP, I am not always free to react in the way I would like. So if I have got to write a prescription, which is going to take me a good half hour to do, then I have either got to put it in the post, or I have got to buy registered mail, or I have got to get it to the pharmacy.

If they are coming up anywhere near my surgery to do some of their other stuff, they will actually come and pick it up, and they will actually check that it is correct, so that if there are any mistakes, we can correct them there and then.

At one point I was, I had some elective surgery and I was off, so I was at home and there was a problem with one of my prescriptions, and the pharmacist came to my home and sorted it out. And I think they have just been really, really supportive, really helpful. Obviously, the people who work in the service believe strongly in the rightness of this process and are very helpful in that sense.

Torrin Wilkins: So, in terms of guidance within the process more widely, what kind of guidance exists for medical professionals and more widely those involved in the process? And has any guidance or regulations particularly stood out as useful for you in the process?

Dr Nancy Burge: Well, when VAD came into practice, anybody who was interested had to do the training. And the training consisted of a series of modules. And they were actually, I actually find them quite difficult. It was not the medical side of it; that is quite straightforward. It was the legal side of it. And there is a protocol that has to be followed. It has to be followed pretty closely; you cannot fudge any of this stuff. It has to be done right.

The training, I think, was useful. In the early days, there was a little email group of local Perth doctors that we had met, and we talked about things, and we had a little email discussion. So if there were issues that we were not sure about, we could talk through them. Three years on, we have had to do the training again.

In terms of the legal aspects, I have used the VAD board sometimes for advice. I had a patient who, it just was not clear whether—well, we did not, he was clearly a WA resident, but we did not have the necessary documentation for all kinds of complicated reasons. So I spoke to the VAD board at length about what we could use as evidence. And at the end of the day, it was down to me to decide. And as long as I documented in good faith that I had extensively researched and found as much as I could, and that I believed that this person was a WA resident for the legal requirement side of it, then yes, that was actually quite helpful.

Torrin Wilkins: I am interested in the training that you have gone through and what it is like when you go from being someone who is a GP to then going, “I would like to join this system; I would like to become a VAD practitioner.” And then what is that training like afterwards, both as a system and also your personal response to going through that training and as one person said to me, it becomes a reality. What is that like?

Dr Nancy Burge: It was something that I always believed. I always believed that it would be right for someone to be able to choose the time of their death if they were really suffering. And I have obviously been aware that palliative care is really worthwhile, but there are some instances where palliative care just cannot fulfil the right things. And there are some deaths that are very painful and unpleasant. And so as soon as it became clear that it was going to become legal, I thought, “Right, I have to put my money where my mouth is and do the training.”

And I think we all found it quite confronting to start with because these were conversations we had not had before. But having said that, as GPs, we are used to having difficult conversations; we are used to asking people deep, meaningful questions about things that they might not want to share. So in some ways, that stood us in good stead.

The handbook that came with the training is like 185 pages. And every time I would take it with me so that I could check. And there are templates for the things that we have to fill in. Because everything that we do, we have to fill in online for the VAD board. So I would make sure I had all the questions and answered all the questions. Then I would go back and log it all.

I have found it incredibly satisfying work in that the responses I have had from people and their families have been amazing. People see VAD as an escape route, and they see the possibility of a really horrible death that they can escape, and it gives them autonomy over that; they can choose. And sometimes I get notes, I have been given bottles of wine and all kinds of things after people have died because their families have appreciated what has happened. These care navigators and the statewide pharmacy are the same. The thanks that people give are tremendous.

That is why I do it, because it is important

Torrin Wilkins: So, of course, some organisations and charities are of the opposite view. So they may be either incredibly opposed or incredibly in favour. And the settings may include at home, in a hospital, within a hospice, when speaking to their GP, or with family and friends. How do we make sure that people feel comfortable asking for or rejecting an assisted death?

Dr Nancy Burge: I think that this has always been a problem. Some of the religious organisations have been opposed to voluntary assisted dying right from the start. We had a big meeting many years ago before voluntary assisted dying came into law, and there were representatives from a number of these organisations, and they were really put on the spot by the questions, and they said, we will not put obstacles in the way of someone who wants to access it, but in fact, in practice, they do.

For instance, many of the public or private hospitals are run by religious organisations. And so, if you are in one of those hospitals and you want to access VAD, I am not allowed to set foot in that hospital for the purpose of VAD in any form. However, they will allow the VAD navigators to set up a video link, but I am not allowed to set foot in that hospital for those purposes. So it can be very difficult.

There are many people who oppose VAD, and if you are a GP and you oppose it, that is completely all right, but you do actually have a legal obligation to say, no, I am not part of this, but this is where you can get the information. But sadly, that does not always happen.

I know that in Victoria, when they set up their legislation, nurses and doctors were not allowed to raise VAD; they had to wait for a patient. Well, how are they going to know about it? A doctor or a nurse practitioner can raise it. And they certainly do.

So when you have someone who has a serious diagnosis, you can mention that this is an option. I mean, I might mention it, but I would not say, “Oh, I am a VAD doctor.” I would just say, are you aware that this is an option? And I have a number of colleagues who have mentioned it to patients and said, as a VAD doctor in our practice, if that is the route you want to go down, let me know, and I will put you in touch.

There was a lot of media interest when it became law originally, but which has died down. And I find it extraordinary even now that people sometimes have no idea that it exists, and they ask their doctor, who might say, No, I do not know anything about it. And they just do not know where to turn. And I do not really know what else you can do. All you can do, I think, is talk about it.

If people ask me about my job, I will tell them. I have told my hairdresser all about VAD, and she has had a most fascinating conversation, knowing all about it. Now she talks to a lot of people, so she will talk to people at some point and say, Oh, I know about that. I have just always been open about it because I think it is important.

Torrin Wilkins: Yeah, I find that really interesting. I mean, another conversation that I had was about the idea of getting it out there, and one of the ideas that was put forward was when you go to doctors surgeries, they will have all kinds of other posters and leaflets and everything else about lots of other services. But not about this.

Dr Nancy Burge: I do not think you have got any.

On the website for the practice that I work in, I have a little bio about the things that I do, but I have not put VAD on it. And maybe I should; I do not know.

Torrin Wilkins: So it is about getting rid of the stigma around the actual process as well. I mean, obviously, when these debates are going on, as they are in the UK, I mean, there is this big debate about whether it should be legalised or not? But then it is really interesting that even once it has become law and it has become legal that assisted dying services exist, that actually it still takes time for society to catch up.

Dr Nancy Burge: If you think about the number of people that actually need it, it is probably relatively small. So it is just not mainstream media, is it? I do not know what the answer is. I just talk about it with everyone who asks me, to be honest.

Torrin Wilkins: So, in terms of liability within the process in Australia, particularly for doctors, what level of responsibility do individuals like yourself have within that process overall?

Dr Nancy Burge: What, within the legal process, do you mean?

Torrin Wilkins: Yeah, so within the legal process, but also on a day-to-day basis. So that thing of having both liability, but also just the general responsibility that being in the process involves.

Dr Nancy Burge: Well, when we did the training, one of the things that was made clear was that if you worked within the law, so you were generally abiding by the rules, if you made a bureaucratic mistake, but it was in good faith, then you would be protected within the law. And that is what happened with somebody in the system. I have done one report; the consulting practitioner had done a report, and the two dates of birth did not match up. Well, clearly, we were not trying to fiddle with anything. And once we got it sorted out, they amended it, but they picked that up.

But it was a genuine error, it would not matter. There was a case where a doctor made a falsification on a document related to VAD. And it was something to do with changing a date and backdating it. And he actually got fined a lot of money.

There was a big outcry at this because they were saying, well, he did not mean to do anything bad. But the point is, it is a legal process which we have to follow. You cannot fudge it. If you fudge it, what else might you be fudging? You have got to stick to the rules. And I think that we have all been clear about that, and I think that was one of the things when we did the training; the medical side of it was relatively easy because that is what we are dealing with all the time.

We have to be clear that we are doing the legal stuff correctly. So, for instance, at one point, the patient has to make a written declaration. It is a form that they have to fill in, and they have to fill it in correctly. And if it is not filled in correctly, you cannot accept it. You have to go back and get it right. You cannot say that they made a mistake. Let us cross it out. I had one person, the way they made their signature had a line through it, which looked as if it crossed it out. I actually had to check that that was their signature. And I actually had to make a note that it was not crossed out. This was how they signed their name.

As long as you cover all the bases, I think that is fine. But on a day-to-day basis, I do not really know what you mean on a day-to-day basis.

Torrin Wilkins: So that was more the responsibility that you feel within the system. You are dealing with people going through that process towards the end of their lives. So, aside from the legal obligations, just the responsibility that you feel towards the families, towards the people going through the process.

Dr Nancy Burge: Yes, yes, more of a personal thing. Yes, I think that palliative care, anything at the end of life, is hugely important to get right. And I would often like to spend more time with people.

If it runs late, it runs into my lunch hour or my catch-up time or my admin time. So I am not keeping someone else late. So it gives me the time to spend with that patient as much as they need.

And the process, when you look at it in the way you are supposed to do this, then it does not happen like that. The first thing they want to know is “How do I access it? Is it a pill, is it an injection?” So in some ways, the first time you see them, it is a massive number of questions. It could be all sorts. And you have to go with that; you have to provide all the answers.

I do take it very seriously. I find that you make quite a connection with these people quite quickly because it is very deep and very personal, quite emotional. I always hug them because I think we both need it. And I often say to them, “Can I give you a hug?” And they say, oh, yes, please. Because it is really important.

Yeah, it is important. It is very important to get it right and to do it right.

Torrin Wilkins: And a lot of it is the personal side of the service as well. Again, as we often talk about rules, regulations and everything else, a lot of it feels like it is that human side of the service.

Dr Nancy Burge: Sometimes they are my own patients that I have known for years. Sometimes they are not.

But there is one interesting little aside. I had a patient who was actually a lawyer, and his wife was a lawyer. And they were the two people who would actually read the Act from beginning to end. Now, I tried to read it, but I cannot read it legally. So I got the gist of it. But they said that they thought it was the most humane Act they had ever read because, in terms of suffering, it says suffering that the patient finds intolerable. There is no bar of suffering that a patient has to declare or show. If they find it intolerable, that is good enough. And that is, I think, very humane.

Torrin Wilkins: So, when people are going through the process, and I suppose it links to the last question a bit, but how comfortable are they with discussing their options, any concerns they may have, and do you spend a large amount of time with individuals who are accessing an assisted death?

Dr Nancy Burge: I think that as you go through the process, you cover all sorts of areas right at the beginning. So the first time they make their formal request, and you accept it, and there is a bit of stuff to fill in on the thing, but then you are mainly answering all the questions. And then the next stage, you have to assess their documents. So you have to see that there is a bit of bureaucratic stuff to go through.

Then they have to see the independent consulting practitioner who makes their independent assessment of all the same things. And then you come back together, and you go through the next stage. So they have to do the written declaration and so on. And you talk about how they are going to access the substance. So at that point, you are getting down to the nitty-gritty of this situation. So really, there are options of whether they are going to have oral administration, where they have complete autonomy; this stuff is delivered to their house, they can take it whenever they like, or whether they are not capable of that, or they would rather have an injection.

So you are getting down to really how they are going to actually end their life. And it is very variable. Some people want the autonomy of having the substance in their house, and they might not take it for months.

Some people, like they come and see me and they say, I know I have got, for instance, a breathing problem; they have got COPD (Chronic Obstructive Pulmonary Disease) and they know it might be a horrible death, but they are not there. But they know that in the next few months, they might be, anytime they might have a bad chest infection and go really downhill. So they want to get their ducks in a row, as they call it. They want to go through the system, get everything ready, have the substance there, and then off they go. And I might not see them then. I might not hear until they have taken the substance or died of something else.

They might end up in the hospital with a chest infection and die, or they might take the substance, and then I will get notified.

But then there are other people where I am much more involved because things are going downhill very, very quickly. And then you try and facilitate getting the appointments in the time and trying to get everything organised. And then you are much more involved. And those ones are much more heartbreaking in a way. Because when someone is going downhill very quickly, the logistics can hold them up, and then you feel bad because you want to help them. That can be very difficult.

But at the end of the day, it is satisfying to help people have a choice to die comfortably. I have had some that have been very stressful because of the urgency at the end of their life when they are deteriorating very fast. And that is much more stressful, I have to say.

Torrin Wilkins: And I assume that takes quite an emotional toll as well, dealing with not only that, but also, of course, generally working as a GP on top. So, is that quite a difficult balance?

Dr Nancy Burge: It is. And one of the amazing things about the navigators is that they always say, if you have not got the time or the emotional capacity, we totally respect you saying no. And that is really important that they do not put pressure on us.

If somebody is going away for a couple of weeks, they might not want to take on any VAD cases because they cannot; they will not be able to commit to them. If you are off sick or you have got some surgery or something, and you are going to be out of action, you have to say no.

I am trying to do GP work at the same time. And if we are going through a spell where we are short of doctors at work, I may not be able to do as much VAD work. I am not doing a whole amount, but it is a steady amount.

But sometimes if it gets too much and you get a question saying, “Could you take on this role?” You have to say no, because there will be someone else who will do it, we hope.

Torrin Wilkins: Something else of interest is the substance being administered. I know that sometimes it is by a VAD practitioner; sometimes the individual does it. So, how important is that choice in allowing people to either do it in one of those ways? I know some systems only allow you to do it one way.

Dr Nancy Burge: Yeah, I think the Canadian system is all injection. I think that when they set the system up in Western Australia, they took note of the fact that there are a lot of very remote people. And I think being able to access the substance as an oral substance and take it yourself at the time of your choosing is great. But there are some people who cannot open the bottles, or they just cannot swallow, or, for various reasons, they are worried that they might mess it up or something. So those people do need to have a practitioner as an administrator.

Now, I choose not to do that simply because I do not have as much experience now. I am de-skilled in cannulation, and trying to cannulate an elderly, skinny person with very bad veins, I would find that incredibly stressful. If you cannot get the needle in and things go wrong, that would be very stressful. And it takes a long time; it would take a couple of hours out of my afternoon surgery, and I am always booked ahead. So I choose not to do that, but there are practitioners who will fill in that role. So that is one aspect of the VAD that I have not been involved in simply because I am not good enough, and I have not got the time to do it at the moment.

I mean, they do run cannulation education sessions and so on. And at some point, if I do less GP work, I might consider doing that. I have helped someone make up the bottle and drink the substance when they have not been able to do it themselves. And I do not mind doing that at all. I have not minded doing that at all. And again, that was very interesting because it was a local nursing home, and the patient obviously was in very bad heart failure, and wanted to take the substance. One of the relatives did not approve of the whole thing at all, but wanted to be there and then watched the whole thing. And afterwards took me outside and said, “Can I speak to you alone?” And I said, “Yeah, of course”. And this woman just hugged me and said, “I did not realise it was going to be so peaceful; I am so glad you allowed it to happen”. And that was very satisfying, knowing that the relative had witnessed the death and saw how peaceful it was.

Torrin Wilkins: So my final question, one of the concerns that has been raised on assisted dying is, of course, palliative care, and it is the idea that assisted dying would be used as a result of a struggling palliative care system. Has this happened in Australia, and what has been the impact more widely on end-of-life care in Australia and on Australia as a whole?

Dr Nancy Burge: Well, it is an interesting question because whenever VAD doctors have discussed this, it turns out that actually palliative care has always been pleading for more money. And they have actually had even more money since VAD came in. The palliative care system in Western Australia is run by an organisation called Silverchain. And they are opposed to VAD as an organisation, but some of their practitioners are not opposed to it, but they cannot become involved.

But one of my longest-standing VAD patients is under Silverchain and has lots of input and help from them. And they are aware that she has the substance and may take it. But I mean, she actually had it for almost 18 months. And in fact, some of her medications expired and had to be replaced. She wanted the substance because she knew she was anticipating a horrible death, and it had not happened, and she is still going, and that is great. And at some point, she will probably access it, or she will die at home, just not wake up one day. She accesses Silverchain. Many of my patients have access to Silverchain palliative care services. I do not think it has hampered them in any way at all. So I think that is just a red herring of an argument. It just does not apply.

And the other one was coercion. Are people going to be coerced into it? Again, I just do not think it happens. Or if it does, it is so minimal.

Torrin Wilkins: Well, thank you so much for joining me today and for taking your time out as well.

Dr Nancy Burge: Oh, it is a pleasure. I am always happy to spread the word about VAD because I think it is so important.

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All interviewees gave informed consent for their quotes to be used within the publication and for their interviews to be published separately. They also had the opportunity to review, approve, and suggest edits to the final transcript before publication to ensure clarity. These interviews have also been edited for grammar by the interviewer. This written version of the interview is the final and definitive version.