BY TAMAH CLAPHAM
December 1, 2021
Source:  NZNO Journal Kai Tiaki

After seeing too many people die without whānau, Auckland NP Tamah Clapham has trained and registered to provide care under the End of Life Choice Act.

In 20 years of nursing, I have been present at dozens of deaths.

As an undergraduate, I worked for three years as a caregiver in a rest home, so witnessed many deaths from natural causes – often without family or whānau present

In the hospital, where I started my registered nursing career in acute care such as emergency, I also saw people die, without family or whānau present.

In primary care, I have seen longer deaths, from complications of chronic or terminal illness.

All these experiences have led me to believe that there is such a thing as a good death.

While we have palliative care options that allow for a good death, for some who are terminally ill with less than six months to live, the most important thing may be to have control over when and how that death may occur – and who will be there with them.

Many experienced nurses are experts in death and dying.

I accept that some nurses, nurse practitioners (NPs) and doctors may choose to not provide this service, due to conscientious objection.

But it is important – as with last year’s decriminalisation of abortion – that patients are referred appropriately to a willing practitioner.

In Aotearoa, many facing imminent death will not choose a death day, as it does not align with their values or belief system. I respect that choice too. The legislation is very clear that a clinician is not to raise the topic with a patient and this is a way of protecting against any coercion.

I have completed the Ministry of Health (MoH) training. The legislation and rollout has many processes to ensure the person seeking assisted dying is competent to do so and free from coercion. This involves up to three practitioners certifying this, two medical initially and – if not satisfied – a third opinion is sought through psychiatry colleagues.

Although this is new to us here in Aotearoa, the MoH can use experience from Australia and Canada, where similar legislation is already in place. This gives us something to base our own interpretation and practice on.

The SCENZ (support and consultation for end of life in NZ) group includes a range of practitioners and oversees the EOLCA, along with a medical officer. There is also an 0800 number for support.

But it is disappointing that the MoH only appointed one nurse representative – NP Jackie Robinson – to SCENZ. See You can’t know what you would decide, Kai Tiaki November 2021.

It is top-heavy with medical practitioners, who comprise seven out of the 12. However, it does appear to have good representation for Māori.

My understanding, from listening to a colleague in Canada, is that the service is deeply valued by the patient and the community supporting them.

From what I have learned about the death day, I think it would best involve two clinicians to support the individual, their whānau and community, as well as the clinicians themselves. The range of skills needed would best be delivered through a collegial approach.

The EOLCA refers to a medical practitioner. The MoH appear to have interpreted that literally, despite 2019 amendments to the Health Practitioners Competence Assurance Act to allow qualified health practitioners to carry out activities that could previously only be done by doctors.

As things stand now, if an NP is approached by a patient about assisted dying, they must refer to a medical practitioner, who must then seek a second opinion from another medical practitioner.

Yet I believe it is entirely within an NP’s competency to be able to provide a first or second opinion on a patient’s eligibility and competency. It does concern me that in rural areas especially, this may increase barriers to access and create inequities.

Currently, NPs are able to administer the life-ending medication but not assess eligibility or initial consent. I find this very strange decision-making and wonder about the hegemony of the MoH decision-makers in their interpretation.

An NP/GP model, and an RN-led assisted dying service in rural areas, would be much more representative of the workforce available. It would ensure a quality and equitable service, as well as shoring up the wellbeing of practitioners.