6 Chapter 6 Winter’s Tale

Chapter 6

Winter’s Tale

6.0 Introduction

Chapter 6 Playlist

What is it with Nick Cave and Australia? It’s like America’s relationship with Barack Obama. Feted outside of his country but feelings in his country of origin are mixed, muted even. I’ve never understood it. The Young brothers in AC/DC and Jimmy Barnes, all born in Scotland and raised in Australia possess near mythical status. Yet, Cave, a child of rural Victoria, narrator of the necropolis, cataloguer of the cruel, author of the appalling, voice of the vengeful and enumerator of the egregious is sidelined. Well, maybe not sidelined exactly. But, unlike success stories where origins are disputed like Pavlova and Phar Lap, Cave is homegrown, and his music is part of this great continent. But what’s this with all the Cave chat, Stephen? Perhaps one or two of you are asking. Another aspect of Cave’s litany of literature is that he is a documenter of the departed. And that’s where we find ourselves in this chapter, at the end of the road heading for Potter’s Field. But before we get to the quietus, we can turn up, full of cheery banter, momentarily mocking the Moirai and sometimes just in time to repair Clotho’s thread, at least for a time. Hopefully by now you know all about governance and the living. Death is a construct. Of course, it is. Why would a living person shell out thousands and thousands to be cryogenically preserved? Even in death there is governance. And that’s where we turn to now.^[1]

Is death absolute? At the time of writing, yes, it is. Sure, some people live on in terms of roles in history, but in terms of corporeal occupation their time is spent. But is it possible to simultaneously be both dead and alive? What does it mean to be alive? What does it mean to be dead? What if the difference is not clear? You will be familiar with the term coma, some of you will be familiar with the term vegetative state, which is now considered pejorative and outdated. Terms such as unresponsive wakefulness syndrome or post-coma unresponsiveness are considered appropriate. A person is considered alive but unable to demonstrate meaningful responses. These patients require artificial hydration and nutrition as well as many other involved and invasive processes. Unable to move, muscles can spasm and pressure sores develop and fester. Depending on the nature of the injury that led to the patient being in the described states, it is unclear to what extent these patients experience suffering and harm.

Remember Kant? Well, he remembers you. He was telling me… Perhaps this isn’t the right place to share this. Look, I’ll tell you later. Well, you remember his version of morality, right? Kant would never support hastening a person’s death to alleviate suffering. Life is sacrosanct. Consequentialists and utilitarians, on the other hand would. They are prepared to recognise suffering as justification for bringing a person to their terminus. For deontologists, the sanctity of life ranks supreme. Consequentialists and utilitarians recognise an individual’s quality of life to support the hastening of their death. The case of Airedale National Health Service Trust v Bland [1993] AC 789 examined Jeremy Bentham’s proposition that suffering is the determining factor to justify ending a life to extinguish suffering.

In this chapter we will discuss the following areas of withholding of withdrawing life sustaining measures, discontinuation of resuscitation, patients who are not for resuscitation, patients with do not resuscitate (DNR) orders and euthanasia.

6.1 End of life care

Some care is therapeutic, and some care is palliative. Discussion of what a patient was willing to accept in terms of care was the main issue in the case of Brightwater Care Group (Inc) v Rossiter (2009) 40 WAR 84. This case demonstrated the concept of autonomy prevailing over the sanctity of life. Patients with capacity are entitled to choose palliative (comfort at the end of life) care over therapeutic (treatment that is expected to either extend a person’s life or, if not, not shorten it) care. Decisions to withhold or withdraw life-sustaining treatment involve complex clinical, ethical and legal considerations, which, ideally should be addressed long before the patient loses decision-making capacity. If a patient lacks the capacity to make a decision at the relevant time, the law that governs decisions regarding the commencement and continuation of life sustaining treatment is found in the Powers of Attorney Act 1998 (Qld) and the Guardianship and Administration Act 2000 (Qld). According to Schedule 2, Part 2, Section 5A Guardianship and Administration Act 2000 (Qld) a life-sustaining measure is health care intended to sustain or prolong life and supplants or maintains the operation of vital bodily functions that are temporarily or permanently incapable of independent operation. The three following measures are examples of a life-sustaining measures:

1. Cardiopulmonary resuscitation
2. Assisted ventilation
3. Artificial nutrition and hydration

A blood transfusion is not classed as a life-sustaining measure according to the Act. The role of paramedics in end-of-life care is not well understood. At times, the role may only be one of transportation. For example, a patient leaving their home residence and transferred to a hospice. Another example where paramedics may be called is when a patient is approaching death and a family member, or another carer becomes overwhelmed. I will try to filter the various laws on what it means for front-facing paramedics operating in emotive and challenging circumstances.

6.2 Death and Dying

“Sooner or later, we all gotta die” sings Nick Cave in The Curse of Millhaven. I’ve watched people die in all manner of ways. Helpless to all but a few. I attended a patient who, from the history appeared to have suffered a pulmonary embolism after being diagnosed with a suspected deep vein thrombosis. The patient was resuscitated over a lengthy period. The other paramedics with me on scene discussed whether the patient was responding to our acts and interventions. We spoke with the patient’s family. And began the process of declaring death. Then there it was, a palpable pulse. A successful resus? The patient remained GCS 3. I spoke with the patient’s family and informed them we were now committed to transport through to hospital. Respiratory arrest remained and spontaneous cardiac output was evident throughout. Handing over to the registrar, who said, in words along the lines of, successful resus. That’s great. Just great. I’ll leave you to draw your own conclusion what meaning can be drawn from these words.

Tragic as it is, it comes to us all. It’s impossible to separate yourself from it working as a paramedic. When I was a boy, whenever a famous person’s death was announced on the news, I would ask my mum what they died of. She would say unfailingly, “old age”. My mum was great like that. She always wanted to protect me and my siblings from the (harsh) truth. Then I became a paramedic. And that all changed.

End of life healthcare has a chequered history. The Liverpool Care Pathway (LCP) developed by the Royal Liverpool University Hospital, which is now a defunct policy, provided guidance for clinicians treating patients who were expected to die in hours or days. The LCP was criticised for preventing full and frank disclosure about its application by treating doctors. The NHS in England and Wales has sought to improve end of life care as a result of its failings. The LCP prevented patients from receiving measures deemed futile given the circumstances. The concept of futility in healthcare is mired in controversy. In relation to paramedic care, a decision to commence CPR or discontinue CPR has its roots, perhaps not in futility, but in value and appropriate use of resources. Perhaps these are better criteria rather than determining whether an intervention is futile. By now you will be familiar with the presentations representing candidacy for resuscitation and the unequivocal presentations associated with obvious death:

• Severe Trauma:
  • Decapitation
  • Cranial and cerebral destruction
  • Hemicorporectomy (or similar massive injury)
• Decomposition/Putrefaction
• Severe Incineration
• Hypostasis
• Rigor Mortis
• Foetal Maceration

Distinct from this list but applicable to not performing CPR is where performing CPR will endanger the life of the treating paramedic and when a lawful direction to withhold CPR has been made to the treating paramedic. In addition to this list is the general discontinuation criteria and rapid discontinuation criteria published by the Queensland Ambulance Service (QAS).

Despite early compressions and early defibrillation having demonstrable outcomes CPR has ethical considerations. The harms of resuscitation might be held to include:

• Unnecessary
  • The harm outweighs the benefit
• Unsuccessful
  • Palliative care
• Unkind
  • Burden
• Unwise
  • Resources
• Unwanted
  • Against patient’s wishes

Additional consideration must be given to quantitative and qualitative aspects of resuscitation. This is based on either interventions historically producing multiple failures (quantitative) and/or issues pertaining to quality of life (qualitative). I question whether it might be best if decisions on whether to commence CPR are removed from paramedics and all patients are candidates for resuscitation. This introduces additional complexities. Successful resus stories are wonderful. By successful, I regard any patient who walks out of the hospital they were taken to in cardiac arrest as a success. Any other definition of success is moot.

Every cardiac arrest attended to by paramedics has a moment where the attending paramedics decide, based on available information, to commence resuscitation. The unequivocal examples stated above are not encountered commonly. More common is the patient who has collapsed from an equivocal cause. Decisions to resuscitate are based upon whether the arrest was witnessed, whether bystander CPR has been performed, whether shocks have been administrated from a community defibrillator or how long the patient has been down for and the circumstances related to the collapse. Supplementary issues are born from the existence of patients’ Advanced Health Directives (AHDs) and Do Not Resuscitate (DNR) orders. It’s amazing what decisions can be made in an instant.

6.3 Advanced Health Directives and Do Not Resuscitate Orders

We have already met Advanced Health Directives (AHD) or ‘living wills’ in chapter 5 in section 5.4 on impaired decision-making. If you’re interested, here is what an AHD in Queensland looks like; please find a link to the official Queensland document here. Anyone over 18 is entitled to complete one. Section 36 Powers of Attorney Act 1999 (Qld) provides the basis for the operation of an AHD in Queensland.

36 Operation of advance health directive

(1) A direction in an advance health directive—

(a) operates only while the principal has impaired capacity for the matter covered by the direction; and

(b) is as effective as if—

(i) the principal gave the direction when decisions about the matter needed to be made; and

(ii) the principal then had capacity for the matter.

Note—

See also section 101 (No less protection than if adult gave health consent).

(2) A direction to withhold or withdraw a life-sustaining measure can not operate unless—

(a) 1 of the following applies—

(i) the principal has a terminal illness or condition that is incurable or irreversible and as a result of which, in the opinion of a doctor treating the principal and another doctor, the principal may reasonably be expected to die within 1 year;

(ii) the principal is in a persistent vegetative state, that is, the principal has a condition involving severe and irreversible brain damage which, however, allows some or all of the principal’s vital bodily functions to continue, including, for example, heart beat or breathing;

(iii) the principal is permanently unconscious, that is, the principal has a condition involving brain damage so severe that there is no reasonable prospect of the principal regaining consciousness;

Note—

This is sometimes referred to as ‘a coma’.

(iv) the principal has an illness or injury of such severity that there is no reasonable prospect that the principal will recover to the extent that the principal’s life can be sustained without the continued application of life-sustaining measures; and

(b) for a direction to withhold or withdraw artificial nutrition or artificial hydration—the commencement or continuation of the measure would be inconsistent with good medical practice; and

(c) the principal has no reasonable prospect of regaining capacity for health matters.

Note—

life-sustaining measure is defined in schedule 2, section 5A.

(3) An attorney’s power for a health matter under an advance health directive is exercisable during any or every period the principal has impaired capacity for the matter and not otherwise.

Note—

However, the priority of an attorney’s power for a health matter is decided by the Guardianship and Administration Act 2000, section 66 (Adult with impaired capacity—order of priority in dealing with health matter). See, in particular, section 66(4).

(4) While power for a health matter is exercisable under an advance health directive, the directive gives the attorney for the matter power to do, for the principal, anything in relation to the matter the principal could lawfully do if the principal had capacity for the matter.

(5) However, the power given is subject to the terms of the advance health directive and this Act.

(6) A person dealing with the attorney may ask for evidence, for example, a medical certificate, to establish that the principal has impaired capacity for the matter.

A health provider is required to obtain consent or authorisation to withhold or withdraw a life sustaining measure. Section 79 the Guardianship and Administration Act 2000 (Qld) states that is an offence for a person to carry out healthcare of an adult with impaired capacity for the health matter concerned unless this or another Act provides the health care may be carried out without consent; or consent to the health care is given under this or another Act; or the health care is authorised by an order of the court made in its parens patriae jurisdiction.

More information of AHDs can be found by clicking here. It is inevitable you will encounter people who have been appointed enduring power of attorney for another. It is important you are familiar with the role of a patient’s health attorney. It is expected that an individual appointed as a health attorney will comply with the wishes of the person they are representing. Schedule 1, Part 1 Powers of Attorney Act 1999 (Qld) detail the general principles expected to be upheld. The role of a health attorney is found here.

Like the topics of consent and refusal discussed in the previous chapter, an AHD must meet several requirements to imbue the document with validity. An AHD requires compliance and therefore provides some protections in order to make sure patients with AHDs who go on to lose capacity have their intentions met as if they still possessed capacity. Substitute decision makers are entitled to make decisions related to withdrawing and withholding life-sustaining measures. It is a likely scenario that paramedics will treat patients with an active and valid AHD as these patients approach the end of their lives. If the explicit intentions set out in the AHD are complied with there should be no issues to cause concern for treating paramedics. Challenges may be encountered where an AHD is in evidence, an instruction is clear, such as the patient has documented refusal of resuscitation. Despite this, the health attorney either demands resuscitation is performed or a person close to the health attorney is exerting their influence. Generally, a HCP (commonly a paramedic in this situation) should follow the directions of the AHD. However, section 103(2) Powers of Attorney Act 1999 (Qld) states that a health provider does not incur liability for failing to act in accordance with a direction in the AHD if a direction is uncertain or inconsistent with good medical practice.^[2] A health attorney may be ordered to compensate for failure to comply (section 106 Powers of Attorney Act 1999 (Qld)).

Finally, HCPs need to be sure what a person is willing to accept and what they are willing to refuse:

“A Do Not Resuscitate (DNR) order applies to situations a person has a respiratory or cardiac arrest. A Do Not Intubate (DNI) order means that chest compressions and cardiac drugs may be used, but no breathing tube will be inserted. An Allow Natural Death (AND) order is a term used at some hospitals as an alternative to the more traditional DNR order. While a DNR simply states that no attempts should be made to restart breathing or restart the heart if it stops, an AND order is used to ensure that only comfort measures, designed to provide excellent control of pain or other symptoms, are taken. This includes withholding or discontinuing resuscitation, artificial feedings, fluids, and other treatments that prolong the dying process. Allowing a natural death means not interfering with the natural dying process”.^[3]

A face-value interpretation of DNRs and ANDs may reveal little. The choice of language may not seem helpful to some. HCPs may value the direct language used to convey instruction in a DNR. Whereas families may be comforted by the process captured by ANDs.^[4]

The Australian Commission on Safety and Quality in Health Care has published guidance on end-of life care. It can be accessed here. It is not the purpose of this Pressbook to detail your role responding to every patient receiving end-of-life care beyond legal and ethical frameworks. However, I can’t detach governance from the practical demands of the role. You are there to help people. It might just be the person you need to help is not necessarily the person you were called to. It’s hard saying good-bye. No matter how well a person thinks they are prepared for the inevitable moment. Being in the company of someone who has come to the end of their life can be vivid, painful and despairing. I say can be. Not everyone with a terminal illness was pleasant and loving when they were well. It might mean that their demise ends years of abuse, coercion and control. But more on this in part 3. These situations require you to be at your most empathetic. Don’t deny your own responses to these moments. Although a different experience from the one the patients and their family and/or friends are experiencing, it is important to acknowledge the impact of providing end-of-life care.

6.4 Euthanasia and Voluntary Assisted Dying

Euthanasia has a mixed history in Australia. We know that people with capacity can refuse treatment. Refusal on this basis can lead to their death. For a brief time in the 1990s, the Northern Territory permitted euthanasia, but this law was overturned by federal legislation. The Queensland parliament is due to debate voluntary assisted dying (VAD) in an upcoming (post-election) sitting. Currently, it is an illegal and a criminal offence, according section 311 Criminal Code Act 1899 (Qld) to procure, counsel or aid another to suicide. However, the Voluntary Assisted Dying Act 2021 (Qld) was passed in statute on 1 Janury 2023. Despite this there is much weight and support given to people with advanced and progressive terminal or chronic or neurogenerative condition to die with dignity of their own choosing and with support from services.

We are very fortunate at QUT because of the research undertaken by a group of academics and professionals in end-of-life care. QUT’s End of Life Law in Australia can be accessed by clicking here. Free training on End of Life Law for Clinicians can also be accessed by clicking here. This is not a mandatory part of this unit. Future versions of CSB338 will contain this. If you have time and you are sufficiently interested, I will appreciate and value your feedback on its inclusion in future version of this unit.

Currently, the only states where VAD is available is Victoria and Queensland. Western Australia has legislation (Voluntary Assisted Dying Act 2019 (WA)) but this has not been implemented and is not expected to be available to Western Australia citizens until 2021. More information on the WA Act can be found here. Section 115 of the WA has similarities with the section in the Victorian Act found below. It’s worth having a peek at this legislation as it could impact paramedic care of the dying resulting from a deliberate act. Section 81 Voluntary Assisted Dying Act 2017 (Vic) states:

81 No liability for registered health practitioner or ambulance paramedic present after person administered voluntary assisted dying substance

(1)   A registered health practitioner or an ambulance paramedic who, in good faith, does not administer life saving or life sustaining medical treatment to a person who has not requested it, and believes on reasonable grounds that the person is dying after being administered or self-administering a voluntary assisted dying substance in accordance with this Act, is not, in respect of that omission to act—

(a)   guilty of an offence; or

(b)   liable for unprofessional conduct or professional misconduct; or

(c)   liable in any civil proceeding; or

(d)   liable for contravention of any code of conduct.

(2)   This section does not prevent a registered health practitioner or an ambulance paramedic from providing medical treatment for the purpose of ensuring the person’s comfort.

(3)   In this section—

ambulance paramedic means a person employed or engaged by an ambulance service, within the meaning of the Ambulance Services Act 1986—

(a)   as an ambulance paramedic or intensive care paramedic; or

(b)   in any capacity to provide medical or other assistance to patients in an emergency.

The legislation anticipates that paramedics are likely to respond to patients who are participating in voluntary assisted death. It’s a helpful inclusion. The inclusion of paramedics in the Act assumes that paramedics may instinctively attempt to resuscitate. It recognises that there are times when we might need to be observers as oppose to interventionists. It also recognises that we might administer medication, not for therapeutic purposes, but for palliative purposes.

6.4.1 Voluntary Assisted Dying in Queensland

The Voluntary Assisted Dying Act 2021 (the Act) was passed in September 2021. Voluntary assisted dying will be available to eligible Queenslanders from 1 January 2023.^[5]

The five criteria required to be illegible for voluntary assisted dying in Queensland found on the Queensland Health, Queensland Government website are:

“1. Have an eligible condition

An eligible disease, illness or medical condition is one that is:

• • • advanced, progressive and will cause death
    • expected to cause death within 12 months
    • causing suffering that the person considers to be intolerable. Suffering can include:
      • physical suffering
      • mental suffering
      • suffering caused by treatment provided for the disease, illness or medical condition.

Whether the person’s suffering is intolerable is a subjective assessment by the person themselves.

2. Have decision-making capacity

A person has decision-making capacity for voluntary assisted dying if they can:

• • • understand the nature and effect of decisions about access to voluntary assisted dying
    • freely and voluntarily make decisions about access to voluntary assisted dying
    • communicate decisions about access to voluntary assisted dying in some way (verbally, or by other means of communication such as hand gestures).

A person is presumed to have decision-making capacity for voluntary assisted dying unless there is evidence to the contrary.

To determine if a person has decision-making capacity, the following will be considered:

• • • a person may have decision-making capacity to make some decisions but not others
    • capacity can change or vary
    • a person may temporarily lose and later regain capacity
    • whether the person has enough and suitable support.

It should not be presumed that a person does not have decision-making capacity because:

• • • of a personal characteristic
    • the person has a disability
    • the person makes a decision that other people don’t agree with.

3. Be acting voluntarily and without coercion

A person must want to access voluntary assisted dying. The person must be acting without force, influence or persuasion by another person.

4. Be at least 18 years of age

Voluntary assisted dying will only be available to adults (people aged 18 years or older). It is also the approach taken in other Australian states where voluntary assisted dying is legal.

5. Meet residency and citizenship requirements

To be able to access voluntary assisted dying in Queensland a person must:

• • • be an Australian Citizen, or
    • be a permanent resident of Australia (this includes New Zealand citizens who hold a special category visa as defined by the Migration Act 1958 (Commonwealth)), or
    • have been ordinarily a resident in Australia for at least three years immediately before making the first request, or
    • have been granted an Australian residency exemption by Queensland Health, and
    • the person must also have been:
      • ordinarily a resident in Queensland for at least 12 months immediately before making a first request, or
      • granted a Queensland residency exemption by Queensland Health.

‘Ordinarily a resident’ is someone who regularly or normally lives in Australia. It does not include people who temporarily live in a place, for example, for a holiday, business or education.

Queensland Health can grant a residency exemption:

• • • for compassionate grounds, and
    • if the person has a substantial connection to Queensland. For example, a person who is:
      • a long-term resident of a place close to the Queensland border, who works in Queensland and receives medical treatment in Queensland. For example, someone who lives on the northern New South Wales border, or
      • lives outside of the state but is a former Queensland resident and whose family live in Queensland.” ^[6]

Similar to Section 81 Voluntary Assisted Dying Act 2017 (Vic) is Section 149 Voluntary Assisted Dying Act 2021 (Qld), which offers protection for health practitioners and ambulance officers if, [a health practitioner or ambulance officer] in good faith, does not administer life sustaining treatment to another person in accordance with voluntary assisted dying.

The full Act can be found here.

6.5 Therapeutic Care and Palliative Care

Therapeutic care is care designed to improve. It relates to healing. Palliative care focusses on easing suffering. It is not designed to prevent deterioration or promote recovery. Palliation does ameliorate in the sense that if a person is in pain caused by their terminal illness, then administering a drug with the aim of a reduction in pain distinct from the medical complaint, could be held to be an improvement in the patient but not in their overall condition. The terminal illness persists.

An imperative aspect of palliative care is the distinction between medication that reduces pain and suffering from medication that shortens a patient’s life. Opiates can lessen or even eliminate pain. They also act as central nervous system depressants, depressing respiratory and cardiac output. The effect on an already compromised system can lead to respiratory and cardiac arrest. Despite this, the intention is to relive pain and suffering, not hasten death. This is described as the doctrine of double effect.

6.6 Doctrine of Double Effect and Cases of Assisted Death

Suicide is not a crime in Queensland. However, it is an offence to aid, abet and advise an individual seeking assistance in bringing about their death. It is an offence to administer anything to hasten a person’s death, but it is not an offence if the intention is to alleviate pain and suffering. Despite the alleviation concomitantly shortening a person’s life. This is the doctrine of double of effect and it has turned up in quite a few legal cases, including criminal trails, over the years.

As you can see, the courts are prepared to acknowledge the doctrine of double effect. They are also prepared to act with leniency despite for all the intents and purposes, the act fulfills the criteria of murder. These cases seem to have paved the way for VAD legislation to be enacted in Victoria and signal possible changes to the statute books on VAD in WA and Queensland. We will return to the topic of suicide in chapter 8 but from a different perspective.

The doctrine of double effect is predicated on the foreseeability of death not on it as an intended outcome. The topic remains controversial. Paramedics are only ever permitted to administer a limited amount of schedule 8 opiates. To administer more requires permission following medical consult. However, the Voluntary Assisted Dying Act 2017 (Vic) appears to suggest that it might be possible for Victorian paramedics to administer medication to alleviate discomfort. A registered health practitioner or an ambulance paramedic is not precluded from providing medical treatment for the purpose of ensuring the person’s comfort (s 81(2) Voluntary Assisted Dying Act 2017 (Vic)). Time will only tell whether Queensland and the QAS are prepared to incorporate similar measures.

6.7 Ethical and Legal Issues at Major Incidents

This section can be reduced to the final principle in the four bioethical principles: justice. Or more accurately distributive justice. The Word Medical Association has produced a statement on medical ethics in the event of disasters. It provides a guidance where, due to the number of casualties, demand outstrips available resources:

“It is ethical for a physician not to persist, at all costs, in treating individuals “beyond emergency care”, thereby wasting scarce resources needed else-where. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered an ethical or medical failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals. However, the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives, and if possible ask somebody to stay with the patient and not to leave him/her alone.

The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum.

In selecting the patients who may be saved, the physician should consider only their medical status and predicted response to the treatment, and should exclude any other consideration based on non-medical criteria.”^[7]

Of course, all bioethical principles apply at major incidents incorporating disaster management. Expectations are based on resources promoting maximum benefit for the greatest number. To achieve this, difficult choices make for difficult decisions. I will leave the discussion here as I believe you will return to this Major Incident Management.

6.8 Final Word

6.9 Case Study

Maxie Lamington-Brown is an Australian oil worker based in Papua New Guinea (PNG). He works 21 days on, 14 days off roster. When not at work he returns home to Brisbane and his wife, Laura and 2 year-old daughter, Lexie. Laura is 8 months pregnant with their second daughter when she receives news that Maxie has suffered a workplace accident. Part of his left bicep was torn from his shoulder while fixing a generator sited on unstable ground. He returned to Brisbane for day surgery, which was successful followed by recuperation at home. Not long after the surgery, Maxie suffers gross episodes of haematemesis and haematuria. Laura contacted Maxie’s GP. Maxie was seen by his GP; bloods were taken, and Maxie was diagnosed with primary testicular cancer with metastasises to his liver and brain. Maxie’s prognosis is terminal, and he is given less than a month to live. To say the young family is devastated is beyond an understatement. Maxie, Laura and Lexie decide to waste not one moment of precious time together. Maxie promises Laura he will stay alive long enough to meet their second daughter. Laura’s brother is a solicitor and takes legal responsibility for the family’s affairs so they can enjoy what little time is left. Maxie chooses to complete an AHD stating that he is not a candidate for resuscitation, requests no therapeutic care, and is willing to accept palliative care to eliminate pain and suffering. At the time of completion, it is acknowledged that Maxie has testamentary capacity. The AHD is put in a prominent place in Maxie and Laura’s house. Visitors to the house must walk past it to enter the house. Maxie has nominated Laura as his health attorney. Every 24 hours there is a marked deterioration. Some days are better than others. But everyday Maxie is overall slightly less well than he was the day previously. A day before Laura’s due date, despite his promise to her, there is a pronounced and marked deterioration in Maxie.

It is your third day with a television production company responsible for the catchily titled programme, Perfect Paramedic Protagonists. A situation you are not altogether comfortable with. You do not consider yourself telegenic and it is this that informs your hostility to the production crew. Your participation has been sold to you on the basis that the public are better educated on the professional role of paramedics thanks to the programme. Mid-morning, you, your crewmate and the film crew are dispatched to Maxie and Laura’s house for a male in (query) cardiac arrest.

As the paramedic in charge of patient care for this shift you enter the property first, closely followed by your crewmate, Sukie. Sukie’s paramedic degree didn’t have a specialist law and ethics unit. Poor Sukie. The TV crew wait outside pending approval to come in and start filming. You move straight to Maxie and it is clear he is not in cardiac arrest… yet. You gather Maxie’s past medical history while obtaining some preliminary observations. You recognise the situation is grave. Politely, you ask Laura whether Maxie has an AHD and what the plans are related to Maxie’s end-of-life care. Laura’s interminable tear-filled gaze locks with yours and is only broken when Sukie enters the room holding Maxie’s AHD. You take it from Sukie, read it and hope that Laura did not detect a faint sigh of despair pass your lips. You try to find the words to convey the enormity of the situation while simultaneously recognising how helpless you feel given the contents of the AHD. You reach out with your left hand to hold Laura’s right elbow and you manage to say, “I’m sorry” before your voice trails off. Laura replies,

“I couldn’t give two flying ducks, you jumped up pair of teal testicles. Your job is to save lives. Save his. Now!”. She shouts, “I want the baby I’m carrying to meet her father once at the absolute least!”.

And with that, Laura buckles forward forced by the feeling from her first contraction. The TV production crew grin at each other like Cheshire cats. Sukie’s hands are poised to commence CPR. Laura is indisposed intermittently. And then there is you standing there wishing that someone would solve the dilemma for you. As luck would have it, over 200 law and ethics paramedic students turn up and begin yelling suggestions from outside the property. You excuse yourself to avail yourself of some of the suggestions…

6.10 Podcast

Voluntary Assisted Dying with Professor Ben White

https://end-of-life.qut.edu.au/palliative-care

https://palliativecareeducation.com.au/login/index.php

6.11 Further reading

Moritz, Dominique (ed), Paramedic Law and Regulation in Australia (Thomson Reuters (Professional) Australia, 2019) pp 269-297

Inquest into the death of June Woo

https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/131961/cif-woo-j-20090601.pdf