Two questions in palliative medicine selection test honesty and the law together: how you would respond to a patient who asks about voluntary assisted dying, and what you would say to a patient who asks how long they have to live. Both are asked because every palliative trainee will be asked them by patients, and both have wrong answers that panels hear often. This guide covers each.
Voluntary assisted dying
Every Australian state now has voluntary assisted dying legislation, with differences in eligibility, process and the obligations of clinicians, and the territories have followed or are following. The panel expects you to know your state's law at the level of a registrar: who is eligible, what the process involves, who can be involved, and what a clinician must and must not do.
The scenario: a patient asks about voluntary assisted dying. How do you respond, and what are your obligations?
Respond with respect and curiosity, not deflection. Find out what lies behind the question: fear of suffering, loss of control, a wish to spare the family, intolerable symptoms, or a settled wish to end life on their terms. Many questions about assisted dying are questions about something that palliative care can address, and the panel wants to hear that you would explore that first, without using it to avoid the question.
Give information. In most states a clinician may provide information about the law when asked, and in some states must not initiate the discussion; know which applies to you. Explain the process accurately and without judgement. Say who the patient can speak to, including the state's care navigator service.
Know your obligations. In most states a clinician may conscientiously object to participating but must not obstruct the patient's access to information, and in some states must refer or provide contact details. Say what you would do whether or not you participate, and that your own view does not change the patient's rights.
Involve the team and the consultant, document, and continue palliative care regardless of the patient's decision. The patient who chooses assisted dying still needs symptom control and support, and so does the family.
The probe: the family disagree with the patient; the patient asks you to be involved; the patient lacks capacity. Each has an answer grounded in the law: the decision is the patient's, participation is yours to decide, and capacity is required at every step.
The prognosis question
A patient asks you directly how long they have to live. What do you say?
Find out why they are asking and what they want to know. Some want a number to plan; some want reassurance; some are testing whether you will be honest. Ask.
Be honest with ranges, not false precision: days to weeks, weeks to months, months. Acknowledge the uncertainty and say that you have been wrong in both directions. Say what you are watching for that would change your estimate.
Link it to what they need to know for: the family visit, the wedding, the affairs to settle, the place they want to be. The prognosis is useful because of what it allows the patient to decide.
Stay with the reaction. Silence is allowed. Offer to talk again, and to talk to the family if the patient wants.
The common failures are deflecting with "nobody can say", giving a single number, and leaving the room after the answer.
The family who want everything done
Often asked alongside: a family want their dying mother to have fluids and antibiotics that will not help. The goals of care, what the treatments would and would not do, the patient's wishes if known, the comfort that will be given, and the consultant involved. The family's fear of abandonment addressed directly.
Cultural safety at the end of life
How do you provide culturally safe end of life care to an Aboriginal patient and their family? The wish to die on country, the family's role in decisions, the Aboriginal liaison officer and the community health service, the practices around death and the body, and the humility to ask rather than assume.
What the panels score
The law known accurately, the patient's question explored before it is answered, honesty with ranges, obligations met regardless of personal view, the family handled with compassion, and a registrar who stays in the room.
Preparing
Read your state's voluntary assisted dying legislation and the guidance for clinicians. Practise both conversations aloud with someone who asks the hard follow ups. Know what you would and would not participate in, and be able to say so without judgement of the patient or of colleagues who choose differently.