On a moonless night earlier this year, a car was parked at a beach and a doctor was kneeling at the open front door.
In the front seat, his patient was dying, quietly.
The doctor had administered medication that amounted to a lethal dose.
It was a still night and only the waves could be heard. The doctor waited until the patient had died, and then walked away from the car to allow the family some time with their loved one.
“I thought that people would want to die in their own bed,” said the doctor (who cannot be named under assisted dying legislation).
“But then people don’t want their family to remember them dead in bed. Or they want to take in views and see the process as one door closing and another door opening. They want to be in a place or a time where they think the door will open in the most appropriate manner for them.”
In the first year since legalisation, New Zealanders have taken to voluntary euthanasia in their own way. They are choosing to die in the dunes at the beach, in their garden, in their favourite armchair, or in their bed with their labrador at their feet.
Aside from the surprising locations of death, the new system had gone mostly as he anticipated, the doctor said. Once the End of Life Choice Act was backed in a public referendum, he read the required documents provided by the Ministry of Health and attended training workshops, which lasted around seven hours in total.
In all, 130 medical professionals have volunteered to be part of the assisted dying regime. There are gaps in some areas, especially rural regions. That meant the North Island-based doctor had flown to the West Coast for one assessment, and driven on a five-hour round trip for another.
He had assessed 15 patients so far, all of whom had gone on to have an assisted death. He was present for the majority of them. After administering the medication, patients typically fell asleep within seconds, he said, and died within five minutes.
“At times, the person is so weak and so ill and you see the relief in their faces and the relief in the families’ faces as they see a very peaceful event,” the doctor said.
For those who want voluntary euthanasia, the law change has been relatively smooth so far. There have been no breaches of the law, though there have been four formal complaints, including one which was serious enough to be referred to the Health and Disability Commissioner.
Patients applying for an assisted death must be assessed by two doctors, with each of their reports checked for compliance by a registrar in Wellington. The whole process takes a few weeks between a first inquiry and the lethal dose, but some cases have been expedited to days when a patient’s death was imminent.
No applicant has required a third opinion from a psychiatrist - which is mandatory if either of the assessing doctors has any concern about a person’s competency to make a decision about assisted dying.
Nationally, the rejection rate for applications is relatively high compared to other jurisdictions, at about 20 per cent. That reflects the relative strictness of New Zealand’s law, in particular, a requirement that the patient has only six months to live. A third of ineligible patients were rejected for this reason.
The doctor said estimating when a person might die was relatively straightforward for patients with cancer or neuromuscular disorders. It was more complicated for people with conditions like heart failure.
“With today’s medications, it is very hard to give a prognosis,” he said. “Many people respond very well to medications. But there’s a group who are very disabled, very immobilised, often with multi-comorbidities, that is kidney failure, strokes, lung disease. And they say ‘I’ve just had enough of this, I don’t want another trip to hospital, I can’t do anything, I’m stuck at home.’ And they are very, very ill. But it’s very hard to give them a six-month prognosis.”
Among those who support euthanasia, this has been one of the key themes of criticism since assisted dying was made legal.
“The legislation is not as enabling as some people were hoping for with the criteria making an assisted death more restrictive than overseas jurisdictions,” the Assisted Dying Registrar Kristin Good said in her annual report in June. “This was coupled with hope for a broadening of criteria over time.”
This push for a more permissive law has led to concerns from religious groups of a “slippery slope”. But any reform is unlikely before a review in 2024, and would have to pass public and Parliamentary scrutiny.
Among those who oppose assisted dying, other concerns are the lack of data collected from applicants, which makes it more difficult to determine their reasons for choosing voluntary euthanasia. Rising demands for underfunded palliative care is also a cause for anxiety.
In a small, plain room on the ground floor of a hospital in April, Denis Davison was asked one last time if he wanted to die.
Davison had been diagnosed with muscular dystrophy in 2010, when he was in his early 60s. It is an incurable condition in which muscles gradually become weaker.
A keen outdoorsman who loved water-skiing and hiking, his family first noticed a change when he was twice unable to complete a hike to the summit of Mt Egmont because of a newfound weakness in his legs.
He and wife Celia lived in Zimbabwe until 2002. Denis had owned a small silica mine until it was claimed by the Mugabe-led Government as part of widespread land seizures in the 2000s. They emigrated with their two sons to Auckland, where Denis worked as a handyman and Celia as a town planner for the Auckland Council. Denis’ thick Zimbabwean accent never faded, nor did his taste for biltong and blood sausage.
After his diagnosis, he kept working as a warehouse foreman for another two years, increasingly doing tasks that did not require fine motor skills. His deteriorating condition forced him to retire in his early 60s. By his late 60s, he could no longer stand or walk and had to use a wheelchair.
Denis was a practical, no-nonsense, person - “straight up and down”, a friend said. He didn’t read books or watch TV. He was good with his hands, was a Scoutmaster, and wanted to be outside or to be making and fixing things. That meant life was near-intolerable when he eventually lost the ability to use his hands. During one of many trips to hospital, his fingers were so weak they couldn’t push the call button.
“If he needed to blow his nose. I had to blow it,” Celia said, speaking to the Herald at her home in Auckland. “I had to do everything. He couldn’t do anything for himself. Nothing.”
Feeling trapped in his own body, Denis attempted suicide twice. Celia investigated a trip to Switzerland, where foreigners can get an assisted death, but worried they were breaking New Zealand law. Denis liked to do things by the book. At the time, assisted dying was not yet legal in this country.
By Christmas last year Denis was unable to swallow, and contracted pneumonia because he could not keep food out of his airways. His suffering continued to pile up. In February, he was hit by a car while driving his motorised wheelchair over a pedestrian crossing and was hospitalised.
At this point, New Zealand’s voluntary euthanasia regime had been in force for a few months. Celia had been strongly resistant to her husband’s request for an assisted death. But now that he faced being fed through a pipe in the nose, she agreed that his life had become intolerable.
They had supported voluntary euthanasia in the public referendum, but they were not ideological about it. In the end, they sought an assisted death out of desperation.
Celia read the criteria on the Ministry of Health website and was certain her husband would not qualify. He was competent to make a decision about his death, he was suffering unbearably, and was in irreversible decline, but there was no certainty he would die within six months.
She emailed the ministry, which contacted her two days later with a referral to a doctor (Denis’ GP declined to be involved).
“The process was amazing,” Celia said. “Everyone is critical of government for being so slow, too bureaucratic, or not caring, but this was very good.”
Denis had two assessments, each lasting around 1.5 to 2 hours, to check his competence, his condition, and his prognosis. The doctors consulted with his specialists, including one who had worked with Denis on his swallowing and who confirmed there was a likelihood that if he continued to contract pneumonia infections he could die within six months.
Denis was taken to hospital in March with another infection, and began refusing treatment. He was miserable. Then the news came through - he had been approved for an assisted death.
“The doctor said, ‘Look, don’t worry, I’ve got the permission. It’ll happen tomorrow.’” Celia said. “That was a bit of a shock.” She wanted a few more days, but Denis was adamant: He would die the next day.
The following morning, Celia and their two adult sons gathered at his bedside. He was wheeled from the ninth floor of the hospital to a room on the ground level. It was the first assisted death at the hospital since legalisation. Staff had put aside a small, no-frills room with a lounge next to it for family members to sit in.
The doctor who had carried out the first assessment took Denis into the room while Celia and her sons stayed in the lounge area. Then came the final check. Did he want to go through with it, the doctor asked. “Yes,” Denis said.
Celia and her two sons were let into the room and held his hands on either side of the bed. They chatted for a few minutes and Denis said “goodbye”. The doctor carried out the procedure and he fell asleep quickly. He died within a few minutes. He was 74 years old.
“Denis faced his fate in a very practical way,” Celia said. “He knew exactly where he needed to go and what he needed to do.
“We all didn’t necessarily agree with him. But in the end, he knew that was what needed to happen. And he was right.’
His final moments contrasted to those who died at the beach or other natural settings. But he was a pragmatist, Celia said. After losing control of his body, Denis’ final act was one of ultimate control: to die when, where and how he wanted.