The Australian state of Victoria legalised assisted dying a year ago. As New Zealand prepares to vote on a similar law change next month, Isaac Davison spoke to a doctor who has been deeply involved in Victoria's new regime.
When the end comes, most patients take their lethal dose of medicine without hesitation.
"It's remarkably consistent how brave they are," said Cameron McLaren, a medical oncologist based in Melbourne who has witnessed dozens of assisted deaths in the last year.
"No one really balks too much at it. It really gives you an insight into how much suffering these patients are undergoing. They just take the drink as if it was a shot of whiskey and don't think twice."
McLaren was one of a minority of doctors who agreed to carry out assisted dying assessments when Victoria made voluntary euthanasia legal last June. The Victorian law's key provisions are similar to New Zealand legislation which is being voted on in a public referendum next month.
An initial shortage of willing doctors meant McLaren was in demand. He has done 100 assessments, of which 40 patients have been deemed eligible and 30 have taken the lethal dose. That is nearly a quarter of the assisted deaths in Victoria so far.
McLaren has been in the room for most of the deaths, including several where he had to administer the medicine intravenously (it must be taken orally unless the patient is unable to). No one had changed their mind at the last minute, though one patient delayed his death by a few hours.
"I usually say you've got between two and five minutes before you fall asleep. In that time they do say their last words to their family. It's usually 'Love you, be good, look after each other'."
Patients died in their bedrooms and living rooms, surrounded by family. One person chose to die in their garden. Another man had a barbecue for 100 people and at around 2pm told McLaren he was ready to go. He went to his shed, lay on his workbench and took the medication. There was humour in their last moments - one held up his drink and said "to good health". It usually takes 20 or 30 minutes for them to die.
McLaren's first case was a woman in her 70s with advanced lung cancer who wasn't responding to treatment. She was not in severe pain, but was confined to a chair and was unable to enjoy life.
"That is the main reason people want this medication," McLaren said. "It's actually not to do with physical pain or symptoms. Because they're really well-controlled by palliative care but what they can't control is the patients' own perception of their quality of life."
The woman chose to die in an armchair in her daughter's living room. She had all of her children around and her granddaughters. She listened to Frank Sinatra's "I Did It My Way", took the medication, and her family played Van Halen on the stereo while she fell asleep.
"It was quite lovely, actually," McLaren said. "We all hugged afterwards - this was before Covid - and most of the experiences are very similar. I can't think of a negative experience."
McLaren's voice trembles a little.
"People get that moment of closure with their loved one that they really don't in many other ways that people pass away currently.
"This is not for everyone, but for some people … it is a peaceful way to die. It is uncomplicated, it provides families that last moment together, and that has been really beautiful."
As of June 2019, 348 people have applied for assisted dying in Victoria. Of that total, 231 have been given the green light to proceed and 124 people have died. Four out of five of the people who died had cancer. The average of age was 71, the youngest person to die was 32.
The number of assisted deaths was far more than anticipated. In July 2019, Victoria's health minister said it was expected that about a dozen people would get assisted dying in the first year. Experts said the higher-than-expected demand was partly because of the difficulty in estimating a population's response to assisted dying.
In countries where euthanasia was more established, assisted deaths made up around 2 per cent of all deaths. In Victoria, that would be around 800 deaths a year.
So what lessons are there for New Zealand as it votes on legalisation?
Professor Ben White, from the Australian Centre for Health Law Research, said concerns about Victorians being coerced into death did not appear to have eventuated.
"The evidence that's available to date, and some of this is anecdotal, shows that the law has worked as anticipated," he said.
"There are two big questions: One, Are people who are eligible for assisted dying able to get access? And two, are the safeguards working to make sure there is good decision-making and people who aren't eligible are excluded.
"On the safeguards, that is very clear, they have worked."
The main problem with the assisted dying regime in Victoria so far had been ensuring it was available to all people who wanted it, White said. Access was uneven, depending on where you lived and your ethnicity.
That was made partly because of the initial shortage of doctors who opted to take part in the Victorian system. McLaren said just 28 out of 265 oncologists went through the mandatory training provided by the state.
There were some problems unique to Australia. Doctors cannot carry out assessments via teleconference with people in rural areas because it is illegal under Australian federal law to discuss suicide on the phone or via video conference. Supportive doctors were now hoping to change this law.
Victoria's legislation is fundamentally the same as New Zealand's End of Life Choice Act. Terminally ill patients can get access to voluntary euthanasia if they get approval from two doctors, and satisfy a number of safeguards which test competency and other factors.
But there are key differences.
Catherine Marks, a special counsel at law firm Russell McVeagh, said New Zealand's proposed law had some more restrictive provisions.
"And the Victoria law is not at all permissive," she said. "New Zealand is possibly the strictest legislation [in the world]."
In New Zealand, there were explicit rules around coercion, which meant doctors had to stop a patient's application as soon as they detected any external pressure.
Marks - who represented Wellington lawyer Lecretia Seales in her failed legal bid for voluntary euthanasia - said Victoria also had slightly more lenient eligibility criteria in some cases.
It allowed terminally ill people with neurodegenerative conditions to apply for assisted dying if they had 12 months to live. In New Zealand, the threshold is six months for all patients.
Some have argued that New Zealand's law is more permissive because it does not have a "cooling off" period. In Victoria, there is a minimum period of nine days between a patient's first request for assisted dying and their date of death. Opponents in New Zealand have said that a person could choose to die and go through with the procedure without having time to properly reflect on it.
Ministry of Justice advice shows this is unlikely. While it is technically possible to die four days after requesting it, bureaucratic hurdles mean the process is more likely to take weeks or months.
Another key difference is that people in Victoria do not have to take their lethal dose of medicine within a specific timeframe. They can take it home and keep it in their bathroom cabinet - though a contact person must be responsible for it and ensure it is not abused.
In around a quarter of McLaren's cases, the patient died naturally without taking the lethal dose.
"They keep it under lock and key and they are very reassured that it is there," he said.
"They feel very comforted that if their worst fears about their end of life process are coming true they have the ability to take control and avoid extreme pain or suffering.
"For many people, it is enough."
Five things to know
New Zealand will vote next month on whether it wants voluntary euthanasia to be legalised.
Before you cast your vote, here are five things you should know.
1. You have the final say.
The referendum is binding, and a majority "yes" vote will mean voluntary euthanasia will be made legal exactly a year after election day (October 17). A "no" vote will mean we keep the status quo.
2. We've been here before - sort of.
Parliament has twice voted against laws to legalise euthanasia in New Zealand. Former National MP Michael Laws' Death with Dignity Bill was heavily defeated in 1995. And NZ First MP Peter Brown's bill by the same name was narrowly defeated - by just two votes - in 2003.
On the latest attempt, Act Party MP David Seymour's End of Life Choice Act has already been passed by Parliament - but relies on a public vote to get it over the line.
3. If legalised, euthanasia would not be available to anyone.
It would be limited to NZ citizens or permanent residents who are 18 years or older and suffer from a terminal illness which is likely to end their lives within six months.
They also need to be:
• In an advanced state of irreversible decline in physical capability.
• Experiencing unbearable suffering that cannot be relieved in a manner that they consider tolerable.
• Competent to make an informed decision about dying.
They also cannot be eligible on the basis of age, mental illness, or disability alone.
4. Opponents are concerned, however, that legalisation might create risks for a broader group.
Some countries have broadened their euthanasia laws. This is being considered in Canada, which New Zealand's law was partly based on. A law change there could soon make euthanasia available to non-terminal patients.
Supporters of the End of Life Choice Act say that doesn't foreshadow what could happen here. Those changes were specific to Canada's constitution and law-making. Any further changes to New Zealand's law would need to get through Parliament.
5. Euthanasia generally benefits the most privileged people in society.
Analysis of deaths in the United States, Canada and Europe found those most likely to access assisted dying were old, white, well-educated and relatively wealthy.
This is mainly because this group is more likely to be able to have better access to the healthcare system, and are better able to navigate the medical and bureaucratic hurdles to assisted dying.