X-Message-Number: 6985 Date: Thu, 26 Sep 1996 18:00:12 -0700 From: David Brandt-Erichsen <> Subject: more details from Australia From the SYDNEY MORNING HERALD (Sept 27) LUNCH, A FINAL JOKE AND THEN GOODBYE By GAY ALCORN in Darwin Bob Dent was well known in the still small town of Darwin. So well known that the local newspaper, the Northern Territory News, ran an obituary of him yesterday without mentioning the fact that he was the first person in the world to die using voluntary euthanasia legislation. The newspaper called 66-year-old Mr Dent a "true blue Territorian with a big sense of humour". He was a carpenter and a pilot who had turned to Buddhism and therapeutic massage. He was extremely close to his wife, Judy, to whom he had been married for 20 years. The couple left Darwin after Cyclone Tracy in 1974 and returned to retire in 1991.They had no children. In the manner of his death, according to his doctor, Dr Philip Nitschke, Mr Dent was a brave man, a man who wanted to control exactly how andwhen he died. (Picture of computer screen used by Mr. Dent in making his "final choices") Last Sunday, the day he decided he wanted to end five years of suffering from prostate cancer, he joked with Dr Nitschke and tried to relax him. Dr Nitschke had joined the couple for a simple last lunch - a ham sandwich and a glass of stout. "He was a very calm, very sick, very ill man," said Dr Nitschke. "He kept saying that he was a pilot and he knew about whether planes were fit to fly. He said, "look mate, if you walked around this plane, you'd say it's not going anywhere'." Then he turned to Dr Nitschke and said: "Let's get on with it, you're here to do a job." Mr Dent dictated his final statement to his wife in the last days before dying under the Northern Territory's Rights of the Terminally Ill Act, which enables a doctor to assist a patient to die. The two-page statement was produced by Dr Nitschke yesterday at a hastily-arranged press conference. Dr Nitschke, who assisted at Mr Dent's death at his Darwin home, fought back exhausted tears. His life has almost collapsed with the stress of coping with the desperate hopes of his patients and the firm opposition from the medical establishment, Churches and many political leaders. Mr Dent outlined his suffering, from being diagnosed with prostate cancer in 1991, having both testicles removed, his impotence, failed repair jobs on his hernia and the embarrassment of having to use a catheter and leg bag. He lost 25 kilograms and was taking 30 tablets a day. For Philip Nitschke, the 49-year-old doctor with just seven years in the profession, the experience has almost broken him. His relationship with his girlfriend has all but collapsed and more than once he has wondered whether this issue, that affects just a handful of people, is worth it. Some of his friends have asked him why he would take on such an issue when there are bigger political fights - issues such as Aboriginal health and the environment (he stood for the Greens in the March Federal election). Dr Nitschke said he woke up in February last year to a radio report that the then Chief Minister, Mr Marshall Perron, was to introduce a euthanasia bill and the Australian Medical Association saying that no Darwin doctor would be involved. "Well, that's not on," he thought. Nineteen months later, his after-hours medical practice, AusDoc, has all but collapsed. "I'm going to take a holiday for about three months right now. This has taken a toll on my personal live, it's made things extremely difficult, it was a very bitter tough fight," he said. "It's worth it if we get this law in. I believe in this passionately. It would be an awful tragedy if this law was lost ... it would be very similar to the overturning of progressive abortion legislation." Mr Dent's funeral is to be held today at the Buddhist Temple in Darwin. ------------------------------------------ THE FIGHT TO END A LIFE 'Let's do it,' says Bob Dent and minutes later he is dead. GAY ALCORN looks at the months of planning to end the Darwin man's life and the doctor who was with him every step of the way. Dr Philip Nitschke had waited for days for the telephone call he was dreading. It came last Sunday morning and, as the phone rang, he felt a chill. The GP left his rural home just outside Darwin and drove to a house in suburban Tiwi, where Bob Dent was waiting. A few hours later, the 66-year-old Darwin man, who had suffered from prostate cancer for five years, became the first person to die using the Rights of the Terminally Ill Act, the first law in the world that legalises voluntary euthanasia. As he said in a statement released yesterday, both of his testicles had been removed, he was impotent, he had lost 25 kilograms, had worn a catheter and leg bag, and required 24-hour care. "I cannot even get a hug in case my ribs crack," he said. Nitschke, who has become, reluctantly, the most vocal medical supporter in Australia of euthanasia, had fought for weeks to get the necessary specialist's and psychiatrist's signatures for Dent, as required under the act. Yet he feels he barely had time to consider what he was about to do. "My fears about the whole thing was that I was in the executioner's role," said Nitschke. "I realised what a grisly business it is. He went right out of his way to try to calm me down. I was quite anxious, I was sweating, I was worried that there was sweat on my shirt. It was hot, but not that hot. I thought, "I can't muck it up.' What if my nerves failed me? I was half hoping that he might change his mind." Nitschke sat down for lunch with Dent and his wife of 20 years, Judy. She was the strong one in the last few weeks, extremely supportive of his decision, but worried that something would go wrong. The final meal was simple: a ham sandwich and glass of stout. There were some jokes, macabre but well-meant. Dent told Nitschke that if he drank too much, he would be unable to go through with it. He said more soberly that his experience as a pilot had taught him when planes were unable to fly - and his time had come. The last supper over, Dent said: "You're here to do a job. Let's get on with it." At 2.30pm, Nitschke set up the so-called "death machine", a computer hooked up to a "driver" that would dispense lethal drugs at the touch of the keyboard's space bar. It allows the patient to decide exactly when to die and enables the doctor not to have to physically inject lethal drugs. There were three questions to make sure Dent knew exactly what he was doing. The last was: "In 15 seconds, you will receive a lethal injection and die. Do you wish to proceed? YES/NO." Dent said, "Let's do it," and pressed the space bar. A drug called thiopentone put him to sleep in seconds. Pentobarbitone, a longer-lasting sleep agent that Nitschke had to get from veterinary supplies, because it is now off the market, was next. Finally there was atracurium, a muscle relaxant which stops the breathing. Dent died peacefully within minutes. At a media conference yesterday, Nitschke, 49, looked terrible. He barely contained his tears at times. Even the strongest supporters of euthanasia do not pretend it is easy, but Nitschke's scars are raw. He had been told to wear a tie and trousers instead of his customary shorts, but his respectability could not hide his deep emotion. "It was a very tense time. There was a great deal of apprehension, disquiet. The patient did as much as he could to keep trying to put people at ease, reminding me that this was an act of love and I should see it as an act of love," he said. "It [voluntary euthanasia] takes a toll out of those people who are participating, but perhaps, ultimately, it is the greatest thing you can do for a person. I felt at the end of it enhanced by the experience. I did not feel in any way that I have done the wrong thing." Every profession has its mavericks and Nitschke is one, although, this time, the costs have been huge. His relationship with his partner, also a doctor, has virtually collapsed, as has his AusDoc after-hours medical practice, whose patients are mostly heroin and narcotics users. This area is another of Dr Nitschke's passions, fighting the Territory Government's refusal to introduce a methadone program. He's been abused, labelled "Dr Death" and a murderer, and become an increasingly isolated figure within the medical hierarchy. "I'm going to take a holiday for about three months right now. This has taken a toll on my personal life. It's made things extremely difficult. It was a very bitter, tough fight. I had no idea that it was going to take on the bitterness. There's no kid gloves in this." THE beginning of what Dent called the "miracle" of euthanasia really began with a tragedy - the death of Broken Hill taxi driver Max Bell in early August. Bell, 66, drove 3,000 kilometres to Darwin to use the NT law, which came into force on July 1. But under the act, Nitschke had to find an NT-resident specialist in Bell's illness to confirm his diagnosis of stomach cancer and prognosis, and a psychiatrist to confirm that he was not suffering a treatable clinical depression. Not one would come forward, and Bell returned home to die what is termed a "natural" death in hospital. Nitschke was devastated by his death, at which he was present, and partly blamed himself. Bell's story upset many doctors and made others feel a sense of guilt. A local psychiatrist agreed to help the next time, then pulled out, citing fear of legal reprisals if the High Court challenge to the legislation was successful. Nitschke kept trying. Bob Dent first contacted Nitschke around March, wanting a doctor who could visit after hours. It was the usual pattern for terminally ill patients, who would not immediately mention euthanasia, but eventually did. An Adelaide psychiatrist rang to say that if a specialist was found, he would fly to Darwin to see Dent. Then, almost out of the blue, a local specialist said he would see the patient, on the condition that he remain anonymous. Nitschke was elated. He and Dent sat in the specialist's waiting room "with about a million other patients" on Friday August 30. At 11.15am, Dent, Nitschke and the specialist signed the necessary forms. Nitschke faxed the forms confirming the news to the Adelaide psychiatrist that day, but there was no response. Finally, the psychiatrist wrote back saying that he was not going to be involved. Dr Nitschke had not considered approaching Dr John Ellard, the Sydney psychiatrist, saying: "It would have been like approaching God." Ellard is the chairman of the Ellard Practice in Sydney and editor of Modern Medicine of Australia. But following a colleague's suggestion, Nitschke approached him and got an immediate "yes". The Dent family is not well-off and voluntary euthanasia societies around Australia donated the $1,500 for Ellard's air fares and accommodation in Darwin. He flew in on the midnight flight on September 7 and saw Dent for several hours the next morning. He signed the form without hesitation: Bob Dent was not suffering a treatable clinical depression. What seemed impossible had happened. The three signatures had been garnered and the nine-day "cooling off" period under the legislation had begun. The Dents were still desperately worried something would go wrong, that, somehow, the anti-euthanasia forces would stop him carrying out his wish. Very few people knew. Dr Robert Marr, a spokesman for the Coalition of Organisations for Voluntary Euthanasia, was made aware and wanted Nitschke to take the precaution of videotaping a final request from the patient in case of legal repercussions. Dent declined, preferring to make his written statement. "There are two issues here," says Nitschke. "What do I think about it? Am I worried about he ethics in what I'm doing? The answer's no. Am I worried about the risk to myself, the fear of consequences? No, not really. "God almighty, Christ. There are risks you take in this world, but this is not one of them. This bullshit about retrospective legal penalty. Come on. Compare that with the risks that Jack Kevorkian has been taking [in America] - that's dangerous. This is not an act of bravery." Nitschke says that in his "more cynical moments, I think this law was designed so no-one could ever use it". "I think they wanted to accept the international kudos for the piece of legislation but, at the same time, setting the bar so high that no-one could ever use it. Then, we could quietly repeal it. I guess they are a bit surprised that someone was actually able to fit the exhaustive criteria and use this act. "This patient has described that he's been searching for a miracle for five years. I agree with him. It was a miracle." ---------------------------------------- TRIUMPH OVER THE ETERNAL FOE By LEONIE LAMONT IT is a momentous time for Australia's voluntary euthanasia groups, the pinnacle of their ambitions coming with the death of a man who took a computer-assisted lethal injection in Darwin. While the president of the Northern Territory Voluntary Euthanasia Society, Lynda Cracknell, said that the organisation "operates about one level removed from the patient-doctor exercise", the national VES network had helped facilitate his death. Cracknell confirmed that Bob Dent had been a member of the 100-strong NT branch, set up a year ago after the NT Parliament passed the Rights of the Terminally Ill Act. "We operate on a shoestring and we don't have the finances to do anything dramatic, like support an individual, and nor do we do have the charter," she said. However, the national VES network paid for a Sydney psychiatrist, Dr John Ellard, to go to the Territory to examine the man and fulfil the requirements for euthanasia. Dr Robert Marr, a spokesman for the Coalition of Organisations for Voluntary Euthanasia (COVE), said: "It was extremely courageous of Dr Ellard and the other two doctors to really do what a doctor should be doing, and that is putting the interest of the patient ahead of their own interests. "Certainly, Dr Ellard didn't charge a fee. He took time out to go there. We felt it was fair enough for everybody to share his costs to get him up there. We didn't think it was appropriate the dying patient should have to pay out of their own pocket." The death, coming just before the contentious bill by the Liberal backbencher Kevin Andrews to override Territory powers to legislate on euthanasia, is a blow to anti-euthanasia forces. "I would say it would give them cause for pause," said Tony Wright, the NSW president of VES. "It's been shown to work - and work effectively - in a humane way. "The person has made a free choice, which has been backed up by a system that works, and enables a person to end their life in dignity, with their family around them, in a humane way." Had the VES movement overstepped its lobbying role by financially facilitating death? "We have given donations to various sister organisations, or people who have interests similar to ourselves, and this would be an instance where we have helped out," he said. "We are following our aims, as it were. "Although lobbying is our main tool, our main objective at the end of the day is to see legalised opportunity for free choice in the end-of-life situation." As for the nation, Wright says it is only a matter of time before other States and Territories introduce euthanasia bills, with safeguards, putting power into the hands of patients. Its main fight, he says, is nobbling the Andrews bill, and wise eyes should look to the Senate. ---------------------------------------- ALL TALK BUT NO ACTION By DAVID HUMPHRIES Euthanasia will be debated in the NSW Parliament on October 16 but there will be no vote and no resolution, the Premier said yesterday. Ruling out support for pro-euthanasia legislation because "no bill could deal adequately with the complexity and profundity of the issues involved", Mr Carr said MPs would be restricted to 10 minutes' speaking time each and "two eminent members of the community" would address the Parliament on the pros and cons. "There will be no vote," Mr Carr told Parliament. "The forthcoming debate will give an opportunity for members of the community to present their views to parliamentarians and for members [MPs] to place on the record their own views." The Coalition made clear its opposition to euthanasia laws. * The Herald yesterday wrongly reported that the Liberal backbench MP Mr Jeremy Kinross was planning a private member's bill in support of euthanasia. Mr Kinross announced last April he would not proceed with such legislation. ------------------------------------------ SIGNATURE THAT SIGNED AWAY A LIFE By RICHARD GUILLIATT John Ellard, the psychiatrist who helped authorise the world's first legally sanctioned euthanasia death, has long embraced thorny social issues and their attendant controversies. At 72, Ellard is an iconoclastic figure in a profession that normally avoids public scrutiny. An outspoken critic of the ethical lapses of some doctors, he has also publicly advocated political causes such as drug decriminalisation and the banning of guns. It transpires that euthanasia is another issue Ellard feels strongly about - so strongly that on September 7 he flew from his home in Sydney to Darwin, examined a man in his mid-60s with terminal cancer, and signed a release form that effectively endorsed the man's wish to die. No psychiatrist in Darwin was prepared to take such action. Up to that point, many of Ellard's colleagues and acquaintances were unaware of his views on euthanasia. "He's never discussed volun tary euthanasia with me, and I know him very well," says Professor Peter Baume, the patron of the Voluntary Euthanasia Society and a former colleague of Ellard's. "In other words, he runs his own life." Ellard's actions are all the more intriguing, says Baume, because his religion opposes euthanasia. "He is, as it happens, a Buddhist, but his own religious views are his own and he accepts other religious views. He lives his own life and he expects others to be allowed to do the same ... I suspect that he objects to third parties telling people how to run their lives." Ellard entered the medical profession after serving in the armed forces during World War II. Educated at Sydney University, he practised at Royal North Shore Hospital from 1952 to 1972, a period in which he also served in Vietnam, was a consultant psychiatrist to the RAAF and a member of Sydney University's Board of Studies. From the mid-1970s he was influential in psychiatry's pro fessional bodies, becoming chairman of the board of accreditation of the Royal Australian and New Zealand College of Psychiatry (RANZCP) and helping conduct an inquiry into psychosurgery. Since then he has often spoken out on ethical issues, criticising sexual misconduct among medical practitioners and faddish psychotherapy techniques. Unlike many medical practitioners, Ellard supported the work of the NSW Health Care Complaints Commission (HCCC), even when psychiatrists in his own practice in northern Sydney were investigated by the HCCC. Last year he publicly condemned a colleague, Dr Hugh Jolly, who was disciplined after admitting to a sexual relationship with one of his patients. "Ten years ago John was seen as very different because he had a sense of very high ethical duty," says Merrilyn Walton, the head of the HCCC. "He has been very supportive of this complaints unit when it has been accused of doctor-bashing." One of the psychiatrists who worked in Ellard's practice, Dr Alexander Macfie, resigned earlier this year after a complaint was made to the College of Psychiatry about alleged sexual misconduct. Ellard's influence has been heightened by his willingness to speak frankly and write accessibly. His 1989 book, Some Rules For Killing People, took its title from an essay that criticised the "abuse excuse" which enables murderers to claim diminished responsibility for their actions because of childhood abuse. Among his 100 published papers is a parody of psychiatric literature, which purports to measure the relative benefits of talking to a parrot as opposed to talking to a psychotherapist. "John is one of the truly important figures in Australian psychiatry and has been for many years," says Dr Jonathan Phillips, the chairman of the fellowships board of the RANZCP and a former psychiatrist at The Ellard Practice. "I think within John there's a deep sense of social justice." Uncharacteristically, Ellard was silent on that issue yesterday, confining his comments to a one-paragraph statement which said he had "no hesitation" in signing the documents that permitted Dr Philip Nitschke to help his patient commit suicide. "That's John," says Walton. "He will be committed to his principles and act them out." -------------------------------------------------------- WHY I WANT TO DIE A personal statement By BOB DENT I WAS diagnosed with prostate cancer late in 1991. In December I was sent to a specialist urologist in Brisbane for a bone scan and possible prostatectomy (removal of prostate gland). Before such a difficult procedure could be performed, it was necessary to check the lymph nodes in the groin area to see if the cancer had spread out of the prostate. An incision was made across my lower abdomen from hipbone to hipbone and several lymph nodes were removed. They were all cancerous. It was now too late to remove the prostate and, instead, both testicles were removed. The incision was sewn up, but two days later a large hematoma (blood clot) developed at the right-hand end of the incision. I had then to return to theatre for the incision to be recut and sewn. My bone scan at this stage was inconclusive so I was sent back to Darwin hoping that the removal of my testicles and consequent loss of testosterone production would stop the cancer progressing. Unfortunately, this also made me impotent (I had been told that impotency was a remote possibility). Six months later, a hernia developed under the same right-hand end of the hematoma. Darwin specialist surgeon Mr Dan Campbell repaired the hernia, but one year later it popped out again. Mr Campbell did a second repair job on the hernia and again, one year later, it recurred. Mr Campbell was apprehensive about attempting a third repair on the same site. I approached another specialist surgeon, Mr Jonathon Wardill, but he took one look and declined to even consider such a repair. Fortunately, a plastic and reconstructive surgeon, Mr Chandra Arianayagam, agreed to do the job and this repair is still holding. By mid-1995, I was having difficulty urinating as the cancer in the prostate gland had closed off the urethra. I had to have a catheter inserted in order to empty my bladder. I continued with daily self-catheterisation until the passage closed right over. An indwelling catheter and leg bag was the next step. In August 1995, a trans-urethral resection of the prostate (TURP) was done by a Perth urologist to chip away the cancer and reopen the urethra so that I did not have to use the catheter and leg bag to collect the urine. By May 1996, the urethra had once again become blocked and I again had to make use of a catheter and leg bag - an embarrassing and uncomfortable situation, especially in Darwin's climate. In June 1996, I had another TURP and this operation worked reasonably well, but the rest of my body was deteriorating quickly. I have lost 25kg in weight. My latest blood tests, taken on (2/9/96, indicated an acceleration of the cancer, with the prostatic specific antigen rising to 1,298 (normal is 0 to 4). The red cell picture was suggestive of infiltration of the bone marrow by the cancer. This was confirmed by chest X-ray. The full results of these tests were withheld from me by Dr Guy Bannick of palliative care. I have always wanted to know everything, the bad news as well as the good. I could easily have broken some of my ribs by allowing myself to be hugged and surely should have been warned of this. Dr Philip Nitschke, my after-hours doctor, requested a copy of the X-ray report from the Darwin Hospital for me. The X-ray also revealed an area of collapsed lung which could have been contributing to my breathing distress. Two specialists, Mr Wardill, who performed the 1996 TURP, and Dr Sid Selva, oncologist, have both said nothing further can be done. (I did have three months' hormonal therapy supervised by Dr Selva but the cancer is hormone-resistant and was not slowed by this treatment.) Already my urine flow is diminishing. Further TURPs are not advisable, even if my weakened body could tolerate a general anaesthetic. I have no wish for further experimentation by the palliative care people in their efforts to control my pain. My current program involves taking 30 tablets a day! For months I have been on a roller-coaster of pain made worse by the unwanted side effects of the drugs. Morphine causes constipation - laxatives taken work erratically, often resulting in loss of bowel control in the middle of the night. I have to have a rubber sheet on my bed, like a child who is not yet toilet-trained. Other drugs given to enhance the pain-relieving effects of the morphine have caused me to feel suicidal to the point that I would have blown my head off if I had had a gun. I can do little for myself, and require 24-hour nursing care. My hemoglobin has fallen to 8.3 (normal is 13.5 to 18.5). My red cells are decreased in number and deformed because of the cancer in the bone marrow. This anaemia causes shortness of breath and fainting because of the cells' inability to carry the required oxygen. An attempt was made to alleviate the symptoms of the anaemia by giving me two units of a healthy person's blood. The procedure took all day, was uncomfortable, and did no good whatsoever. There is now a constant fear of a fall, which could cause terrible injury to my fragile bones. I cannot even get a hug in case my ribs crack. My own pain is made worse by watching my wife suffering as she cares for me: bathing and drying me, cleaning up after my "accidents" in the middle of the night, and watching my body fade away. If I were to keep a pet animal in the same condition I am in, I would be prosecuted. I have always been an active, outgoing person, and being unable to live a normal life causes much mental and psychological pain, which can never be relieved by medication. I read with increasing horror newspaper stories of Kevin Andrews' attempt to overturn the most compassionate piece of legislation in the world. (Actually, my wife has to read the newspaper stories to me as I can no longer focus my eyes.) The Church and State must remain separate. What right has anyone, because of their own religious faith (to which I don't subscribe), to demand that I behave according to their rules until some omniscient doctor decides that I must have had enough and goes ahead and increases my morphine until I die? If you disagree with voluntary euthanasia, then don't use it, but don't deny me the right to use it if and when I want to. I am immensely grateful that I have had the opportunity to use the Rights of the Terminally Ill Act to ask my doctor, Philip Nitschke, to assist me to relieve this interminable suffering and to end my life in a dignified and compassionate manner. I did want to write this statement in my own hand, but the weakened state of my body makes this impossible. It has been dictated by me and written down by my wife. Darwin, 21/9/96 Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=6985