The debates about MHD prior to legislation being introduced frequently centred upon a false dichotomy of palliative care or MHD. Such debates often involved discussions that included statements that “if palliative care were available then MHD would be unnecessary”, “the solution to suffering is broader access to palliative care”, or conversely, that “palliative care was tried and failed” to relieve the suffering experienced [28]. Funding and resources for palliative care services have been a focus of a number of representations to legislative bodies in the setting of MHD public debates [29]. Of note, the public understanding of palliative care, including of its goals, philosophy and practices, is poor [30], while media representations of palliative care in times of MHD debate have been documented to be deficient, with MHD represented as enhancing choice and relieving suffering and palliative care as limiting choice and forcing prolongation of suffering, precisely because it does not intentionally hasten death [31]. Yet palliative care clinicians and many patients consider palliative care a creative option—providing relief of current and future suffering through symptom relief, access to information, counselling, and care for the whole person and their family [32]. To facilitate a more nuanced debate in those jurisdictions where future legislation is considered, it has been proposed that palliative care should actively seek to shape, rather than react to, the debate, with a particular aim of enhancing community understanding of its goals and activities [33].

One concern expressed has been that investment in MHD may have an impact upon investment in palliative care—either limiting growth or indeed effectively reducing funding. The impact of this, it has been suggested, would be to further increase the demand for MHD as people experience unaddressed suffering that could otherwise have been ameliorated in a well-serviced system [34]. The impact upon service development is, however, difficult to assess. In a study of European countries between 2005 and 2012, spanning both MHD permissive and non-permissive countries, there was, by 2012, comparative palliative care service activity across all countries, reflecting a substantial increase in palliative care, particularly in the Netherlands following MHD legislative introduction in 2002. Interestingly, these had begun at a lower level in the Netherlands, at 8.45 services per million inhabitants, later growing to 15.32 by 2012, compared with the UK, which only increased minimally from 14.73 to 15.43 [34]. It is not possible to state if funding to support MHD services has either detracted from or been accompanied by expansion of palliative care services in other jurisdictions.

Concerns that MHD may be chosen as an alternative to palliative care [35, 36] have not generally been born out. For example, 74% of people who access MHD in Canada, and over 80% in Victoria, have had palliative care input into their care [5, 7], while in Belgium, palliative care clinicians are involved in the decision-making for 60% of those who go on to have a MHD death [37].

Data from recent qualitative studies of the rapidly accumulating experience of MHD have largely supported these conclusions. For example, palliative care professionals have highlighted the tension in practice between honouring the patient’s “personal autonomy and control” at the end of life and honouring a commitment to the sense that life is “inherently valuable and meaningful” [38]. For these interviewees, the commitment to the “compassionate care for the dying person” was a unifying value and helpful in working in this space of co-existence [38].

The relationship of co-existence between the practices of palliative care and MHD across countries where MHD is legal, has been shown to cover a range of stances from supportive, integrated and cooperative through to ambivalent and then to opposed, and mutually exclusive [39]. In interviews with clinicians and policy makers from Quebec, Canada; Flanders (Belgium) and Oregon (USA) different themes were identified across the three jurisdictions [40]. In Quebec a set of contested relationships were evident in the context of a lack of knowledge about and access to palliative care. In Flanders an adoption of an integrated approach with palliative care and MHD developing contemporaneously was evident, although it was noted that patients at times viewed palliative care as a “barrier” to MHD, meaning it was not always offered or accepted, and others expressed concern about a progressive liberalisation of assisted dying laws. In Oregon there was some variation in the protocols enacted at the end of life creating fear of breaching policies or being the subject of litigation, along with concerns about access to medications that were not always available or affordable [40].

In Victoria, an accommodation of MHD by palliative care services appears to have developed, with a lessening of anxiety surrounding its practices and procedures (see box statement c).

This increasing tolerance amongst palliative care providers has also been described in Canada where after initial strong opposition, over time, a position developed of co-existence with MHD [18]. Within this state of co-existence, however, several key stress points for palliative care continue to be highlighted. First, the significant time taken to respond to and facilitate the wishes of a person seeking MHD has a workload impact on palliative care. These add extra tasks to usual palliative care delivery which must also be part of the person’s care. In Victoria, Australia senior clinicians have taken on the responsibility for MHD, thereby protecting their junior colleagues from these tasks. Even for those not involved in MHD, there are, in addition to discussions with the patients (and their families as permitted), multiple interactions with colleagues to enact referrals, assessments, and all the other the processes that unfold up to the point of MHD death. These tasks inevitably have an impact upon the delivery of services to other patients who are not seeking MHD who receive less senior clinician attention (see box d).

Secondly, and likely unforeseen by legislators, for some patients, high-quality end-of-life care is actually undermined by the possibility of MHD [18]. Clinicians have highlighted situations where patients, in the last weeks (or days) of life, unexpectedly express a strong desire to access MHD. In seeking to enable exploration of that pathway, such patients may refuse medications and interventions that would usually be part of standard, good-quality end-of-life care, apparently for fear of compromising their decision-making capacity during the requested MHD assessments. For many such patients, the proximity to natural death means they are not able to access MHD and simultaneously they are forsaking good relief of symptoms and suffering at the end of life. Tragically, they lose on both fronts (see box e).

Thirdly, and related to these, is the impact on palliative care practitioners themselves. Despite some accommodation over time with reduced anxiety amongst a number of palliative care practitioners, the emotional toll was described by many [18]. In addition to the distress felt by some when a patient undertakes MHD while under their care, additional organisational processes needed to be enacted—for example, a manager might have to assume ward nursing duties to care for a patient in order to relieve the rostered nurse who has a personal objection to MHD. All of these factors may have an impact upon the day-to-day tasks of providing palliative care and may be distressing for some. Of course, these negative experiences do not negate that many other clinicians have described a deep satisfaction from being part of a care team at a time of MHD enactment [41].

In summary, the impact of MHD upon palliative care providers suggests that there is an expansion of workload associated with this practice, even when the practitioners are not directly participating. There is also a concurrent emotional impact that can be heightened when the delivery of MHD or its exploration affects the delivery of what the treating clinical team considers to be the best palliative care.