Dementia is the second leading cause of death for Australians aged over 65. More than 421,000 Australians currently live with dementia and this figure is expected to almost double in the next 30 years.

There is ongoing public discussion about whether dementia should be a qualifying illness under Australian voluntary assisted dying laws. Voluntary assisted dying is now lawful in all six states, but is not available for a person living with dementia.

The Australian Capital Territory has begun debating its voluntary assisted dying bill in parliament but the government has ruled out access for dementia. Its view is that a person should retain decision-making capacity throughout the process. But the bill includes a requirement to revisit the issue in three years.

The Northern Territory is also considering reform and has invited views on access to voluntary assisted dying for dementia.

Several public figures have also entered the debate. Most recently, former Australian Chief Scientist, Ian Chubb, called for the law to be widened to allow access.

Others argue permitting voluntary assisted dying for dementia would present unacceptable risks to this vulnerable group.

Australian laws exclude access for dementia

Current Australian voluntary assisted dying laws exclude access for people who seek to qualify because they have dementia.

In New South Wales, the law specifically states this.

In the other states, this occurs through a combination of the eligibility criteria: a person whose dementia is so advanced that they are likely to die within the 12 month timeframe would be highly unlikely to retain the necessary decision-making capacity to request voluntary assisted dying.

This does not mean people who have dementia cannot access voluntary assisted dying if they also have a terminal illness. For example, a person who retains decision-making capacity in the early stages of Alzheimer’s disease with terminal cancer may access voluntary assisted dying.

What happens internationally?

Voluntary assisted dying laws in some other countries allow access for people living with dementia.

One mechanism, used in the Netherlands, is through advance directives or advance requests. This means a person can specify in advance the conditions under which they would want to have voluntary assisted dying when they no longer have decision-making capacity. This approach depends on the person’s family identifying when those conditions have been satisfied, generally in consultation with the person’s doctor.

Another approach to accessing voluntary assisted dying is to allow a person with dementia to choose to access it while they still have capacity. This involves regularly assessing capacity so that just before the person is predicted to lose the ability to make a decision about voluntary assisted dying, they can seek assistance to die. In Canada, this has been referred to as the “ten minutes to midnight” approach.

But these approaches have challenges

International experience reveals these approaches have limitations. For advance directives, it can be difficult to specify the conditions for activating the advance directive accurately. It also requires a family member to initiate this with the doctor. Evidence also shows doctors are reluctant to act on advance directives.

Particularly challenging are scenarios where a person with dementia who requested voluntary assisted dying in an advance directive later appears happy and content, or no longer expresses a desire to access voluntary assisted dying.

Allowing access for people with dementia who retain decision-making capacity also has practical problems. Despite regular assessments, a person may lose capacity in between them, meaning they miss the window before midnight to choose voluntary assisted dying. These capacity assessments can also be very complex.

Also, under this approach, a person is required to make such a decision at an early stage in their illness and may lose years of otherwise enjoyable life.

Some also argue that regardless of the approach taken, allowing access to voluntary assisted dying would involve unacceptable risks to a vulnerable group.

More thought is needed before changing our laws

There is public demand to allow access to voluntary assisted dying for dementia in Australia. The mandatory reviews of voluntary assisted dying legislation present an opportunity to consider such reform. These reviews generally happen after three to five years, and in some states they will occur regularly.

The scope of these reviews can vary and sometimes governments may not wish to consider changes to the legislation. But the Queensland review “must include a review of the eligibility criteria”. And the ACT bill requires the review to consider “advanced care planning”.

Both reviews would require consideration of who is able to access voluntary assisted dying, which opens the door for people living with dementia. This is particularly so for the ACT review, as advance care planning means allowing people to request voluntary assisted dying in the future when they have lost capacity.

This is a complex issue, and more thinking is needed about whether this public desire for voluntary assisted dying for dementia should be implemented. And, if so, how the practice could occur safely, and in a way that is acceptable to the health professionals who will be asked to provide it.

This will require a careful review of existing international models and their practical implementation as well as what would be feasible and appropriate in Australia.

Any future law reform should be evidence-based and draw on the views of people living with dementia, their family caregivers, and the health professionals who would be relied on to support these decisions.

Ben White, Professor of End-of-Life Law and Regulation, Australian Centre for Health Law Research, Queensland University of Technology; Casey Haining, Research Fellow, Australian Centre for Health Law Research, Queensland University of Technology; Lindy Willmott, Professor of Law, Australian Centre for Health Law Research, Queensland University of Technology, Queensland University of Technology, and Rachel Feeney, Postdoctoral research fellow, Queensland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Australia has one of the highest skin cancer rates globally, with nearly 19,000 Australians diagnosed with invasive melanoma – the most lethal type of skin cancer – each year.

While advanced melanoma can be fatal, it is highly treatable when detected early.

But Australian clinical practice guidelines and health authorities do not recommend screening for melanoma in the general population.

Given our reputation as the skin cancer capital of the world, why isn’t there a national screening program? Australia currently screens for breast, cervical and bowel cancer and will begin lung cancer screening in 2025.

It turns out the question of whether to screen everyone for melanoma and other skin cancers is complex. Here’s why.

The current approach

On top of the 19,000 invasive melanoma diagnoses each year, around 28,000 people are diagnosed with in-situ melanoma.

In-situ melanoma refers to a very early stage melanoma where the cancerous cells are confined to the outer layer of the skin (the epidermis).

Instead of a blanket screening program, Australia promotes skin protection, skin awareness and regular skin checks (at least annually) for those at high risk.

About one in three Australian adults have had a clinical skin check within the past year.

Why not just do skin checks for everyone?

The goal of screening is to find disease early, before symptoms appear, which helps save lives and reduce morbidity.

But there are a couple of reasons a national screening program is not yet in place.

We need to ask:

1. Does it save lives?

Many researchers would argue this is the goal of universal screening. But while universal skin cancer screening would likely lead to more melanoma diagnoses, this might not necessarily save lives. It could result in indolent (slow-growing) cancers being diagnosed that might have never caused harm. This is known as “overdiagnosis”.

Screening will pick up some cancers people could have safely lived with, if they didn’t know about them. The difficulty is in recognising which cancers are slow-growing and can be safely left alone.

Receiving a diagnosis causes stress and is more likely to lead to additional medical procedures (such as surgeries), which carry their own risks.

2. Is it value for money?

Implementing a nationwide screening program involves significant investment and resources. Its value to the health system would need to be calculated, to ensure this is the best use of resources.

Narrower targets for better results

Instead of screening everyone, targeting high-risk groups has shown better results. This focuses efforts where they’re needed most. Risk factors for skin cancer include fair skin, red hair, a history of sunburns, many moles and/or a family history.

Research has shown the public would be mostly accepting of a risk-tailored approach to screening for melanoma.

There are moves underway to establish a national targeted skin cancer screening program in Australia, with the government recently pledging $10.3 million to help tackle “the most common cancer in our sunburnt country, skin cancer” by focusing on those at greater risk.

Currently, Australian clinical practice guidelines recommend doctors properly evaluate all patients for their future risk of melanoma.

Looking with new technological eyes

Technological advances are improving the accuracy of skin cancer diagnosis and risk assessment.

For example, researchers are investigating 3D total body skin imaging to monitor changes to spots and moles over time.

Artificial intelligence (AI) algorithms can analyse images of skin lesions, and support doctors’ decision making.

Genetic testing can now identify risk markers for more personalised screening.

And telehealth has made remote consultations possible, increasing access to specialists, particularly in rural areas.

Check yourself – 4 things to look for

Skin cancer can affect all skin types, so it’s a good idea to become familiar with your own skin. The Skin Cancer College Australasia has introduced a guide called SCAN your skin, which tells people to look for skin spots or areas that are:

1. sore (scaly, itchy, bleeding, tender) and don’t heal within six weeks

2. changing in size, shape, colour or texture

3. abnormal for you and look different or feel different, or stand out when compared to your other spots and moles

4. new and have appeared on your skin recently. Any new moles or spots should be checked, especially if you are over 40.

If something seems different, make an appointment with your doctor.

You can self-assess your melanoma risk online via the Melanoma Institute Australia or QIMR Berghofer Medical Research Institute.

H. Peter Soyer, Professor of Dermatology, The University of Queensland; Anne Cust, Professor of Cancer Epidemiology, The Daffodil Centre and Melanoma Institute Australia, University of Sydney; Caitlin Horsham, Research Manager, The University of Queensland, and Monika Janda, Professor in Behavioural Science, The University of Queensland

This article is republished from The Conversation under a Creative Commons license. Read the original article.