Going Back, But Not Backwards

This week I am recording from my deck in the Sydney rain, wearing an Oodie, accompanied by the dog and a one-week-old baby goat called LeBron because apparently this is adulthood now.

In this episode, I reflect on starting a new job in the same hospital, and the same physical department, where I worked for 15 years. It made me think about what it means to return to an old place without becoming the person you were when you left.

I also talk about being new again, the irritation of competency hurdles, and learning to manage my own ego when a role involves more process than I might like.

From there, I move into a careful educational discussion about the NSW Voluntary Assisted Dying Act, what is publicly available in the legislation, and why voluntary assisted dying needs to be understood as a regulated process rather than a slogan.

And because no conversation about voluntary assisted dying is complete without it, I also talk about palliative care: what it is, what it is not, and why it should never be framed as simply “giving up.”

This episode is about work, parenting adult children, goats, legislation, palliative care, and the strange relief of realising that going back to an old place does not mean going backwards.

Transcript

SPEAKER_01 0:00

You're listening to On the Moans, where we have conversations about hormones, midlife, and the moments that make us wonder Is it just me? I'm Kate, I'm a 48-year-old pharmacist and newly minted perimenopausal oversharer. This is where we talk openly about the changes we aren't prepared for, so we never have to feel alone in them again. I acknowledge the Camaragle people of the Eyora Nation, the traditional custodians of the land which I am recording today. I pay my respects to elders past and present, and I extend that respect to all Aboriginal and Torres Strait Islander peoples listening. Always was, always will be, Aboriginal land. Hello friends. I'm recording this episode from my deck in my woody, in the rain in Sydney, with the dog and a one-week-old baby goat. So obviously things are going really smoothly. The goat is called LeBron because he is the goat. And he's here because my son, Obi, wants to be a vet, and last week asked whether he could bring home a rejected baby goat to foster until he's big enough to go back to the farm. And this is one of those strange moments when you realize just how much your life has changed. A younger version of me might have thought, absolutely not. I need a quiet house, I need clean audio, I need to record properly, and I need everything to sound smooth and professional. But apparently this version of me is sitting outside in the cold because the goat is not house-trained and needs must. And you know what? I'm okay with it. Because part of growing older or growing up or whatever we want to call this stage of adulthood is becoming a little less precious about the conditions needing to be perfect before you do something. Sometimes the podcast has background noise. Sometimes the house contains livestock. And sometimes you record outside in the rain because saying yes to your lovely son matters more than having perfect audio. And I'm always looking for ways to say yes to my children. Not to everything, obviously, I'm not completely unhinged, but to the good things, the generous things, the slightly inconvenient things that matter to them. And over 21 years, OB and I have built this lovely understanding together. I support him where I can, and he supports us too. My husband's mum, Obi's Nan, is in hospital at the moment, and Obi goes to visit her partly because he loves her, of course he does, but also because he knows it supports his dad. His dad works more than full-time, and Obi wants to take some of that emotional load off him where he can. He also goes to the gym with his dad at 5.30 in the morning. Not because he couldn't go later, and certainly not because he has a deep passion for getting up at 4 45 a.m., but because it keeps his dad company, it gives them time together, and that is one way he shows up. And I could not be prouder of the lovely young man he has become. So yeah, I'm in the rain, in an hoodie, podcasting next to a beige goat. And that's quite a good place to begin this episode because today I want to talk about going back to an old place, but not going backwards. I've recently started a new job, and what is strange about it is that it's in the same hospital where I worked for 15 years. Not just the same hospital, it's physically located within the same department. The actual service is different, the staff are mostly different, some familiar faces, the work is different, the calls are different, but I'm walking through the same doors and standing in the same place that formed such a substantial part of my early working life. And before I started, I wasn't entirely sure how I was going to feel. There are places that hold versions of us. You can walk into an old workplace, an old school, or a house you used to live in, and suddenly you can almost see the person you used to be moving around inside it. The last time I worked here, I had two very young children. When I left in 2013, Willoughby was eight and Audrey was five. My working day didn't begin when I arrived at work, it began long before that with lunches and uniforms, bags, drop-offs, plans for the pickup, and the constant mental arithmetic involved in working whilst raising small children. Now Obi is 21 and Audrey is 18. They are still my children, obviously, but my responsibilities surrounding work are completely different. I don't need to organize another human being before I leave the house. I don't have to calculate whether I can make it to after school care before it closes. I can get on an e-bike, ride eight minutes to work, and ride home again. So although I've returned to the same building, I haven't returned to the same life. And I think that's what I was afraid of before I went back. Would it feel as though I'd gone backwards? Would it feel like the younger version of myself who worked there before? Would it feel strange seeing people who remembered me from a completely different stage of my career? A bit, but it was actually okay. There were a few familiar faces which was lovely, and lots and lots of people I'd never met before. The building was familiar, but the experience wasn't. And maybe that is what makes the difference between going back and going backwards. Going backwards would mean trying to become the person I was then. Going back simply means revisiting a place as the person I am now. This job I've taken is with the New South Wales Voluntary Assisted Dying Statewide Pharmacy Service. It's an area of pharmacy that I could not have easily gained experience in anywhere else. Not many pharmacists have experience in voluntary assisted dying, only a handful really. Interestingly, not particularly worried that the work will be sad. People often assume that sadness would be the main concern when you work around death and dying, but I have worked in palliative care and oncology, and I know that work involving serious illness can also contain enormous amounts of meaning, humanity, humour, and connection. My concern is much less profound. I'm worried it could be procedural, and I'm worried it might not feel clinical enough, and I'm worried I might find parts of it a bit boring. And I think it's worth admitting that because sometimes we make every career decision sound like it's a calling. We say, we are passionate about the new job opportunity and thrilled to begin the next chapter. But sometimes you begin a job because it's interesting, it's an unusual opportunity, it fits within your existing experience, and you would like to find out whether it suits you. You don't necessarily know in advance that you're going to love it. This is a 12-month contract, and that gives the whole decision a boundary. If I love it, I'll have gained experience in an area that very few pharmacists understand. And if I don't love it, the contract will end. And it does not have to become my identity, and it does not have to be the final answer to the question, what am I doing with my life? It can simply be something I try. And I think sometimes we behave as though every decision needs to be permanent before we are allowed to make it. We want certainty that the new job will be fulfilling, that the move will be right, that the relationship will work, or that the project will succeed. But most of life doesn't offer that kind of certainty. Sometimes the decision is not a declaration, it's an experiment. The other practical change is that I'm now working three days a week, and if I take a shift at the community pharmacy, then four days a week, which means I need to pull myself together slightly. My time has become less amorphous. I have to be more organized about the podcast, the videos, the palliative care work, exercise, the animals, and everything else I seem to collect. But two weeks in, even that's been okay. There can be something helpful about having a little less time. It forces you to decide what actually needs to be done rather than imagining you will do absolutely everything at some point during an endlessly available week. And the e-bike commute has been one of those unexpectedly lovely parts of the change. I arrive having moved my body, sort of. I get outside, I don't have to negotiate traffic in quite the same way. The journey has become part of the day rather than simply lost time between home and work. So I've gone back to an old hospital and I've gone back to the same physical department. But I haven't gone back to being the woman who left there in 2013. She had an eight-year-old and a five-year-old. She had school pickups to organise and a completely different understanding of work, family, and herself. I'm arriving now with adult children, a much more complicated career, an e-bike, and less certainty that every job needs to become a lifelong commitment. Maybe that is what returning to an old place can show you. Not that nothing has changed, but just how much has. Not in a policy document, not in a training module, not in an online competency, but in someone's home with their family, their dog, their medications, their kitchen table, and their very real life. That part I really like. But before you are properly let loose in a role like this, there's a lot of background processes to get through. There is training. There are endless competencies. There are a billion systems, and there is a mountain of documentation. There are hurdles that need to be jumped over before anyone is going to hand you responsibility in such a tightly regulated area. And intellectually, I understand why that exists. Of course I do. This is not the sort of work where the vibe can be, she'll be right. Kate's been a pharmacist for 25 years. The whole point is that the process has to be careful, consistent, and legally compliant within the legislation. But emotionally, if I'm being honest, I'm finding some of it a little bit condescending and dull. Which is probably not the most noble thing I have ever admitted into a microphone. Because there is part of me that wants to say, yes, yes, I know how medicines work, I know how governance works, I know how documentation works, I've worked in hospitals, oncology, palliative care. I can be trusted with the grown-up scissors. But that is also my ego talking. And sometimes your ego is not wrong exactly, but it's not the most helpful person to put in charge of the meeting. So part of this new job is not just learning about voluntary assisted dying, it's also managing my own reaction to being new again. Managing the boredom, the irritation, the slightly bruised feeling of having to prove competencies in areas where I already feel competent. Because being experienced does not mean you get to skip the process. And in a role like this, the process is not just bureaucracy for the sake of bureaucracy. It's part of the safety structure. And that does not mean every module is thrilling, and it does not mean every competency feels personally enriching, and it does not mean I have transcended the human desire to roll my eyes in an online training package. But it does mean I need to keep reminding myself that the same systems that feel tedious from inside may be part of what keeps the service safe and accountable from the outside. And that brings me to the broader question. So what does voluntary assisted dying mean under New South Wales law? Because most people have heard the phrase by now, and I'm sure most people understand the structure around it, and I think we can talk about that carefully. The legislation is public, the New South Wales health information is public, the eligibility criteria are public, and the fact that there is a formal process is public. This is not secret knowledge, and if you want deeper discussions about this, I can tell you that Go Gentle Australia has a podcast called Better Off Dead, hosted by Andrew Denton, and he goes into all of this in much more detail than I will be here today. In the next part, I want to talk about voluntary assisted dying as far as what is publicly available by Google search using only publicly available New South Wales legislation and New South Wales health information. And to be crystal clear, this is not advice in any way, shape, or form. This is just an explanation of the legislation in New South Wales. Before I go any further, I want to be very clear about the boundaries of this conversation. I'm speaking generally using publicly available New South Wales legislation and New South Wales health information. This is not individual medical advice, it is not legal advice, and it is not advice about whether voluntary assisted dying is right for any particular person. If this is relevant to you or someone you love, that conversation belongs with your treating team, palliative care supports, or the New South Wales Voluntary Assisted Dying Care Navigators Service. This is an explanation of what is publicly available in the legislation and New South Wales health information. It involves illness, death, autonomy, suffering, family, medicine, ethics, religion, fear, grief, and law. So, yes, of course, people have feelings about it. But if we are going to discuss voluntary assisted dying properly, we need to start with what the law actually says. In New South Wales, voluntary assisted dying became available to eligible people from the 28th of November 2023. The act is called the Voluntary Assisted Dying Act of 2022. And its purpose is to provide for and regulate access to voluntary assisted dying for people with a terminal illness. And that word regulate is important. This is not a casual process. This is not someone saying I've had enough and a doctor simply handing over a medicine. There are eligibility criteria, assessments, practitioner roles, documentation requirements, oversight, safeguards, and very specific legal steps. To be eligible in New South Wales, a person must be an adult, so 18 or older. They must be an Australian citizen, a permanent resident, or have been a resident in Australia for at least three continuous years. They must also have been ordinarily resident in New South Wales for at least 12 months, although the Voluntary Assisted Dying Board can consider a residency exemption on compassionate grounds for a person with substantial connection to New South Wales. The person must have at least one disease, illness, or medical condition that is advanced and progressive. It must be expected to cause death within six months or within 12 months if the condition is neurodegenerative. And it must be causing suffering that cannot be relieved in a way the person considers tolerable. That last part matters. The law does not say suffering must be intolerable according to the doctor, the family, the hospital, the pharmacist, or the neighbor with a very strong opinion. It's about suffering that cannot be relieved in a way the person considers tolerable. The person must also have decision-making capacity in relation to voluntary assisted dying. They must be acting voluntarily. They must not be under pressure or duress. And their request must be enduring. So this is not about a fleeting thought on one terrible day. The act also makes clear that the person is not eligible merely because they have a disability, dementia, or a mental health impairment. That does not mean a person with one of those conditions could never be eligible if they also had an advanced progressive terminal illness that met that criteria. But those things alone are not enough. Another important point is that voluntary assisted dying is not a substitute for palliative care. The act sits inside end-of-life care, not outside it. People still need excellent palliative care, they still need symptom control, they still need support, they still need communication, planning, family care, and proper clinical attention. And in New South Wales, healthcare workers can initiate a discussion about voluntary assisted dying, but only as part of a broader discussion about treatment and palliative care options. That distinction is important. It cannot be raised as a standalone suggestion, and it cannot be raised in a way that pressures or steers anyone. Again, this is why the paperwork and competencies exist. This is not healthcare running on vibes. There are formal roles under the act. The coordinating practitioner has the main responsibility for the request and assessment process. The consulting practitioner provides an independent assessment. The administering practitioner is involved if the person has chosen and is eligible for practitioner administration. And there is also the authorised supplier, which is where the statewide pharmacy service comes in. The statewide pharmacy service also has a defined role within the control system, including responsibilities around the VAD substance that are governed by strict procedures. That means the pharmacy service is not just dispensing a medicine in the usual sense. There is also a voluntary assisted dying board. The board has oversight functions including monitoring and reporting on the operation of the act and deciding whether to approve or refuse applications for access to voluntary assisted dying substances. And there is a New South Wales Voluntary Assisted Dying Care Navigator service, which is a free service available to answer questions from patients, loved ones, health practitioners and providers. So when people talk about voluntary assisted dying as though it's a simple yes or no issue, they often miss how much structure the system actually has. You can support it and still think safeguards matter. You can oppose it and still need to understand what the law actually says. And you can be uncertain and still want accurate information. And for health professionals, this is especially important because our job is not to turn a complex legal and clinical process into a slogan. Our job is to understand the boundaries, the safeguards, the language, the obligations, and the role we do or do not play. Voluntary assistant dying is not just a moral argument. In New South Wales, it is a legislative process. And whether you are comfortable with it, uncomfortable with it, or somewhere in the middle, the starting point should always be the same. What does the person want? What care and support are available, and what does the law actually say? And I think if we're going to learn about voluntary assisted dying, we probably also need to talk about palliative care. Because one of the problems with this conversation is that people often set the two up as though they are opposites. As though one side is saying we should relieve suffering and the other side is saying we should help people die. But that is too simplistic. Palliative care is not giving up. It is not the thing that happens when medicine has failed. And it is not just care in the last few days of life. Palliative care is specialist care for people with serious, progressive, or life-limiting illnesses. Its focus is quality of life. That can include symptom control, medication review, emotional support, family support, advanced care planning, communication, equipment, home supports, and helping people work out what matters most to them. And yes, sometimes palliative care involves caring for someone who is actively dying, but it can and probably should be involved much earlier than that. People can receive palliative care whilst they are still having active treatment. And they can be having chemotherapy in palliative care, they can be having radiotherapy in palliative care, they can be seeing their oncologist, their GP, their specialist team, and the palliative care team all at the same time. Because palliative care is not defined by there is nothing more we can do. It's about recognizing that there is still a lot more we can do. We can treat pain, nausea, constipation, breathlessness, anger. Anxiety, agitation, dry mouth, secretions, insomnia, and delirium. We can stop medicines that are no longer helping, think statons, multivitamins, some blood sugar medicines to name a few. We can simplify complicated medication lists. We can help families understand what is happening, and we can help people stay at home if that's what they want and if it's safe and possible. We can talk honestly about what might happen next, and we can help people make decisions before they are in a crisis. One of the great misunderstandings about palliative care is that it's only about death. But palliative care is actually about life. Our patient is not dying, our patient is living. Not in the abstract inspirational quote sense. Real life. Can this person get out of bed? Can they eat? Can they sleep? Can they breathe comfortably? Can they sit in the garden? Can they go to their daughter's wedding? Can they stop taking 14 tablets a day when only five of them still matter? Can their family cope? Can they stay at home? Can they have some control over what happens next? That is palliative care. And I think this is why the voluntary assisted dying conversation needs to be handled carefully. Because voluntary assisted dying should never be presented as a replacement for good palliative care. People deserve access to excellent palliative care, whether or not they are interested in voluntary assisted dying. The two are not mutually exclusive. A person can want every reasonable symptom managed and still want to understand their legal options. A person can be deeply grateful for palliative care and still feel that their suffering is not relieved in a way that they consider tolerable. A person can be opposed to voluntary assisted dying and still need palliative care that is compassionate, skilled, and honest. This is not an easy space. It is clinically complex, it's emotionally complex, it's ethically complex, and it's very human. My own background in palliative care is probably part of why I am not especially frightened of working around death. Death is sad, obviously, but the work itself is not sad. It's beautiful. Sometimes it's funny. Sometimes it's practical in the most ordinary way imaginable. There are Webster packs and syringe drivers and bowel charts and family rosters and dogs that need feeding and relatives who are trying hard not to cry in the kitchen. There are moments of grief, but there are also moments of relief. There are people who have been in terrible pain who finally sleep. There are families who finally understand what's happening. And there are patients who are able to say, I want to be at home. And a whole team of people help make that possible. As a pharmacist, palliative care has always felt very clinical to me. Medicines, root, dose, renal function, swallowing, side effects, deprescribing, the boring-looking details can make a huge difference to whether someone is comfortable or distressed. So when we talk about end-of-life care, I think we need to resist the temptation to turn it into a slogan. Palliative care is not giving up, voluntary assisted dying is not a casual shortcut, and suffering is not always solved by saying, but palliative care exists, or here is an opioid. Good palliative care is essential, but it's not magic. And voluntary assisted dying in New South Wales sits within a legal framework for a very specific group of people who meet very specific criteria. Whether someone supports that law, opposes it, or feels conflicted about it, I think the conversation becomes much more honest when we understand both parts properly. What is voluntary assisted dying? What is palliative care? Where do they overlap? How are they different? And most importantly, how do we make sure that the people who are seriously ill are treated as whole human beings, not just as arguments in someone else's debate? So that's where I am at the moment, back in an old hospital, learning a new role, trying not to be personally offended by online competencies, thinking about voluntary sister dying, palliative care, legislation, suffering, autonomy, safeguards, and what it means to care for people properly at the end of life. And I'm and I'm also trying to stop a baby goat from toileting in my house. Life is nothing if not thematically inconsistent. But maybe that's actually the point. We are always living several lives at once. A professional life, a family life, parenting life, caring life, animal chaos life, the life where you are trying to be competent and serious. The life where you are outside in the rain because your son bought home livestock, but then left you to care for it because he himself went to work. A portent of times to come, no doubt. And sometimes returning to an old place shows you just how much has changed. I'm not the woman who left that hospital in 2013. My children are no longer eight and five. They're 21 and 18. One of them is bringing home goats and visiting his nan in hospital and getting up before dawn to go to the gym with his dad. Not because it's convenient, but because he's kind. And that is one of the greatest privileges of getting older. You get to see the people that you have loved and raised and worried about become themselves. And you get to realize that you've also become someone else too. Someone who can go back without going backwards. Someone who can start something new without needing it to be the final answer. Someone who can sit outside in the cold, in their oodie, with a dog and a goat, and think, this is not quite how I imagined adulthood, but it's mine, and it's pretty lovely. As always, you can find me on the socials Instagram, TikTok, Facebook at prescribe or pass, LinkedIn, Kate Thomas Medication Clarity Clinic, or on YouTube, my channel On the Moans, M-O-N-E-S. If you would like a one-on-one appointment with me about general medication questions, you can go to www.medicationclarity.com.au and book a time that suits you. Again, I do not provide individual VAD advice through Medication Clarity Clinic. Questions about voluntary assisted dying should go through your treating team on the New South Wales Voluntary Assisted Dying Care Navigator service. Until next time, we get on the moons. Bye bye, lovely friends.