On March 15, 2018, the French High Authority for Health (“HAS”) published its recommendations for good practice in implementing “deep and continuous sedation until death”.

These recommendations have been awaited since “Claeys-Leonetti” end-of-life law was enacted in February 2016, giving new rights for those at the end-of-life.

Before the law was voted, “deep and continuous sedation until death” had been previously practiced by professionals in rare cases, for circumstances of unbearable, resistant suffering which could not be relieved by any other means, and when faced with a short-term vital prognosis. Basically, sedation alters the patient’s consciousness and thus severs any further relationship. The sedative doses may be proportional to the intensity of the symptoms and reversible. Professionals prioritize using painkillers which allow patients to remain conscious.  Conversely, sedating a patient whom we know will not wake up is difficult for both loved ones and caregivers. The official High Health Authority “HAS” text correctly emphasizes this and provides specific support for the various participants concerned to ensure that these situations are not trivialized, and must remain a rare practice.

The law provided that sedation request could be initiated by the patient himself. When stopping or restricting care, including nutrition and hydration, this practice risks to veer towards euthanasia.

Alliance VITA, participates in the movement Relieve Suffering without Killing” which also brings together health professionals, and together they denounced this gray zone during debates for revising the law. Relieve Suffering without Killing” recalled these warnings during the “Let’s Speak about the End-of-Life” campaign organized by the public authorities in March 2017 to promote the law. “The simplistic promotion of a” right to deep and continuous sedation until death, “without justifying its’ objective, may open the door to a drift toward euthanasia (…) On this complex and often sensitive subject, it would be grave injustice to threaten the confidence between caregivers and patients to imply that the law partially allows abolishing the prohibition to kill.

 

In an attempt to remove this ambiguity, the authors of the recommendation endeavored to differentiate this type of sedation from euthanasia, whose intention is to provoke death. They explained the six characteristics below:

 

  Deep and continuous sedation until death Euthanasia
Objective Relieve a persistent unbearable suffering with doses adapted to obtain deep sedation Respond to the patient’s request for death
Means Deeply alter conscienceness Provoke death
Method Use of sedatives Use lethal doses of medication
Result Deep sedation until death due to natural causes of illness progression Immediate death of the patient
Time-frame You can’t say when death will occur Death is rapidly provoked by the lethal product
Legislation Autorised by law Illegal, (homicide, poisoning …)

 

The recommendation more clearly defines safeguards for avoiding expansive interpretations, while accepting the complexity of situations at the end-of-life:

  • Collegiality of the decision and the evaluation of the request;
  • Resistant aspect of pain, with no other alternatives for relief;
  • Short-term vital prognosis: beyond a few days time, a reversible sedation must be practiced.

 

The most critical situations concern the limitations or treatment stoppage in situations whereby people cannot express themselves.

The “HAS” specifies that the constrictions for limitations are mainly for artificial ventilation, in very specific cases, which qualify as unreasonable obstinacy and that patient’s vital prognosis is short-term. “The doctor may be confronted with this situation when there is a request to stop life-sustaining treatments: mechanical ventilation (for example: patients undergoing cardiopulmonary assistance, patients with amyotrophic lateral sclerosis or other neurodegenerative diseases and dependent on artificial ventilation, etc.). Patients who suffer from a disease for which the absence of treatment will cause death only in the long term or, will not lead to unbearable sufferings, are not immediately affected by this law of deep and continuous sedation. Each case is unique: the treatment, adapted to the symptoms and to the patient’s request, will be given, including the possibility of appropriately measured sedation.

Alliance VITA declares that ambiguity still persists for those in a pauci-relational state, unable to express themselves.  “The deep and continuous sedation until death aims to prevent a possible pain. If the only life-sustaining treatment is artificial nutrition combined with artificial hydration, its arrest may lead to a longer duration of deep and continuous sedation until death (of the order of 7 to 14 days): this duration requires special support from relatives and caregivers “. Such an analysis would require further clarification. Recall that the people mentioned are not at the end-of-life, and a priori do not suffer from unbearable suffering which cannot be relieved, but are unable to clearly express themselves.