Medium term and advanced phase : Dr. Olivier Trédan deciphers the report by the High Authority for Health
Oncologist Dr. Olivier Trédan deciphers the report published on 5th May 2025 by the High Authority for Health (HAS) which considered the expressions “threatened life expectancy in the “medium term” or “advanced or terminal phase” to be indefinable. The HAS was consulted on 22nd April 2024 by the Health Minister in order to “enlighten health professionals on the evaluation of the notion of “life expectancy threatened in the medium term” in the context of a request for assistance in dying, then extended the scope to “the definition of the notion of advanced phase in order to specify the perimeter and to establish objective criteria“.
Are there any objective criteria for defining life expectancy ?
In order to define life expectancy in medical terms, as a general rule, and in oncology in particular, which is my discipline, the number of objective criteria evaluated scientifically in research is rather limited.
Threatened life expectancy, is threatened either in the very short term, or the short term, or the medium term. In “the very short term” means a few hours before death, which most doctors are able to determine. In the “short term”, i.e. a few days, there again exist certain clinical and biological indicators, with scores which are helpful, but which involve a certain degree of uncertainty. It is what the HAS report refers to as a clinical assessment.
The clinical assessment, is the result of the subjective perception by a doctor linked to his/her experience and also to prognosis scores, i.e. objective criteria such as a biological result or a multimodal performance score (Performance scales are used as a matter of routine in medicine, particularly in oncology. They are helpful for establishing indications for the continuation of active treatments such as chemotherapy). It is such a clinical assessment which allows doctors to say that death will occur in the next few days. In oncology, for example, breathlessness called dyspnoea, oedema, i.e. swelling with water, typically in the legs, and confusion are signs among others which indicate that death will occur within a few days. And that is the terminal situation of the end of life.
Is this clinical assessment still valid for evaluating life expectancy threatened in the medium term ?
First of all, there is no consensus on the definition of “medium term”. Is it 2 weeks, 3 weeks, 1 month or 3 months ? In clinical research there are different definitions. From the moment that such definitions are variable, it is difficult to homogenise our ability to predict the so-called medium term.
Also, the scientific literature states that there are no objective criteria defining medium term. The HAS which has studied the scientific literature, clearly states in paragraph 2.1 of its report, that it had not identified any data in the literature on the subject of the notion of medium term prognosis. As the concept is indefinable, it is not pertinent to refer to it for any reason at all.
What about the notion of advanced phase? Can it be objective according to the HAS ?
Contrary to medium term prognosis, which has no definition, advanced phase does have definitions. However, the HAS points out that these definitions are very variable from one situation to another, one pathology to another. For example, according to an American gerontology association, advanced disease occurs when one or several pathologies become serious enough for the general state of health and functional state of the patient to decline. The focus is applied to the notion of polypathology, resulting in a general deterioration of the patient. A single pathology, for example diabetes, is not enough to deteriorate the state of the patient and to declare it as an “advanced phase”. Conversely, diabetes combined with a cardiovascular disease, plus a neuro-degenerative disease (for example a stroke), will cause a loss of activity for the patient. In that context, the American gerontology association states that it is an advanced phase with geriatric complications.
For a given pathology, such as cancer, different specialist associations express their opinion on the notion of advanced phase. According to the American National Cancer Institute, the term “advanced” signifies that the cancer is locally aggressive, i.e. it has started to attack the adjacent healthy tissues surrounding the tumour. They then refer to “locally advanced cancer”, which can be interpreted as “advanced cancer”.
On the other hand, some people use the expression “advanced cancer” to mean that it has spread more widely. It is what is known as metastatic. In that case, the HAS indeed indicates that the cancer may be advanced locally, or in the metastatic phase. Nevertheless, an advanced cancer with metastases does not mean it is incurable. Nowadays, many cancers, even advanced cancers, have become curable. Certain patients suffering from metastatic breast cancer, a disease considered incurable a few years ago, may now survive for several decades in remission of their cancer, thanks to new treatments.
But often, as the HAS has pointed out, in the thinking of health professionals, “advanced” means incurable. Therefore the same term is used for various very different situations.
As a result there is considerable confusion regarding the term since in our medical practice it is used in situations which are very different. The same is true with patients, the simple fact of using the word “advanced”, which is the correct term, conveys the idea that the disease is incurable. By introducing advanced phase as a criterion in the law, there is a risk that once the term advanced is mentioned, patients could consider themselves eligible for assisted suicide or euthanasia according to the criteria in the bill being debated.
In fact what counts for the patient, in any case regarding cancer, is indeed to know whether the disease can be in extended remission for several years. Therefore, it must really be underlined the fact that the word “advanced” in itself is inappropriate, specifically in oncology.
With such a notion of advanced phase, which diseases would come within the scope of eligibility of the law on assistance in dying ?
Using a broad definition of the term “advanced”, diseases which affect the functionality and general condition of the patient, such as diabetes, cardio-vascular diseases (whenever there are complications), most cancers, neuro-degenerative diseases and chronic diseases (such as kidney failure or chronic breathlessness), would be concerned by the law.
There could therefore potentially be hundreds of thousands of people suffering from long-term conditions who would become eligible for assistance in dying.
The HAS has defined advanced phase as the entry into an irreversible process marked by the aggravation of the state of health of the patient which affects his/her quality of life. How do you analyse those 3 notions ?
In the absence of a homogenous definition, the HAS determines three criteria, with the purpose of specifying the notion of advanced phase.
The problem, is that of these three criteria, two are extremely subjective.
1) Concerning “irreversibility”, no doctor is capable of establishing that a situation is irreversible. In essence, our medical activity exists in order to attempt to reverse the impact of a disease. Again taking the example of cancer, when there are metastases, it does not mean that the situation is irreversible. Again, sometimes we manage to cure patients in metastatic situations. Moreover it changes with time : certain situations considered irreversible yesterday are no longer so today.
Irreversibility would appear to be impossible to apply in 100% of cases.
2) As for the “quality of life” of a person, it is largely dependent on the perception by the person of his/her own condition at a given moment, of his/her ability to do things on his/her own, to interact with others. It is not because the quality of life is degraded today that it will remain so permanently. It is important not to underestimate the impact of medical intervention to improve the quality of life of patients, which is one of the prime objectives of carers. The rapid development of palliative medicine and integrative medicine provides for overall care for patients, in all aspects of their life. In that way, all the symptoms which impact the activities of day to day life are considered and therapeutic interventions and/or supplementary medicine aim to alleviate (or reduce as much as possible) the impact of such symptoms.
3) The aggravation of the state of health of the patient possibly constitutes the most objective criterion. When certain stages in the evolution of the disease are reached, medical teams can say that an additional level of gravity has been reached by the disease.
In its attempt at defining “advanced phase”, the HAS is not convincing.
What do you think about the HAS recommendation of adopting a logic of anticipation and prediction of the quality of life remaining in view of the inability to predict the quantity of life remaining ?
The HAS has the merit of saying that in an incurable disease situation, it is essential to consider the quality of life. It is important to consider the patient as someone who is living and who must enjoy a certain quality of life.
However, in view of the impossibility for doctors to have objective criteria, the HAS establishes the patient as the sole judge of his/her quality of life, the only person able to decide whether his/her life is worth living or not. The advice attempts to provide a framework, but it is so broad, so subjective that it does not at all specify what is meant by “advanced phase”, nor “threatened life expectancy”. As we are unable to say what is meant by “advanced phase”, or “threatened life expectancy”, we rely on the patient who defines it him/herself, for him/herself.
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