The citizens’ convention on the end of life supports the “opening of active help to open” and in response the Head of State has promised a bill to review the right to end of life in France by in the summer of 2023, this Monday, April 3. For now, what does the law provide for end-of-life patients?
[Mis à jour le 3 avril 2023 à 12h30] The right to the end of life must be reconsidered. The citizens’ convention on the end of life and the President of the Republic have agreed on this point and consequently a new objective is in sight, that announced by Emmanuel Macron on Monday April 3: to propose a bill by the end of summer 2023. The Head of State did not remain deaf to the conclusions of the 184 members of the convention who debated for three months on end-of-life care in France with the help many experts. In a report published on April 2, 92% of citizens who are parties to the agreement consider the current “end-of-life support framework” insufficient and are multiplying the recommendations to optimize it.
If there is one thing to remember from the conclusions of this convention, it is the large majority call for the opening of active assistance in dying (AAM) in France: 76% consider the measure “necessary” to ” better respond” to the difficult end of life of certain patients or quite simply to “respect everyone’s freedom of choice”. This position which tends to authorize, under conditions, the recourse of patients to assisted suicide or euthanasia is already a big step, but it is now up to the government to concretize the recommendations by carrying out “a work of co-construction on the basis of this solid reference, which is that of the convention, and of all the stakeholders”, added Emmanuel Macron.
What recommendations on the right to end of life?
The citizens’ convention defends a “majority position, but with many nuances” on the medical care of the end of life: “The need to set up assisted suicide and euthanasia” by bringing together the two procedures under the term of assistance active to die. Should one or the other be preferred? This is where opinions differ. 40% of the members of the convention say they are “rather in favor” of the undifferentiated legalization of the two measures. But others (28%) prefer assisted suicide to be preferred and euthanasia to be an exception when a patient is physically unable to perform the lethal injection. This second option should make it possible “to avoid excessive involvement of caregivers” who for many are opposed to the idea of helping a patient to die. The Order of Physicians has moreover made an opinion “unfavourable” to the active participation of doctors in euthanasia. As for assisted suicide, the medical order requires compulsory legal protection for a “doctor who participates in the procedure of active assistance in dying”.
Active aid in dying, accessible under what conditions?
If active assistance in dying must be put in place, it must be under certain conditions and the agreement provides for a complex process and sows safeguards to avoid abuses and ensure the patient’s will and discernment. . It suggests making access to end-of-life processes conditional on the patient’s state of health and several criteria have been mentioned: an incurable situation and/or suffering, particularly physical, which resists any treatment. Another avenue, which would limit access to AAM, would be to condition it on a vital prognosis, but the measure is still subject to discussion. Other conditions at the AAM should concern “complete medical and psychological support” throughout the patient’s journey with the possibility of retracting. Caregivers should also be supervised and never be forced to participate in an end-of-life process.
Access to active assistance in dying has not yet been decided for specific cases: minor patients or patients unable to express a will. In the absence of a majority, the debate is still open. The opinion of the Order of Physicians is final on these points and is “unfavorable to any possibility of setting up an active assisted death procedure for minors and people unable to express their will” .
If a bill is to see the light of day by the summer, the legislative process could take several months before a possible adoption of a new law on the right to end of life. Changes are therefore possible and the work is underway but until the promulgation of the said project it is the Claeys-Leonetti law of February 2, 2016 which governs the right to end of life in France in strict terms and with prohibitions. including that of resorting to euthanasia or assisted suicide.
Euthanasia and assisted suicide banned in France
Impossible to kill or help a patient die, French law is clear on this subject: neither euthanasia nor suicide assisted by the injection of a lethal product are authorized. A doctor or healthcare professional who performs such acts, even at the request of the patient, commits a criminal offence. Only one form of euthanasia is possible in the French health system and it can only be used under certain conditions: passive euthanasia, that is to say that caused by the cessation of care provided for by the prohibition of therapeutic relentlessness or by the patient’s refusal to receive treatment.
The right to long and deep sedation
End-of-life law evolved with the Claeys-Leonetti law of February 2, 2016, which gave the patient the right to request “long and deep sedation until death”. But only patients in very great suffering whose vital prognosis is committed in the short term – a period ranging from a few hours to a few days according to the High Authority for Health – or those whose death is recognized as inevitable and imminent can take advantage of this right. Right which is not an aid in dying but rather pain relief until death. The patient is asleep and continues to receive painkillers or palliative care until the disease prevails, all treatments being stopped.
In addition to being reserved for a handful of patients, long and deep sedation can only be implemented after discussions with health professionals in a collegial procedure, even if the advance directives or the person of trust support this choice.
Is it possible to stop treatment in France?
Doctors and the medical profession must offer their patients all the solutions to save them and keep them alive, only the patient himself can oppose a treatment. This also applies if the non-use of drugs and other medical procedures results in death. It should be noted that artificial nutrition and hydration of unconscious people are considered as treatments. Refusal of treatment may therefore be a way for patients to shorten their lives.
The Claeys-Leonetti law of 2016 made refusing treatment binding on doctors, even if stopping treatment can be fatal. In this case, the patient must simply reiterate his refusal to be treated knowingly. If all treatment is then prohibited, doctors have an obligation to “safeguard the dignity of the patient, ensure his quality of life and relieve his suffering” by resorting to palliative care if necessary. Refusal of treatment can in some cases lead to long and deep sedation.
Is unreasonable stubbornness allowed?
Formerly called therapeutic relentlessness, unreasonable obstinacy and artificial prolongation of life have been prohibited since 2005 and the Leonetti law, the first law to legislate the end of life. This measure is similar to the counterpart of refusal of treatment, except that the decision to stop treatment comes from the medical profession. This decision must, however, be collegial and necessarily requires the agreement of the patient or his trusted person when the latter is no longer able to express himself. Again, despite the discontinuation of care, physicians must take care of the patient’s pain.
If making his will to die heard by the medical profession can be difficult in certain cases, the situation is much more complex when the patient is no longer able to express himself. However, provisions exist to allow doctors to be aware of the patient’s desire to end it. This is in particular what the advance directives are for, in place since 2005 with the Leonetti law, then limited to three years of validity, the directives no longer have any time limits and above all they are binding since the revaluation of the principle since 2016. Any adult is able to write advance directives concerning their end of life to express their wishes.
The other means of defending one’s desires for the end of life is to appoint a trusted person: a third party designated by the patient to accompany him in his medical journey and also to defend and express his will when he does not no longer able to do so. When the patient is no longer able to make himself heard, it is the person of trust who is consulted in priority by the doctors before the close family.