De la Tour-WMA EoL Presentation Vatican-Nov2017

11/23/17
1
SEDATION, NUTRITION,
HYDRATION
AT THE END OF LIFE
HOW TO DECIDE ?
Docteur Anne de la Tour : SFAP President
Docteur Claire Fourcade : SFAP Board
November 2017
HISTORY OF END OF LIFE LAW
• 2005 : a young blind and mute tetraplegic asks for the right to be euthanized. Law
Leonetti : euthanasia was refused, limited treatment was chosen.
• 2012 : A conflict tore apart the family of a patient in a chronic vegetative state,
some wishing to stop life treatments, others demanding to carry them on.
• 2016 : until the law Claeys-Leonetti, the debates were long and difficult and this
conflict keeps going. New rights, including sedation, are granted to people at the
end of their life but euthanasia is still excluded.
LAW CLAEYS-LEONETTI 2016
• Unreasonable obstinacy is forbidden.
• Trusted person.
• Binding advance directives.
• Nutrition et hydration are considered as treatments and can therefore
be stopped.
• The collegial procedure : caregivers present with one or two
consultants without reporting to relationship.
• Deep and prolonged sedation continues until death.
DEEP AND PROLONGED SEDATION
CONTINUED UNTIL DEATH
• When a patient is in terminal phase and suffers from a serious and incurable life
threatening condition and whose suffering is non-responsive to
treatment/refractory.
• When a patient decides to stop his/her treatment that has an impact on his/her
short term vital prognosis, and when this is likely to trigger an unbearable pain.
• When the patient cannot express his/her wishes, in order to stay in agreement with
the law which prescribes to refuse unreasonable obstinacy, the doctor can use
medication even if this could lead to the shortening of life.
• Sedation is a combination between sedatives and analgesics.
• The assessment of the sedation is done using scales (Richmond, Rudkin) and clinical
aspect.
THE REFRACTORY SUFFERING
• Suffering is defined as refractory if all the available and adapted therapeutic and
accompanying means have been proposed and/or put in place without getting the
anticipated relief or if they bring undesirable side effects, or if their therapeutic effects
are not expected to act soon enough.
• The patient is the only person able to appreciate the unbearable character of suffering,
the undesirable effects of treatments, and the timing.
• The assessment of global suffering is multidimensional : physical, mental, spiritual,
social and related to family or friends ; it should be done repeatedly.
• Advice from a psychologist or a psychiatric physician is required and a collegial multi-
professional process is necessary.
THE SHORT-TERM VITAL PROGNOSIS
• According to international recommendations from the EAPC and Quebec, the
prognosis should be between a few hours and a few days.
• Two possibilities :
– Palliative Performance Scale (PPS) : if 10%, the average time of survival is 3
days. A PPS dropping from 40 to 20% in 3 days is evocative of death within 2 weeks.
– A question : Would you be surprised if the patient passed away in the
following hours or days? The predictive value on a 7-day prognosis is 96%.
• Clinical evaluation :
– speed of functional decline
– vital organs attacked
– many symptoms and alteration of vital signs
11/23/17
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DIFFERENCES BETWEEN SEDATION AND
EUTHANASIA
subject to the guidelines of French High Autority of Health – end of 2017
Deep and continuous sedation Euthanasia
Intention Relieve refractory pain Answer the patient’s request to die
Means Deeply alter consciousness Lead to death
Procedure Use of sedative medicine with doses
adapted to get deep sedation
Use of a lethal dose of medicine
Result Deep sedation up until the passing of the
soothed patient
Immediate passing of the patient
Legislation Authorized by law Illegal (homicide, poisoning…)
• Consequently, deep and continuous sedation cannot be seen as a request for euthanasia.
NUTRITION AND HYDRATION
• They are treatments which could be stopped.
• Needs decrease at the end of life.
• Thirst decreases if mouth care is provided.
• Continuing hydration could involve oedema as well as increased
hypersecretions. If the wish of the patient or family through cultural
aspect is to continue the treatment then it will be done ( but less than
250 ml) except in pulmonary congestion cases.
• All cares will still be given.
• The support of the family by caregivers, volonteers… and the
supervision of the team, are organised.
CONCLUSION
• France has clearly decided so far against euthanasia in favor of a worthy and friendly
caring.
• Doubt and reflexion cannot be avoided by means of a law.
• Patients talk about their ambivalence… Few patients say they are willing to die and even
less would say this when they feel relieved and cared for.
• The daily goals of a palliative care team are to provide tailored and personalized help.
• The caring of patients is not only about medicine but the whole society plays a role. We
are not independent from one another but all inter-dependent from each other.
• We keep in mind that every single decision we make shows everyone how much we
care about the weakest members of our society.
• Our choices all have a universal dimension because that is where human dignity is.
• The goal is living alongside those whose life is coming to an end as it is our common
fate.