Lwoff-WMA EoL Presentation Vatican-Nov2017

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Guide on decision-making
process regarding medical
treatment in end-of-life
situations
Laurence Lwoff
Head of Bioethics Unit
DGI- Human Rights Directorate
Council of Europe 1
Why a guide?
• Medical progress:
– Enables life to be prolonged and increases prospects of survival
– Acute or rapid progression illnessess turned into chronic or slow progression illnesses
Give rise to complex situations
– Place of the patient – Protection of his/her autonomy and dignity
• Convention on Human Rights and Biomedicine (Oviedo Convention ) (CETS No 164, 1997)
« European patient rights Treaty»
• Committee on Bioethics (DH-BIO): to facilitate the implementation of principles laid down in the Oviedo
Convention
– Article 2 – Primacy of the human beings
– Article 3 – Equity of access to health care
– Article 4 – Professional obligations
– Article 5 – Free and informed consent
– Article 6 – Protection of persons not able to consent
– Article 9 – Previously expressed wishes
• To address these complex and sensitives questions taking into account societal, cultural, legal,
organisational diffferences as well as the diversity of the medical end-of-life situations
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Steps
• Symposium on decision making process: 30 November – 1 December
2010
• Draft Guide made public for consultation Spring 2013
• Adoption by the DH-BIO: November 2013
• Launching conference : 5 May 2014, under the auspices of the Austrian
chairmanship of the Council of Europe Committee of Ministers2013
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Object
• To propose reference points for the implementation of the decision-making :
Actors – Stages of the process– Factual elements influencing decisions
• To bring together normative, as well as ethical reference works, and
elements relating to good medical practice
• To contribute, through clarifications provided, to the overall discussion on
decision-making process in end-of-life situations in particular complexe ones
(debated issues outlined)
• Does not aim at taking position on the relevance or legitimacy of one decision
or another in a given clinical situation
• Does not address the issue of euthanasia or assisted suicide
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Scope
• Decision-making process
• Regarding medical treatment
• In end-of-life situations
Definition of end-of-life for the purpose of the guide:
« For the purpose of this guide, end-of-life situations are understood
as those in which a severe deterioration in health, due to the evolution
of disease or another cause, threatens the life of a person irreversibly
in the near future.»
Ø Applicable in whatever the place and the conditions in which end-of-
life situation is being dealt with
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Target audiences
• Health professionals concerned (primarily)
• Patients, their relatives and family or other support providers, for them to better
understand the implications of the situations and thus, participate in the process
• The public, offering a tool for the discussion and public debate on the decision
making process in end-of-life situations.
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• Introduction
• Ethical and legal frames of reference for the decision making process
A. The principle of autonomy
B. The principles of beneficence and non-maleficence
1. The obligation to deliver only appropriate treatment
2. The concept of needless or disproportionate treatment
C. The principle of justice – Equitable access to health care
• The decision making process
A. The parties involved and their roles
1. The patient, his/her representative, family members, attorney, persons of trust and
other support providers
2. Carers (doctor, care team, other bodies)
B. The deliberative process and decision making
1. Preliminary remarks
2. Different phases of the decision-making processes: description and analysis
• Conclusions
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Content
Highlights
« Focus on »:
• Assessment of the patient’s ability to take decision (criteria)
• Arrangements for previously expressed wishes
• Arrangements for the application of advance directives
« Disputed issues »
• Limiting, withdrawing or withholding artificial hydration and nutrition
• Advance directives: content and legal status
• Sedation for distress in terminal phase
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Conclusions
The Guide
• Contributes to promoting respect for patient rights
• Anchored into the reality of the actors in the field
• Takes into account the diversity of
– legal, societal, cultural… contexts
– the clinical situations and care conditions
• Useful tool for training professionals and informing the public
• Proposes benchmarks relating both to the practices and the principles that can be applied in
the situations concerned
a source of material for discussion within our societies on the issue
• Used as a reference by the Conseil d’Etat (France) and the European Court of Human Rights:
Lambert and others v. France (no. 46043/14, 59, judgment of 5 June 2015 )
• Available in 15 European languages
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laurence.lwoff@coe.int
www.coe.int/bioethics
https://www.coe.int/en/web/bioethics/end-of-life
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