Claire Anne Brule

Continuous Sedation Till Death: 3 questions for Olivier Jonquet, Emeritus Professor of Intensive-Care and Resuscitation Medicine

by Claire Anne Brule | October 7, 2022 | End of life, News

1. What is the exact meaning of deep and continuous sedation?

The term deep and continuous sedation maintained until death, first appeared in law dated 2^nd February 2016, which established new rights for the sick and people at their end-of-life. The law is intended to control situations in which this procedure is liable to be used.

Regarding sedation, what exactly does it mean?

As a general rule, sedation consists in administering sedative products to patients (which diminish vigilance) in order to counter a situation considered unbearable for the patient, in spite of properly conducted specific treatments.

Sedation may be transient or intermittent. It must be adapted to the intended purpose, i.e. proportional and reversible. Degrees of sedation are available which enable the doses of products to be adapted to the desired result.

Deep and continuous sedation maintained until death is a procedure introduced by the Claeys-Leonetti law. It consists in the administration of sedative products (in most cases Midazolam) which are supplemented with neuroleptics (Chlorpromazine) in the event of agitation. Opoids may be added in order to relieve pain or respiratory difficulties. As its name suggests, the administration is maintained until death, which may occur in a few hours or days.

2. What are the conditions for its application ?

The intention is to relieve chronic suffering in patients with a short-term critical life-threatening condition.

What is meant by chronic suffering?

Suffering is considered chronic if all available and suitable therapeutic and assistance means have been offered and/or provided:

Without achieving the relief hoped for by the patient,
Or which result in unacceptable undesirable side-effects,
Or where their therapeutic effects are not liable to act within a time-frame acceptable to the patient.

The patient alone is able to appreciate the unbearable nature of his/her suffering, of the undesirable side-effects or of the time-delay for the treatment to take effect.

In the event that the patient is unable to express his/her wishes, the public health code also provides for deep and continuous sedation maintained until death. Whenever it is decided to discontinue treatments (dialysis, artificial ventilation etc.), in order to avoid unreasonable life-support obstinacy, it is conducted following a medical decision in the context of a collegial procedure involving the advice of the next of kin or the person of confidence, if one has been designated.

What is meant by short-term life-threatening condition?

The notion of short-term is characterized when death is imminent, expected within the hours or a few days to come. The medical decision is based on the medical case and a collegial reflection.

If the life-threatening condition is not short-term critical, then the sedation administered must be transient, intermittent, proportional and reversible.

The prescription of deep and continuous sedation maintained until death is not considered lightly, it stems from a request by a terminally sick patient with a short-term critical life-threatening condition, with a life expectancy of a few hours or days. It necessitates a collegial procedure involving a team of multiple professional specialists to evaluate the pertinence and the method of application. Its sole intention is to relieve the suffering considered unbearable by a terminally sick end-of-life patient, not to end the patient’s life. The date and time of death are not pre-determined, and in any case are expected to occur within the coming hours or days.

3. Who can say that there is no suffering under those conditions with no food or hydration ?

The depth of sedation can be assessed by evaluation scales such as for example the Richmond (RASS) scale: RASS is an instrument designed for evaluating the level of vigilance and behaviour in critically ill patients.

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Stage -4 / -5 is achieved in a few hours. The level of sedation reached makes it possible to consider relief of pain and suffering, as has been described by patients who have been subjected to these levels of sedation and for whom the process has been interrupted. The discontinuation of feeding and hydration is often mentioned to suggest that such patients die of hunger. This is incorrect. These patients are at their end-of life, under sedation, and one does not die of hunger within a few hours or days of interrupting feeding and hydration.

Nevertheless, the law states that “nourishment and hydration are treatments which may be discontinued”. The law does not say “must be discontinued“, which leaves some freedom of choice. The symbolic value of discontinuing hydration and/or nourishment can be disturbing for relatives and carers. It is also true that such needs during the end-of-life are diminished, and that continuing hydration and/or nourishment may result in unnecessary discomfort. It is possible to maintain a minimum level of hydration of around 250cc/24h.

4. In the event of “Deep and continuous sedation maintained until death”, what actually causes death ?

Firstly, it is the disease which causes death, since the patient is “within a few hours or days” of his/her death.

Secondly, sedation with the products used (anxiolytics, and possibly morphinic opioids) is liable to reduce respiratory frequency and therefore accelerate death.

This is within the realm of double effects: the relief of pain coupled with the possible acceleration of death, which is not in itself the desired effect. It can be accepted for patients who, in any case are dying and for whom there is no other means available to relieve their suffering. In such situations, which are inevitably complex, life is respected, but one has to accept the inevitability of death.

In euthanasia and its varying terminologies (medically assisted suicide, active assistance for death etc.), the objective and intention are to provoke the death of patients immediately, irrespective of whether or not they are at their end-of-life.

Reference

https://www.has-sante.fr/jcms/c_2832000/fr/comment-mettre-en-oeuvre-une-sedation-profonde-et-continue-maintenue-jusqu-au-deces

Euthanasia in Canada: The Legitimate Concerns Regarding the Slippery Slope

by Claire Anne Brule | October 7, 2022 | End of life, Euthanasia and Suicide, News

Tom Koch, the research scientist specializing in ethics has studied how the situation of medical termination, which covers euthanasia and assisted suicide, has evolved in Canada since its legalization in 2016. His study deals in particular with the question of whether or not the concerns of those persons opposed to legalization (skeptics) have proved to be justified or unfounded. His approach is not philosophical, but based on facts.

He analyses two types of argument:

The probable “slippery slope” effect resulting in the gradual relaxation of the eligibility conditions and consequent increasing number of deaths.
The probability that euthanasia will supplant palliative care, especially in areas where palliative care is poorly developed.

First argument: The rapidly broadening of eligibility criteria and the increase in deaths

The yearly total of euthanasias has strongly increased over 5 years, increasing from 1,018 to 7,589. The author mentioned that this increase has continued through 2021. The last statistical report, released after this study, records 10,064 deaths in 2021, i.e. some 3.3% of Canadian deaths and an increase of 32% relative to the previous year.

The law governing “Medically assisted death” adopted in 2016, from the outset established broad and subjective eligibility criteria, especially as the doctor or paramedic calling on them may have an “erroneous understanding” of them, whilst remaining blameless, according to article 227(3). In order to qualify for euthanasia or medical termination, the person must be of age and “afflicted with serious and irremediable health problems“. This expression means in particular that “his/her sickness, ailment, handicap or advanced and irreversible decline in capacities are causing him/her intolerable persistent physical or psychological suffering which cannot be relieved under conditions which he/she considers acceptable” and that “his/her natural death has become reasonably foreseeable in view of the overall medical situation, without any forecast having been given on his/her life expectancy.” In addition to the opinion of a second doctor or paramedic, a time-delay of 10 days was necessary between the written request by the person and the application of euthanasia or medical termination. This time-delay could be shortened, only at the discretion of the medical team, if the death of the person or the loss of the capacity to provide an enlightened consent is imminent.” In the event of the person’s inability to sign and date the request, “a third party of at least 18 years of age and who understands the nature of the request for medical termination, may do so expressly on his/her behalf, in his/her presence and in accordance with his/her instructions.”

In 2021 a new law was adopted, law C7, which removed the short-term end-of-life criterion and the time-delay for application. In practice, this relaxation means that a physically handicapped or chronically sick person is now eligible for euthanasia. The law states that it is possible to carry out euthanasia on a patient who is unable to express his/her final consent (for example if unconscious) and whose death is reasonably predictable, in the event that he/she has made an anticipated statement to that effect, or if the self-administered lethal injection has failed.

The possibility of extending euthanasia to mental sickness is currently under discussion in Canada.

Since 2016, the eligibility criteria have been so relaxed that people who are merely worried about possible future illnesses may choose to end their life. The report mentions the case of a couple, reported in 2018: George and Shirley Brickendens (Grant 2018) who were granted euthanasia not on the grounds of pain or distress, but because they feared a future invalidating disease.

In a recent report at the World Lung Cancer Conference [1], Canadian research scientists reported that with the relaxation of medical termination criteria, “Patients are seeking this option despite the availability of more effective and better tolerable treatments.”

Second argument: Could euthanasia become a substitute for palliative care?

The other subject of concern was that euthanasia could become a substitute for palliative care and other support services. Palliative care, in this case is taken in its widest sense, to include not only the management of pain, but also the accompaniment of chronically ill patients in their living environment. This may include continuous care for those suffering from chronic disease (ALS, multiple sclerosis etc.) which, with appropriate medical care and social support, are not end-of-life conditions.

According to the author, the problem could be due in part to a lack of specialists able to explain and provide such therapies. Indeed, a report [2] by Health Canada 2020 on the reasons given by patients requesting medical termination, indicated that over 50% of respondents mentioned inadequate pain control or concern about the possibility that their pain could become uncontrollable. More than 50% also gave as a reason the generally inadequate control of other symptoms. Finally, over 35% gave as a reason the feeling of being a burden on family and friends.

Generally speaking, the level of specialist care and support services available in most Canadian States is inadequate. In 2016, the Canadian Society of Palliative Care Doctors [3] reported that “a mere 15% of patients requiring specialist palliative care, are able to receive it, and such care is often provided only for short periods before death”. A subsequent study in 2018 has shown the limited availability of palliative health care in most States. The Canadian Institute for Health Information (CIHI) reported [4] that according to the available data “few providers of health care in Canada are specialized in or practice essentially palliative care…”.

Evidently, the concerns of the “skeptics” were justified. Tom Koch thus questions the reality of the claimed autonomy and freedom of choice in the absence of high-quality accompaniment and medical care.

[1] Susman, E. 2021. Study sheds light on physician-assisted suicide in lung cancer patients. Medpage Today (Sept. 9). http://www.medpaget0day.com/meetingcoverage/iaslc/ 94429.
[2] Health Canada. (2021). Second annual report on medical assistance in dying in Canada 2020. Ottawa:Health Canada. https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annualreport-2020.html.
[3] CSPC. (2016). How to improve palliative care in Canada: A call to action for federal, provincial, territorial,regional and local decision-makers. Ottawa: Canadian Society of Palliative Care Physicians. http://www.cspcp.ca/wp-content/uploads/2016/11/Full-Report-How-to-Improve-Palliative-Care-in-Canada-FINAL-Nov-2016.pdf
[4] CIHI. (2018). Access to palliative care in Canada. Canadian Institute for Health Information.

Current State of Health in France

by Claire Anne Brule | September 29, 2022 | Health, News

An annual report on the health status of the French population has just been published by the “DREES“, the National Directorate of Research, Studies, Evaluation and Statistics. The report includes a summary which emphasizes there are “divergent developments intertwined with clear-cut inequalities“.

Aging and Its’ Impact

Firstly, the report deals with the well-known phenomenon of ageing. Compared to 1960 when only 4.3% of the population were over age 75, this group now represents 9% of the population. Population forecasts predict this age group will reach 13% by 2032 and 16% by 2052. Chronic pathologies or multiple pathologies are also more prevalent for them, with 91% having at least one pathology or chronic treatment. Compared to 9% of the general population who use psychotropic medications, 27% of those over age 75 use them. Another important health issue is Alzheimer’s disease and other dementias which cause suffering for 760,000 people and for those around them.

This means that the needs of this ageing population will continue to be a source of supplementary needs that weigh heavily on the health care system, thus intensifying an already overburdened situation.

Lack of Clarity for Defining Healthy and Disability-free Life Expectancy

One page of the report is devoted to life expectancy and the concept of disability-free life expectancy. Although life expectancy at birth is constantly increasing, lately it has done so at a slower rate. In 2021, women’s life expectancy was 85.4 years, compared to 79.3 years for men, a gap that has been narrowing in recent years.

Healthy life years, (“HLY”) and also referred to as disability-free life expectancy (“DFLE”), is defined as the number of years that a person is expected to continue to live in a healthy condition, taking into account the current health situation. In France, it is estimated at 65.9 years for women and 64.4 years for men. Although life expectancy is calculated from demographic data on the entire population, the difference with healthy life expectancy is that it is based on the responses to the survey question: “Has a health problem been limiting you, for at least six months, from performing normal everyday activities? »

The possible answers are:

1-yes, severely limited; 2- yes, somewhat limited; 3- no, no limitations at all.”

The methodology states that “only people who have no limitations at all are considered healthy”. This marker is included in the national wealth indicators established by “INSEE”, the French National Statistics and Economics Bureau. The report quotes a former Director-General of the WHO, Dr Hiroshi Nakajima, who declared in 1997: “Without quality of life, increased longevity is of little interest (…) health expectancy is more important than life expectancy.” While the importance of good health is undeniable, it would be prejudicial to view the complexities of aging taking into account only in function one’s disability. The wisdom from the elderly and their contributions to society must not remain unseen by statistical indicators based on the subjectivity of one’s diminished physical activity.

Regional and Social Differences

Many examples of disparities and inequalities in the health status of the French are also described. For example, mortality from cancer deaths is higher in the north and northeastern regions. The socio-professional categories have an impact on Life expectancy. Statistically, when evaluating men from age 35 onward, a male manager lives an average of 6 years longer than a manual worker.

For some chronic diseases, such as diabetes, and psychiatric diseases, there are significant additional risks between those who are less well-off and the more affluent. For example, the poorest 10% of the population is affected by diabetes 2.8 times more than the richest 10% of the population.

Regarding Covid-19, the proportion of people placed in a hospital decreases in correlation with their standard of living. The population has a general tendency towards a sedentary lifestyle, but obesity is more common among people with lower incomes. The report states that “17% of individuals whose standard of living is below the first quarter of the distribution are obese, compared to 10% for those whose standard of living falls in the quartile for a higher standard of living“. The different socioeconomic groups also showed disparities for taking part in early diagnostic health screening. Regarding abortion, the report confirms the previously published data which signaled that the women with the lowest standard of living abort more often than the others. Finally, it should be noted that individuals living in the Overseas Departments and Regions (“DROM”) are particularly affected by many of the disparities studied in this report.

All in all, the DREES’ detailed report on the health status of the French confirms the necessity, even the urgency to make improvements in the current health system in order to provide better care for the all the population. In particular, anticipating and planning ahead for taking care of the elderly will become even more crucial, exactly the antithesis of rationing healthcare.

[Press Release]: Abortion Prevention Policy Urgently Needed

by Claire Anne Brule | September 29, 2022 | Abortion, Press Releases

The latest statistics in France confirm a persistent high abortion rate at 15.5 per thousand, over twice that of neighboring Germany. The majority of women (76%) underwent medically induced procedures with abortive pills, compared to 68% in 2019 and 31% in 2000. Often taking place at home (30%), this type of abortion which is performed prior to 7 weeks of pregnancy, can make a woman feel rushed, without allowing her enough time to consider her decision, especially if she is under pressure or if she is experiencing domestic violence.

The continual clamoring for the “right to abortion” always distracts our attention from having an objective look at the reality of abortion. This prevents any discussion about what a woman is going through or providing her with the needed support to avoid abortion. The prevailing atmosphere of abortion advocacy almost borders on disinformation. Activists insult women’s common sense by trying to make them believe that abortion is completely harmless, without any side-effects whatsoever. The media is discriminatorily silent about the various sorts of aggression women undergo when faced with an unexpected pregnancy, especially from men. In addition, serious misunderstandings between men and women occur due to the lack of information about contraceptive failures. It is illusory to think that all women choose to abort by their own free will.

Abortion should never be inevitable for those experiencing economic and financial difficulties. However, the national statistics’ bureau in France (« Drees : La Direction de la Recherche, des Études, de l’Évaluation et des Statistiques”) reports that women with the lowest incomes more frequently resort to abortion than others. In the current context of ever-increasing costs of living and cutbacks in subsidies for the family, how can we not be alarmed that abortion has already been identified as a marker of social inequality?

We must rally our forces to contest this situation. Prejudicially treating these subjects as taboo, is a grave mistake when abortion is an irreversible act where lives are at stake. Whether abortion is considered as a right or not – and even if there is still much opposition on this issue – this should not prevent our society from protecting the women who want to avoid abortion.

According to an IFOP survey conducted in October 2020, a large majority (92%) of the French believe that “abortion has psychological side-effects which are difficult to live with” and nearly three quarters (73%) of them also believe that “society should do more to help women avoid abortion ».

Alliance VITA continues to call for an evaluation to be conducted on the causes, conditions and consequences of abortion as a pre-requisite to implementing a real prevention policy which is respectful of women.

Press contact
contactpresse@alliancevita.org

No Consensus in Sight for Legalizing Euthanasia in France

by Claire Anne Brule | September 23, 2022 | Euthanasia and Suicide, News

Earlier this month President Emmanuel Macron declared to the actress, Line Renaud, in regard to euthanasia: “This is the time for it, so it will be done.” Is this a calculated diversion at a time when some of the country’s basic foundations, such as retirement pensions, the cost of living, energy, and the health system have all been shaken? Or is it because of a feeling that there would a consensus on the end-of-life so that a law, approved by the majority of the French people, would be a credit to Macron’s government? Is this timing a challenge to pass smoothly into law a subject so far removed from the main preoccupations of the French people, so that the worst reaction to be expected would be nothing but general indifference?

The record high abstention rates in the last presidential election have pushed journalists to assert that the “abstentionists” are the country’s leading political party. Following the legislative elections which revealed that the political world is even more divided, what was the reaction of the main contributors to the end-of-life debate?

Many healthcare professionals have retorted to the Ethics Committee’s latest recommendation that administering death is not healthcare!

Leading the fight against pain and suffering, standing by their patients, many caregivers denounce the announcements made simultaneously on September 13^th by the Ethics Committee and the French government. To date, nine learned societies and associations, all involved in the end-of-life and healthcare, have joined forces to contest the recommendation made by the “CCNE” (French National Consultative Ethics Committee) and to assert that “administering death is not healthcare”. The full text where they point out the fact that the Ethics Committee itself did not reach consensus on this latest recommendation, is available on the website for French Palliative Care Workers, the “SFAP” (Société Française d’Accompagnement et de Soins Palliatifs). Furthermore, they point out that “their current practices are based on a clear deontology and medical ethics, marked by a long and unwavering historical position.” Indeed all doctors taking the Hippocratic oath dating from the 4^th century BC promise: “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.”The president of the National Order of Physicians, François Arnault reiterated during an interview with the Doctor’s Daily that “the Order is not in favor of euthanasia”. In the event that a medical procedure for administering death is legalized, he pointed out the necessity of having a specific conscience clause for caregivers. He also emphasized that palliative care is lagging behind in France and “that we must fight against inequalities in palliative care, by training, and by observing the Leonetti Claeys law”.

On “France Info” radio, a palliative care nurse, Xavier, declared that death has never been and will never be a dignified response to suffering.” Under the pen name of “the star man”, he publishes a successful comic strip entitled “to life”, about his daily life caring for patients. He believes that the current law is “well-written and coherent”. The heart of his vocation is based on care. He added: “I do not believe the role of medicine is to decide who is eligible to die or not.”

In an interview with “Paris Match” a palliative care doctor at the “Institut Curie”, Alexis Burnod states that patients undergo a positive experience when they are properly taken care of and their pain is handled correctly. About the legal framework, he points out the excesses in the countries that have legalized euthanasia. Burnod stresses that “once such a law is adopted, it is hard to prevent it from evolving into an incentive for suicide. ” Jean Leonetti, who wrote the 2005 law and co-authored the 2016 law, calls us to bear in mind that “Human life is the supreme value” and that we must “be extremely cautious” on “the major transgression of conferring death on someone.”

In the Press

In the “Ouest France” newspaper, an op-ed by Jeanne-Emmanuelle Hutin reminds Robert Badinter’s forceful words in 2008. He is the Keeper of the Seals who voted to abolish the death penalty in 1982: “Does the State have the power and the right to say: ‘Since you want to die I will kill you?’ […] In a democracy, no one can take the life of another. This principle must be respected by the State.” Another newspaper article in “Le Figaro” addresses the scenario whereby society would only focus on performance and appearance, in the event that a future law would legalize euthanasia. From a political aspect, in an article in Le Monde, two reporters stress the importance for French president Macron “to avoid giving the impression that he has a preconceived script on the subject”. Among the pitfalls of legalization, they underline how difficult it is “to define exceptions that would not be considered arbitrary. “

Religious Representatives in Favor of a Better Life

Several representatives of different faiths have voiced their support for palliative care and for the urgency of offering equitable access throughout France. The Chief Rabbi of France, Chaim Korsia, said “there is no need to go further than the current law.” He views legalizing euthanasia as a “breach with classic anthropology” that “borders on eugenics.”

The Protestant Federation of France (FPF) stated that it feared the idea behind changing the legislation is “economically or ideologically motivated“. When questioned in the plane on his return flight from Kazakhstan, Pope Francis gave a concise response: “Killing is not human. Period. If there is a motivation to kill, you will end up killing again. It’s not human.” In an article in Le Monde, the French bishops spoke of the discrepancy between the country’s solidarity during the Covid-19 crisis and the current push for legalizing euthanasia. “How is it fathomable that only a few months after this wonderful wave of solidarity and brotherhood, we are now being given the feeling that society can find no other solution for weakness, vulnerability or the end-of-life, than active assistance in dying, than assisted suicide? “

“Euthanasia is a sign that a community lacks brotherhood and solidarity.” This quote from Philippe Pozzo’s book “The Immobile Walker” is a good summary of what is at stake in the upcoming discussions.