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One decade of a law passed by a unanimous vote, then criticized and yet hardly ever applied
Anaesth Crit Care Pain Med 34 (2015) 71–72
Editorial
One decade of a law passed by a unanimous vote, then criticized and yet hardly ever applied
A R T I C L E I N F O
Keywords: End-of-life Intensive care unit
In 2015, we celebrate the 10th anniversary of the French law of 22 April 2005 on patient rights and end of life (also known as the ‘‘Leonetti law’’) [1]. This was the only law to have been passed with a unanimous vote by the National Assembly under the 5th Republic of France. However, since its implementation, it continues to be highly criticized. . . . . .so criticized in fact, the author was contacted (a quite rare phenomenon) and asked to improve it. The text was clearly designed to avoid euthanasia practices and also, but especially, to preclude persistent, aggressive treatment that qualifies as unreasonable obstinacy when treating end of life patients. It permits, within a well-defined framework, the withholding and withdrawing of unreasonable, futile treatments. The patient’s wishes, when he/she can give them or as they were expressed by advanced directives or via a trusted person (personne de confiance) or close relatives, must be taken into account. However, as a last resort, it is the doctor who makes the decisions. An aspect of this law that is considered as incomplete by certain critics is the paucity of space given to ethical considerations by the health care team. How can a law replace this collective thought process, whose case-by-case nature is essential to ethical conduct? In this issue of the ‘‘ACCPM,’’ Roger et al. [2] report the end of life practices in 66 ICUs from Southern France (the AZUREA Network). This study, which was not meant to assess the ethical process, is a one-day snapshot describing the use of withholding and/or withdrawing treatment in ICUs during 2009 (i.e. 4 years after the ‘‘Leonetti law’’). Although this study was performed 6 years ago, the reported findings can be used as a reference or a baseline for further studies on this topic. Indeed, written advance directives were rare and/or poorly reported, and patient surrogates (trusted persons) were rarely designated. Staff discussions included paramedics in only 50% of cases. More importantly, families were not always informed about decisions that were, furthermore, only sparsely expressed in the patient medical record. The first question that comes to mind is ‘‘Why is there such a low implementation of the principles of the law?’’ The implementation of Leonetti law in ICUs reflects the uniqueness
of situations often encountered in ICUs as compared to say, Cardiology, or surgical units. In the ICU, the patients are usually sedated and/or have neurocognitive impairment; their immediate opinion is therefore unknown. In such patients, advance directives and the opinion of his/her relatives should be taken into account during a collegial decision. The decision to limit treatment is often accompanied by delicate situations that aggravate the patient’s status without being able to rely on the medical means at hand and this over a period of time that encompasses staff shifts, underlining the importance of the collegial nature of decision making. Moreover, withholding and withdrawing decisions can rapidly lead to patient death and are immediately felt by the personnel involved. Such attitudes and discussions are frequent and involve 10–20% of patients admitted to ICUs [3]. Failure to comply with the law, in practice and in its spirit, is very surprising given that it has been clearly shown that a lack of transparency in decision-making concerning the withholding or withdrawal of treatment is an important source of dissatisfaction, and even burnout, among medical teams and caregivers [4]. The non-implementation of the law could probably be explained by the intense failure that is felt by the physician when the treatment that he/she proposed is inefficient, leading to patient death. Therefore, physicians must change certain aspects in how they view their role in the ICU; the latter is not aimed at forever fighting death, which is ultimately impossible, but at improving patient quality of life whatever the circumstances. From this point of view, withholding or withdrawing treatment is a part of the daily practice of physicians, always in association with an ethical process. Of course, deciding to withhold or withdraw treatment is never easy nor simple, especially in high-pressure situations, which is one more reason why compliance with this law is important for patients, their families and for the medical teams taking care of them. It is likely, following the Clayes-Leonetti report, that the few modifications made to the law in March 2015 will have any impact on ICU practices, given that sedation is already systematic. On the other hand, the increased constraints surrounding advanced directives must be considered, and may
http://dx.doi.org/10.1016/j.accpm.2015.03.004 2352-5568/ß 2015 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
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Editorial / Anaesth Crit Care Pain Med 34 (2015) 71–72
change doctor–patient relationships. Informing the general population on how to write such directives seems essential. Presently, the few advance directives that are available often concern unreasonable obstinacy in treatment, which is already largely taken into consideration by the law, or the use of particular treatments, such as tracheotomy or dialysis. However, the latter are too often viewed by patients as definitive when they are in fact often used on a temporary basis in ICUs, to treat an acute illness. It is therefore imperative that ICU teams correctly and calmly apply the Leonetti law. The study reported by Roger et al. [2] should lead to improvements in the implementation of the Leonetti law in ICUs, with the hope of seeing rapid improvement via a future, multicentre study by the AZUREA group. Disclosure of interest The author has not supplied his declaration of conflict of interest.
References [1] Leonetti. Loi no 2005-370 du 22 avril 2005 relative aux droits des malades et a` la fin de vie. 2005. [2] Roger C, Morel J, Molinari N, Orban JC, Jung B, Futier E, et al. Practices of end-of-life decisions in 66 southern French ICUs 4 years after on official legal trameworf: a a-day audit. Anaesth Crit Care Pain Med 2015. http://dx.doi.org/10.1016/j.accpm. 2014.10.001. [3] Ferrand E, Robert R, Ingrand P, Lemaire F. Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet 2001;357:9–14. [4] Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, et al. Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 2003;167:1310–5.
Jean-Etienne Bazin De´partement d’anesthe´sie re´animation, hoˆpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France E-mail address: [email protected] (J.-E. Bazin)
Editorial
One decade of a law passed by a unanimous vote, then criticized and yet hardly ever applied
A R T I C L E I N F O
Keywords: End-of-life Intensive care unit
In 2015, we celebrate the 10th anniversary of the French law of 22 April 2005 on patient rights and end of life (also known as the ‘‘Leonetti law’’) [1]. This was the only law to have been passed with a unanimous vote by the National Assembly under the 5th Republic of France. However, since its implementation, it continues to be highly criticized. . . . . .so criticized in fact, the author was contacted (a quite rare phenomenon) and asked to improve it. The text was clearly designed to avoid euthanasia practices and also, but especially, to preclude persistent, aggressive treatment that qualifies as unreasonable obstinacy when treating end of life patients. It permits, within a well-defined framework, the withholding and withdrawing of unreasonable, futile treatments. The patient’s wishes, when he/she can give them or as they were expressed by advanced directives or via a trusted person (personne de confiance) or close relatives, must be taken into account. However, as a last resort, it is the doctor who makes the decisions. An aspect of this law that is considered as incomplete by certain critics is the paucity of space given to ethical considerations by the health care team. How can a law replace this collective thought process, whose case-by-case nature is essential to ethical conduct? In this issue of the ‘‘ACCPM,’’ Roger et al. [2] report the end of life practices in 66 ICUs from Southern France (the AZUREA Network). This study, which was not meant to assess the ethical process, is a one-day snapshot describing the use of withholding and/or withdrawing treatment in ICUs during 2009 (i.e. 4 years after the ‘‘Leonetti law’’). Although this study was performed 6 years ago, the reported findings can be used as a reference or a baseline for further studies on this topic. Indeed, written advance directives were rare and/or poorly reported, and patient surrogates (trusted persons) were rarely designated. Staff discussions included paramedics in only 50% of cases. More importantly, families were not always informed about decisions that were, furthermore, only sparsely expressed in the patient medical record. The first question that comes to mind is ‘‘Why is there such a low implementation of the principles of the law?’’ The implementation of Leonetti law in ICUs reflects the uniqueness
of situations often encountered in ICUs as compared to say, Cardiology, or surgical units. In the ICU, the patients are usually sedated and/or have neurocognitive impairment; their immediate opinion is therefore unknown. In such patients, advance directives and the opinion of his/her relatives should be taken into account during a collegial decision. The decision to limit treatment is often accompanied by delicate situations that aggravate the patient’s status without being able to rely on the medical means at hand and this over a period of time that encompasses staff shifts, underlining the importance of the collegial nature of decision making. Moreover, withholding and withdrawing decisions can rapidly lead to patient death and are immediately felt by the personnel involved. Such attitudes and discussions are frequent and involve 10–20% of patients admitted to ICUs [3]. Failure to comply with the law, in practice and in its spirit, is very surprising given that it has been clearly shown that a lack of transparency in decision-making concerning the withholding or withdrawal of treatment is an important source of dissatisfaction, and even burnout, among medical teams and caregivers [4]. The non-implementation of the law could probably be explained by the intense failure that is felt by the physician when the treatment that he/she proposed is inefficient, leading to patient death. Therefore, physicians must change certain aspects in how they view their role in the ICU; the latter is not aimed at forever fighting death, which is ultimately impossible, but at improving patient quality of life whatever the circumstances. From this point of view, withholding or withdrawing treatment is a part of the daily practice of physicians, always in association with an ethical process. Of course, deciding to withhold or withdraw treatment is never easy nor simple, especially in high-pressure situations, which is one more reason why compliance with this law is important for patients, their families and for the medical teams taking care of them. It is likely, following the Clayes-Leonetti report, that the few modifications made to the law in March 2015 will have any impact on ICU practices, given that sedation is already systematic. On the other hand, the increased constraints surrounding advanced directives must be considered, and may
http://dx.doi.org/10.1016/j.accpm.2015.03.004 2352-5568/ß 2015 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
72
Editorial / Anaesth Crit Care Pain Med 34 (2015) 71–72
change doctor–patient relationships. Informing the general population on how to write such directives seems essential. Presently, the few advance directives that are available often concern unreasonable obstinacy in treatment, which is already largely taken into consideration by the law, or the use of particular treatments, such as tracheotomy or dialysis. However, the latter are too often viewed by patients as definitive when they are in fact often used on a temporary basis in ICUs, to treat an acute illness. It is therefore imperative that ICU teams correctly and calmly apply the Leonetti law. The study reported by Roger et al. [2] should lead to improvements in the implementation of the Leonetti law in ICUs, with the hope of seeing rapid improvement via a future, multicentre study by the AZUREA group. Disclosure of interest The author has not supplied his declaration of conflict of interest.
References [1] Leonetti. Loi no 2005-370 du 22 avril 2005 relative aux droits des malades et a` la fin de vie. 2005. [2] Roger C, Morel J, Molinari N, Orban JC, Jung B, Futier E, et al. Practices of end-of-life decisions in 66 southern French ICUs 4 years after on official legal trameworf: a a-day audit. Anaesth Crit Care Pain Med 2015. http://dx.doi.org/10.1016/j.accpm. 2014.10.001. [3] Ferrand E, Robert R, Ingrand P, Lemaire F. Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet 2001;357:9–14. [4] Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, et al. Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 2003;167:1310–5.
Jean-Etienne Bazin De´partement d’anesthe´sie re´animation, hoˆpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France E-mail address: [email protected] (J.-E. Bazin)