End of life: what does the Claeys-Leonetti law currently authorize that some doctors consider sufficient?

Deep and continuous sedation until death (SPCMD) is a practice governed by the Claeys-Leonetti law of February 2, 2016 (continuing the reflection of the Léonetti law of April 22, 2005) which authorizes the support of patients whose vital prognosis is engaged in the short term and whose well-being is questioned with regard to the provision of palliative care. For the High Authority for Health (HAS), SPCMD is not a form of euthanasia, in particular because its objective is to “relieve the refractory suffering” of a patient while the purpose of euthanasia is to “relieve the refractory suffering” of a patient while the vocation of euthanasia is to “ respond to the patient's request for death.

However, "entry into SPCMD is not intended to be reversible", reports Dr Marco A. Gambirasio, hospital practitioner, head of department of the Palliative Medicine Unit at Rouen University Hospital. The latter specifies that there are “three essential criteria for a patient to benefit from SPCMD at their request: having a serious and incurable illness, a short-term prognosis and refractory suffering. A fourth scenario is that of a limitation or cessation of life-sustaining treatments deemed unreasonable: SPCMD then supports the end of life by avoiding any suffering. Without these elements we cannot envisage a SPCMD.” As the doctor explains, "the decision to implement SPCMD is medical, resulting from a multi-disciplinary approach involving the patient and those around them", the decision is informed by a professional panel. The HAS emphasizes that “it must include a doctor from outside the team, as a consultant and without a hierarchical link to the referring doctor for the patient.”

How does the medical procedure work next? Nutrition and hydration by infusion must first be stopped so as not to artificially prolong the end of life, which could then be qualified as unreasonable obstinacy (article R.4127-37 of the public health code). For sedation, the reference treatment recommended by the HAS is midazolam, a sedative hypnotic from the imidazobenzodiazepine group. Administered intravenously or subcutaneously, it causes a profound reduction in alertness. Depending on the dosage, it can also have an anxiolytic and relaxing (muscle-relaxing) effect, but also prevent convulsions. However, it has no effect on pain. Deep sedation is therefore generally combined with opiate analgesia (due to their effectiveness). The doses injected are adapted to the patient.

If you wake up unexpectedly, the dosage of the sedative can be increased. Other sedative molecules can also be used as second-line treatment, when the first treatment is not sufficient for complete sedation. “The molecules used in the case of SPCMD are well identified and their use regulated,” recalls Dr. Marco A. Gambirasio.

To help doctors in this palliative practice, ethical tools exist, as explained by Dr. Marco A. Gambirasio. “Three different texts exist to regulate the practice of SPCMD such as the Claeys-Léonetti law of 2016, the recommendations of the High Authority of Health of 2020 and of the French Society of Support and Palliative Care of 2022. The situations differ in function of the patient and the context of their illness: the practice is not standardized but regulated by law, it involves protocols and tools of good practice. » These texts attempt to find a balance between use regulated by law in order to avoid abuses while allowing the practitioner to adapt his practice to the particular case of each patient. For Dr Gambirasio, these practices remain little known by practitioners, even if there is undeniable progress in this direction.

The patient's decision-making for SPCMD is not easy. Advance directives are the final wishes regarding end-of-life care that the medical team submits to the lucid and conscious patient. The site www.service-public.fr offers a model document which is completed by the sick patient in order to help doctors make decisions when the situation of SPCMD arises.